What is the appropriate workup algorithm for a breast mass?

From the Guidelines

The appropriate workup algorithm for a breast mass is to start with a thorough clinical breast examination, followed by imaging evaluation with diagnostic mammography and targeted-breast ultrasound, with the choice of initial imaging modality dependent on patient age and degree of radiologic suspicion 1.

Key Considerations

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

Imaging Evaluation

• If a clearly benign correlate for a palpable finding can be identified on mammography, this modality alone may be sufficient and clinical follow-up rather than imaging follow-up or tissue sampling is appropriate 1.
• If mammography is negative or an imaging correlate is identified that is not clearly benign, multimodality imaging is usually indicated, with targeted US directed toward a palpable finding 1.
• US can be used as the initial means of image evaluation for women aged 30 to 39 years with a palpable breast mass, although diagnostic mammography or DBT may also be appropriate in this age group 1.

Biopsy and Follow-up

• Any highly suspicious breast mass detected by imaging should be biopsied, irrespective of palpable findings 1.
• Any highly suspicious breast mass detected by palpation should be biopsied, irrespective of imaging findings 1.
• If a solid lesion is suspicious or highly suggestive of malignancy, tissue biopsy should be obtained using core needle biopsy (CNB) (preferred) or surgical excision 1.

From the Research

Workup Algorithm for Breast Mass

The workup algorithm for a breast mass involves a systematic approach to distinguish between cystic and solid masses, and to rule out cancer. The following steps are recommended:

• A careful history and clinical breast examination are crucial in the initial evaluation of a breast mass 2, 3
• Distinguishing between cystic and solid masses is essential, often using fine-needle aspiration or ultrasound-guided algorithms 2, 4
• Solid masses require further workup to rule out cancer, using a combination of clinical breast examination, radiography, and fine-needle aspiration biopsy (FNAB) 2
• The triple-diagnosis method, which involves simultaneous evaluation of a breast mass using clinical breast examination, radiography, and FNAB, can lower the risk of missing cancer to 1% 2

Diagnostic Tools

Various diagnostic tools are available for the evaluation of breast masses, including:

• Mammography, which is the most commonly used technique due to its low cost 5
• Ultrasound, which can be used to characterize palpable masses and guide fine-needle aspiration or biopsy 4, 3
• Fine-needle aspiration biopsy (FNAB), which can be used to distinguish between cystic and solid masses and to rule out cancer 2, 3
• Core vector machines and other machine learning algorithms, which can be used to classify benign and malignant breast masses on mammograms 6

Special Considerations

In pediatric patients, the pathology and management of breast masses are different from those in adults, and a thorough history and physical exam are essential in the initial evaluation 4. The use of ultrasound-guided algorithms and prioritization of conserving developing breast tissue are also important considerations in pediatric patients 4.