What is the initial work‑up for a newly discovered breast mass?

Initial Work-Up for a Breast Mass

For women ≥30 years: begin with bilateral diagnostic mammography plus targeted ultrasound; for women <30 years: proceed directly to targeted ultrasound, reserving mammography only for highly suspicious findings. 1, 2

Age-Based Initial Imaging Strategy

Women ≥30 Years of Age

• Start with bilateral diagnostic mammography with a radio-opaque marker placed over the palpable finding 1, 2
• Follow immediately with targeted ultrasound regardless of mammography results, as ultrasound detects 93-100% of cancers that are mammographically occult 2, 3
• The combined negative predictive value of mammography and ultrasound exceeds 97% when both are benign 2
• Never rely on mammography alone to determine biopsy necessity 2

Women <30 Years of Age

• Proceed directly to targeted ultrasound as the initial study 1, 2
• Breast cancer incidence is <1% in this population, making radiation exposure from mammography unjustified 2
• Consider diagnostic mammography only if ultrasound shows suspicious findings OR clinical examination is highly suspicious for malignancy 1, 2
• Observation for 1-2 menstrual cycles is acceptable for low clinical suspicion cases, but if the mass increases or suspicion rises, proceed with imaging 1

Women 30-39 Years of Age (Intermediate Group)

• Either ultrasound or diagnostic mammography is appropriate as the initial approach, depending on clinical suspicion 1, 2
• Recent evidence suggests mammography may be omitted if ultrasound demonstrates clearly benign features, as no incidental malignancies were detected by mammography in this age group in a 16-year study 4

Critical Pre-Imaging Rule

Never perform biopsy before imaging — biopsy-related changes will confuse, alter, and obscure subsequent image interpretation 2

BI-RADS Classification and Management

BI-RADS 1-3 (Negative, Benign, or Probably Benign)

• If imaging shows BI-RADS 1-2 with definitive benign correlate (simple cyst, lipoma, lymph node): return to routine screening, no further workup needed 1, 3
• If imaging shows BI-RADS 3 (probably benign): short-interval follow-up with physical examination ± imaging every 6-12 months for 1-2 years 1, 3
• Exception: If clinical suspicion remains high despite benign imaging, proceed to core needle biopsy 1, 2
• Geographic correlation is essential — if imaging findings do not correlate with the palpable finding, further workup is required 1

BI-RADS 4-5 (Suspicious or Highly Suggestive of Malignancy)

• Proceed immediately to image-guided core needle biopsy (strongly preferred over fine-needle aspiration) 1, 3
• Ultrasound-guided biopsy is preferred when the lesion is visible on ultrasound, offering real-time visualization without radiation 3
• Obtain at least 2-3 cores from each suspicious lesion 3
• Concordance verification is mandatory: pathology results must match imaging findings and clinical examination 1, 3
• Discordant results require additional tissue sampling or surgical excision 1, 3

Special Clinical Scenarios

Skin Changes or Erythema

• If erythema, peau d'orange, or nipple changes are present, consider inflammatory breast cancer or Paget's disease 1
• Obtain bilateral diagnostic mammography ± ultrasound first 1
• Perform punch biopsy of skin or nipple after imaging, regardless of imaging results 1
• Do not delay diagnostic evaluation with antibiotics unless infection is highly suspected 1

Negative Imaging with Persistent Clinical Suspicion

• If both mammography and ultrasound are negative but clinical examination remains highly suspicious, tissue sampling is warranted 2, 3
• Physical examination alone is unreliable — even experienced examiners show only 73% agreement on biopsy necessity among proven malignancies 2

Common Pitfalls to Avoid

• Do not order MRI, PET, or molecular breast imaging as initial evaluation — these have no role in the workup of a palpable mass 2
• Do not delay imaging evaluation — observation without imaging is not acceptable for women ≥30 years 1
• Do not assume oval-shaped lesions are benign without complete characterization 3
• Do not delay biopsy of BI-RADS 4-5 lesions while pursuing additional imaging 3

Post-Biopsy Management

• Benign concordant results: physical examination every 6-12 months for 1-2 years, then return to routine screening if stable 1
• Indeterminate pathology (atypical hyperplasia, LCIS, papillary lesions, radial scars, phyllodes tumor): surgical excision is typically required 1
• Malignant results: immediate referral for treatment per breast cancer guidelines 1, 3