I discovered a palpable breast lump; should I obtain imaging first or refer directly to a breast surgeon?

Obtain Imaging First—Do Not Refer Directly to Surgery

For a palpable breast lump, you should obtain appropriate imaging before referring to a breast surgeon, because biopsy or surgical evaluation performed before imaging will create hematoma and architectural distortion that obscures subsequent image interpretation and limits diagnostic accuracy. 1, 2

---

Age-Based Imaging Algorithm

Women ≥40 Years

• Start with bilateral diagnostic mammography (with a radio-opaque marker placed over the palpable area), followed immediately by targeted breast ultrasound of the affected area. 1, 2
• This combined approach provides a negative predictive value >97% when both studies are benign. 2
• Mammography detects 86–91% of breast cancers in this age group, but ultrasound must still be performed regardless of mammography results because ultrasound identifies 93–100% of cancers that are occult on mammography. 1, 2

Women 30–39 Years

• Either diagnostic mammography or targeted ultrasound is acceptable as the initial study, based on clinical suspicion. 2
• Ultrasound sensitivity (95%) exceeds mammography sensitivity (61%) in this age group, making ultrasound a reasonable first choice. 2
• If ultrasound detects a suspicious mass, obtain bilateral diagnostic mammography before proceeding to biopsy. 2

Women <30 Years

• Proceed directly to targeted breast ultrasound as the initial study—do not order mammography first. 1, 2
• Breast cancer incidence is <1% in this population, and avoiding radiation exposure is paramount. 1, 2
• Reserve mammography only for cases where ultrasound shows suspicious findings or the clinical examination is highly concerning. 2

Pregnant or Lactating Women

• Begin with targeted breast ultrasound regardless of age, because increased breast density limits mammographic evaluation. 1
• Mammography is not contraindicated during pregnancy or lactation and should be performed if malignancy is suspected, as it demonstrates 90–100% sensitivity for detecting malignancy (particularly microcalcifications and architectural distortion). 1

---

Management Based on Imaging Results

BI-RADS 1–2 (Negative or Clearly Benign)

• Return to routine clinical follow-up only—no further imaging or biopsy is required when a definitive benign correlate is identified (simple cyst, lipoma, benign lymph node, hamartoma). 2

BI-RADS 3 (Probably Benign)

• Schedule short-interval follow-up with physical examination ± imaging every 6–12 months for 1–2 years. 2
• Exception: Proceed directly to core-needle biopsy in high-risk patients (BRCA mutation carriers, strong family history, organ transplant candidates, known synchronous cancers, or extreme anxiety). 2

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

• Perform image-guided core-needle biopsy immediately—this is superior to fine-needle aspiration for sensitivity, specificity, and correct histologic grading. 1, 2, 3
• Ultrasound-guided biopsy is preferred when the lesion is visible on both mammography and ultrasound due to patient comfort, efficiency, absence of radiation, and real-time needle visualization. 3

Negative Imaging but Clinically Suspicious Examination

• A suspicious physical examination should prompt palpation-guided biopsy regardless of negative imaging findings. 1, 2
• Physical examination findings must not be overridden by imaging alone. 2

---

When to Refer to a Breast Surgeon

Refer after imaging is complete and shows:

• Suspicious findings requiring biopsy (BI-RADS 4–5). 2
• Confirmed malignancy on core biopsy. 2
• Discordance between imaging, biopsy results, and clinical findings. 2

Do not refer if imaging shows clearly benign features (simple cyst, benign lymph node, lipoma, hamartoma)—these require only clinical follow-up. 2

---

Critical Pitfalls to Avoid

• Never perform biopsy before completing all imaging, as biopsy-related changes (hematoma, architectural distortion) will obscure subsequent image interpretation. 1, 2, 3
• Do not order MRI, PET, FDG-PEM, or molecular breast imaging as the initial evaluation—these modalities have no role in the routine workup of a palpable mass. 1, 2
• Do not rely on mammography alone—ultrasound must be performed even when mammography appears reassuring. 1, 2
• Do not delay imaging evaluation—observation without imaging is unacceptable for women ≥30 years. 2
• Do not assume benignity based on absence of symptoms—even benign-appearing lesions on ultrasound (parallel orientation, circumscribed margins, posterior acoustic enhancement) can represent malignancy in pregnant or lactating women. 1