Diagnostic Mammography with Spot Compression Views or Digital Breast Tomosynthesis
Order "Diagnostic Mammography" which includes spot compression and magnification views as needed, or preferably "Diagnostic Mammography with Digital Breast Tomosynthesis (DBT)" as the modern alternative that can replace traditional cone compression views. 1
Standard Diagnostic Workup Algorithm
The evaluation of an abnormal screening mammogram follows a structured approach:
Primary Imaging Modality
Diagnostic mammography with additional views is the standard initial step, typically including spot compression views of the area of concern to determine if the abnormality persists or represents summation artifact from overlapping normal breast tissue 1
Spot compression views use a small compression paddle to apply focal compression to the specific area, which helps characterize whether an asymmetry or mass is real or artifactual 1
Magnification views are particularly helpful when evaluating any associated microcalcifications that may accompany the abnormality 2, 1
Modern Alternative: Digital Breast Tomosynthesis
DBT can replace traditional spot compression views in the diagnostic setting with equivalent or superior diagnostic accuracy, as recommended by the American College of Radiology 1, 3
DBT shows pooled sensitivity difference of +2% and specificity difference of +6% compared to conventional diagnostic mammography projections, meaning it detects 4 more breast cancers and has 47 fewer false-positive results per 1000 assessments 4
One-view DBT may be adequate when assessing soft-tissue abnormalities seen only on one screening view, with studies showing no cancers would have been missed using only the corresponding DBT view (84% of cancers were seen on the corresponding view) 5
DBT is particularly effective for evaluating masses, asymmetric densities, architectural distortions, and noncalcified lesions, reducing the tissue overlap effect that can mimic breast cancer 1, 3
Concurrent Ultrasound Evaluation
Targeted ultrasound of the area of concern should be performed concurrently with diagnostic mammography to identify potentially benign causes and provide a target for biopsy if indicated 1
Ultrasound helps distinguish between fluid and solid tissue, which mammography alone cannot reliably differentiate 2
What to Order Specifically
Option 1: Traditional Approach
Order: "Diagnostic Mammography" (this automatically includes spot compression and magnification views as clinically indicated by the radiologist)
Option 2: Modern Preferred Approach
Order: "Diagnostic Mammography with Digital Breast Tomosynthesis" 1, 3
Additional Concurrent Order
Order: "Targeted Breast Ultrasound" of the area corresponding to the mammographic abnormality 1
Critical Pitfalls to Avoid
Do not order "screening mammography" for an abnormal finding—this requires diagnostic evaluation with additional views 1
Do not rely on ultrasound alone without mammographic evaluation, as mammography detects microcalcifications and architectural distortion that ultrasound may miss 6
Recognize that "cone compression view" is outdated terminology—the modern equivalent is either spot compression views (included in diagnostic mammography) or DBT, which can replace these traditional views 1, 3
Never dismiss a palpable clinical finding based on negative imaging alone, as up to 10-15% of breast cancers can be mammographically occult 6
Subsequent Management Based on Findings
BI-RADS 1-3 findings: Clinical re-examination in 3-6 months with follow-up imaging every 6-12 months for 1-2 years to assess stability 1
BI-RADS 4-5 findings: Proceed directly to image-guided core needle biopsy (preferred) or needle localization excisional biopsy 1
Developing asymmetry carries the highest suspicion with a positive predictive value of 12.8% at screening and 42.9% when biopsy is recommended, requiring complete workup even without associated calcifications 1