Diagnostic Mammography with Targeted Ultrasound
For a 40-year-old woman with focal, unilateral breast tenderness in the left lower quadrant, you should order diagnostic mammography (or diagnostic digital breast tomosynthesis) of the left breast PLUS targeted ultrasound of the left breast at the site of pain. 1
Rationale for Combined Imaging in Women ≥40 Years
Mammography should be performed with ultrasound in patients age 40 and older presenting with focal breast pain, as recommended by the American College of Radiology. 1
This patient has focal, unilateral pain (left lower quadrant), which is clinically significant and warrants diagnostic imaging to exclude malignancy, identify treatable benign causes, or provide reassurance. 1
The cancer detection rate in focal breast pain is 2.3% at the site of pain, with both cancers detected in published series visible on both mammography and ultrasound. 1
The negative predictive value of combined mammography and ultrasound for cancer at the site of focal breast pain is 100%, meaning both modalities together effectively rule out malignancy. 1
Why Both Modalities Are Essential
Some cancers presenting with focal pain are only visible mammographically (appearing as microcalcifications), while others are only visible on ultrasound. 1
In the Tumyan study of 86 patients with focal breast pain, 4 cancers were detected (4.6%): 2 at the site of pain visible on both modalities, and 2 incidental cancers presenting as microcalcifications unrelated to the pain site. 1
Ultrasound alone is insufficient in women ≥40 years because it will miss mammographically-occult calcifications and other findings. 1
Mammography alone is insufficient because approximately 20% of focal pain cases are caused by cysts or benign masses best characterized by ultrasound. 1
Specific Ordering Instructions
Order Components:
- Diagnostic mammography with digital breast tomosynthesis (DBT) of the left breast 1
- Targeted ultrasound of the left breast, left lower quadrant 1
Why DBT Over Standard 2D Mammography:
- DBT improves lesion characterization in noncalcified lesions compared to conventional mammographic workup and reduces false-positive findings. 1
- DBT decreases the lesion-masking effect of overlapping tissue, which is particularly valuable in diagnostic settings. 1
- Synthesized 2D images from DBT can replace standard 2D views, maintaining diagnostic performance while potentially reducing radiation exposure. 1
Common Pitfalls to Avoid
Do not order screening mammography – this patient has a symptom requiring diagnostic evaluation, not screening. 1
Do not skip ultrasound – mammography alone will miss benign treatable causes like cysts (found in ~20% of focal pain cases) and some solid masses. 1
Do not order MRI – there are no data suggesting MRI meets risk-benefit or cost-effectiveness criteria for breast pain workup. 1
Do not dismiss the symptom – while most breast pain is benign, focal unilateral pain requires complete evaluation in women ≥40 years. 1
Expected Outcomes and Next Steps
If imaging is negative (BI-RADS 1): Provide reassurance and return to routine screening schedule. 1
If benign findings are identified (BI-RADS 2): Consider cyst aspiration only if a cyst directly correlates with the pain location and is large enough to be clinically significant. 1
If probably benign findings (BI-RADS 3): Short-interval follow-up imaging at 6 months. 1
If suspicious findings (BI-RADS 4-5): Proceed to image-guided core needle biopsy. 1
Age-Specific Context
This recommendation specifically applies because the patient is 40 years old. The ACR guidelines clearly state that for women in the 30-39 age group, adding mammography "may be appropriate," but for women 40 and older, mammography should be performed with ultrasound. 1 This reflects the higher baseline breast cancer risk in women ≥40 years and the increased likelihood that screening-age women may have mammographically-visible findings. 1