Mammography Should Be Performed First
For bilateral palpable breast masses in a woman 40 years or older, diagnostic bilateral mammography is performed first, followed by targeted ultrasound of both palpable areas. 1
Rationale for Mammography-First Approach
The American College of Radiology establishes that mammography is the main modality for initial imaging assessment of palpable lumps in women 40 years of age or older. 1 This approach serves multiple critical purposes:
- Bilateral mammography screens the remainder of both breasts for additional occult lesions that may not be clinically apparent, which is essential given the bilateral presentation in this case 1
- Mammography detects microcalcifications and subtle architectural distortion that ultrasound may miss 1
- A small radio-opaque marker is placed on the skin over each palpable finding during mammography to identify their locations 1
Why Ultrasound Follows Mammography
After mammography is completed, targeted ultrasound is then performed at the specific sites of the palpable masses to provide additional characterization 1:
- The addition of ultrasound detects 93% to 100% of cancers that are occult on mammography alone 1
- Ultrasound allows direct correlation between the clinical finding and imaging 1
- When both mammography and ultrasound are negative or benign, the negative predictive value exceeds 97% 1
- Ultrasound immediately determines if masses are cystic, solid, or complex 2
Critical Sequencing Consideration
A thorough imaging workup should be completed prior to biopsy, as changes related to biopsy may confuse or limit subsequent image interpretation 2. This is why the diagnostic mammogram must precede the targeted ultrasounds—the mammogram provides the comprehensive bilateral evaluation before any intervention occurs.
Common Pitfall to Avoid
Never proceed directly to ultrasound alone in women 40 years or older with palpable masses, as this would miss the opportunity to screen the entire bilateral breast tissue for occult disease 1, 3. The bilateral nature of this patient's presentation makes comprehensive mammographic evaluation even more critical 1.