What is the appropriate diagnostic workup for a breast mass?

From the Guidelines

The appropriate diagnostic workup for a breast mass is a thorough imaging evaluation, which should be completed prior to biopsy, and may include diagnostic mammography, digital breast tomosynthesis (DBT), or breast ultrasound (US), depending on the patient's age and the degree of radiologic suspicion 1.

Diagnostic Approach

• For women aged 40 years or older, diagnostic mammography or DBT is the initial imaging modality of choice for evaluating a clinically detected palpable breast mass 1.
• For women younger than 30 years, breast US is the initial imaging modality of choice 1.
• For women aged 30 to 39 years, either US or diagnostic mammography or DBT can be used for initial evaluation 1.

Key Considerations

• Correlation between imaging and the palpable area of concern is essential to ensure accurate diagnosis 1.
• Any highly suspicious breast mass detected by imaging or palpation should undergo biopsy, unless there are exceptional clinical circumstances 1.
• Imaging evaluation is necessary in almost all cases to characterize the palpable lesion, as many breast masses may not exhibit distinctive physical findings 1.
• Advanced technologies such as MRI, positron emission mammography, or molecular breast imaging have little role in the evaluation of a palpable mass 1.

From the Research

Diagnostic Workup for Breast Mass

The diagnostic workup for a breast mass involves a combination of clinical evaluation, imaging, and biopsy. The following steps are recommended:

• Clinical breast examination to characterize the mass and assess for any suspicious features 2, 3
• Imaging studies, including:
  • Ultrasound as the initial imaging modality for women under 30 years old, pregnant, or lactating 2, 3
  • Diagnostic mammography as the initial imaging modality for women over 40 years old 2, 3
  • Either ultrasound or diagnostic mammography for women between 30-39 years old 2, 3
• Biopsy for masses with suspicious features 2, 3, 4, 5
• Short-term follow-up as a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma 2, 3

Imaging Modalities

The choice of imaging modality depends on the patient's age and clinical presentation:

• Ultrasound is useful for evaluating palpable breast masses, especially in younger women 2, 3, 6
• Diagnostic mammography is the initial imaging modality of choice for women over 40 years old 2, 3
• MRI is rarely indicated for evaluating clinically detected breast masses 2, 3

Biopsy and Follow-up

Biopsy is indicated for masses with suspicious features, while short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma:

• Biopsy can be performed using fine-needle aspiration or open surgical biopsy 4, 5
• Short-term follow-up can be used to monitor the mass for any changes in size or characteristics 2, 3