What diagnostic testing can be offered to a 24-year-old female presenting with a complaint of a breast lump (mass)?

Breast Ultrasound as Initial Imaging

For a 24-year-old female with a breast lump, offer targeted breast ultrasound as the initial and primary imaging test. 1, 2, 3

Age-Specific Imaging Algorithm

• Women <30 years: Start with ultrasound alone 1, 2, 3

  • Breast cancer incidence is <1% in this age group 2, 3
  • Ultrasound detects 93-100% of cancers and has a negative predictive value of 97.4-100% 2, 3
  • Avoids unnecessary radiation exposure in low-risk population 2, 3
  • Most benign lesions in young women are not visualized on mammography 1

• Women 30-39 years: Either ultrasound OR diagnostic mammography acceptable 1

  • Ultrasound sensitivity (95.7%) exceeds mammography (60.9%) in this age group 1

• Women ≥40 years: Start with diagnostic mammography, then ultrasound 1, 2

Critical Workflow Principles

Never perform biopsy before imaging 2, 3

• Biopsy-related changes will confuse, alter, obscure, and limit subsequent image interpretation 2, 3
• Complete imaging workup must be done prior to any tissue sampling 1

Correlation between imaging and palpable finding is essential 1

• Place a radio-opaque marker over the palpable area during imaging 2
• Physical examination alone is unreliable—even experienced examiners show only 73% agreement on biopsy decisions for proven malignancies 2

Next Steps Based on Ultrasound Findings

If Ultrasound Shows Suspicious Features (BI-RADS 4-5):

• Proceed to image-guided core biopsy (not fine-needle aspiration) 1, 2, 3
• Core biopsy is superior in sensitivity, specificity, and correct histological grading 2, 3
• Consider adding diagnostic mammography to evaluate disease extent 3

If Ultrasound Shows Probably Benign Features (BI-RADS 3):

• Short-interval follow-up ultrasound at 6 months 1

If Ultrasound Shows Clearly Benign Features:

• Return to clinical follow-up only 2, 3
• No further imaging or biopsy needed 2, 3

If Ultrasound is Negative but Clinical Suspicion Remains High:

• Consider diagnostic mammography even in women <30 years 1
• Never dismiss a persistent, suspicious palpable finding based on negative imaging alone 3

What NOT to Offer

Do not order these as initial tests: 1, 2, 3

• MRI (with or without contrast)
• PET or FDG-PEM
• Molecular breast imaging (Tc-99m sestamibi MBI)
• Digital breast tomosynthesis as standalone initial test
• Image-guided biopsy without imaging characterization first

Common Pitfalls to Avoid

• Don't skip ultrasound after mammography in women ≥40 years—ultrasound must still be performed regardless of mammography results 2
• Don't delay imaging if the mass persists through a complete menstrual cycle 3
• Don't rely on physical examination characteristics to determine benignity—imaging is mandatory 3, 4
• Don't use screening mammography—only diagnostic mammography with targeted views is appropriate 2, 5