What is the recommended diagnostic and treatment approach for suspicious lesions in both breasts?

Diagnostic and Treatment Approach for Suspicious Bilateral Breast Lesions

For suspicious lesions in both breasts, proceed immediately with bilateral diagnostic mammography followed by targeted ultrasound of both breasts, then perform image-guided core needle biopsy of any BI-RADS 4 or 5 lesions identified. 1

Initial Imaging Evaluation

Start with bilateral diagnostic mammography as the first imaging study for any woman aged 30 years or older presenting with suspicious breast lesions. 1 This provides:

• Characterization of the palpable lesions 1
• Screening of the remainder of each breast for additional occult lesions 1
• Baseline documentation of both breasts 1
• Detection of calcifications or architectural distortions not visible on ultrasound 1

Never proceed directly to biopsy before imaging, as post-biopsy changes will confuse, alter, obscure, and limit image interpretation. 1

Complementary Ultrasound Assessment

After mammography, perform targeted ultrasound of both breasts using a high-resolution linear-array transducer with minimum 10 MHz frequency. 1 Ultrasound provides critical additional information:

• Identifies additional lesions not evident on mammography (detection rate 93-100% for mammographically occult cancers) 2
• Characterizes solid versus cystic nature of lesions 1
• Evaluates bilateral axillae for suspicious lymph nodes 1
• Guides biopsy without radiation exposure and with better patient tolerance 1

The combined negative predictive value of mammography and ultrasound exceeds 97% when both are negative or benign. 2

BI-RADS Classification and Management Algorithm

For BI-RADS 1-3 (Negative, Benign, or Probably Benign):

• BI-RADS 1-2: Return to routine screening 1
• BI-RADS 3: Short-interval follow-up at 6 months, then every 6-12 months for 1-2 years 1

For BI-RADS 4-5 (Suspicious or Highly Suggestive of Malignancy):

Tissue diagnosis is mandatory using core needle biopsy (strongly preferred over fine needle aspiration). 1 Core biopsy is superior because it:

• Provides higher sensitivity and specificity than fine needle aspiration 1
• Allows correct histological grading 1
• Enables evaluation of hormone receptor status (ER, PgR, HER2) 1
• Confirms invasive versus in situ disease 1

Biopsy Technique Selection

Use ultrasound-guided core biopsy whenever the lesion is visible on ultrasound (preferred method). 1 Benefits include:

• Real-time needle visualization 1
• No breast compression required 1
• No radiation exposure 1
• Access to difficult locations (far posterior, axillary) 1

Use stereotactic-guided biopsy only when:

• Lesions are visible only on mammography (e.g., calcifications without mass) 1
• No sonographic correlate exists 1

Obtain at least 2-3 cores from each suspicious lesion. 1 In multifocal/multicentric disease, biopsy all suspicious lesions bilaterally. 1

Critical Post-Biopsy Steps

Place a marker clip in each biopsied lesion with post-biopsy imaging to:

• Confirm tissue sampling of the correct target 1
• Aid in surgical localization if malignancy is confirmed 1
• Enable correlation when biopsy modality differs from detection modality 1

Ensure concordance between pathology results, imaging findings, and clinical examination. 1, 3 This is absolutely essential and non-negotiable.

If Results Are Discordant:

• Benign pathology but suspicious imaging: Proceed to surgical excision 1, 3
• Atypical hyperplasia or LCIS: Surgical excision recommended (select patients may be monitored) 1
• Indeterminate pathology: Surgical excision 1

Management Based on Final Pathology

Benign and Concordant:

• Physical examination with or without imaging every 6-12 months for 1-2 years 1
• Return to routine screening if stable 1

Atypical Hyperplasia or LCIS:

• Consider risk-reduction therapy per NCCN guidelines 1
• Maintain regular breast screening 1

Malignancy Confirmed:

• Refer immediately for treatment according to NCCN Breast Cancer Guidelines 1, 3
• Consider preoperative MRI with contrast for extent of disease evaluation in select circumstances (lobular histology, large clinical-imaging discrepancies, dense breasts, young age) 1

Common Pitfalls to Avoid

Do not use MRI as initial evaluation - there is no evidence supporting MRI without and with contrast as the first step in evaluating suspicious breast masses. 1 MRI may be useful after malignancy is established to delineate extent of disease. 1

Do not rely on single imaging modality - mammography and ultrasound provide complementary information; using only one may miss important findings. 3, 2

Do not delay biopsy of BI-RADS 4-5 lesions - observation is not an option for suspicious findings. 1

Do not accept discordant results - always pursue additional tissue sampling or surgical excision when pathology doesn't match imaging suspicion. 1, 3

Do not forget bilateral evaluation - since both breasts have suspicious lesions, complete assessment of both sides is mandatory. 1