Diagnostic Approach for Chest Lump Above Right Breast in Elderly Patient
Begin with diagnostic mammography or digital breast tomosynthesis (DBT) as the initial imaging study, followed immediately by targeted ultrasound regardless of mammography results, and proceed to image-guided core biopsy if any suspicious features are identified. 1
Initial Imaging Strategy
Perform diagnostic mammography first with standard mediolateral oblique and craniocaudal views of both breasts, placing a radio-opaque marker directly over the palpable finding to ensure accurate correlation. 1
Follow mammography with targeted breast ultrasound in all cases, even if mammography appears normal or benign, because ultrasound detects 93-100% of cancers that are occult on mammography. 2, 1
The combined negative predictive value of mammography and ultrasound exceeds 97% when both modalities show benign or negative findings. 2
Interpretation and Next Steps Based on Findings
If Imaging Shows Clearly Benign Features
Return to clinical follow-up only if mammography demonstrates a definite benign mass (lymph node, hamartoma, lipoma, calcified fibroadenoma, or oil cyst) that unequivocally correlates with the palpable finding. 2
No short-interval imaging follow-up or tissue sampling is needed when benign features are definitively established. 2
Ultrasound is not necessary if mammography shows fatty tissue alone in the palpable region, unless correlation is uncertain. 2
If Imaging Shows Suspicious Features
Proceed directly to image-guided core biopsy rather than fine-needle aspiration, as core biopsy is superior in sensitivity, specificity, and correct histological grading. 1, 3
Ultrasound guidance is preferred over stereotactic guidance when the lesion is visible on both modalities, due to patient comfort, efficiency, absence of ionizing radiation, and real-time needle visualization. 2, 3
If Imaging Shows Probably Benign Features (BI-RADS 3)
Short-interval imaging follow-up is appropriate for solid masses with benign sonographic features (oval/round shape, well-defined margins, homogeneous echogenicity, parallel orientation) when mammography and clinical examination also suggest benignity. 2
Consider immediate biopsy instead of follow-up in elderly patients with high-risk factors, those awaiting organ transplant, those with known synchronous cancers, or when biopsy would alleviate extreme anxiety. 2
Biopsy is mandatory if the mass is new on imaging or increasing >20% in volume or diameter over 6 months. 2
Critical Pitfalls to Avoid
Never perform biopsy before completing imaging, as biopsy-related changes will confuse, alter, and limit subsequent image interpretation. 1, 3
Do not order MRI, PET, or molecular breast imaging as part of the initial evaluation—these modalities have no role in the workup of a palpable breast mass. 2, 1
Never rely on mammography alone to determine whether biopsy is needed—ultrasound must also be performed. 1
Do not dismiss a clinically suspicious examination even when imaging is negative or benign—physical examination findings indicating high suspicion should prompt biopsy regardless of imaging results. 2
Special Considerations for Elderly Patients
Mammography sensitivity for detecting breast cancer in women ≥40 years is 86-91%, making it the appropriate first-line imaging modality in this age group. 2, 1
The location "above the breast" may represent breast tissue extending into the upper chest, an axillary tail mass, or a lymph node—targeted ultrasound will clarify the anatomic origin. 3
Consider the patient's overall health status and life expectancy when deciding between immediate biopsy versus short-interval follow-up for probably benign lesions. 2