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The Symptomatic Breast
Despite early detection of asymptomatic cancers from screening mammography, the breast radiologist will still frequently encounter women presenting with signs and symptoms of breast cancer. Symptomatic breast malignancies remain widely prevalent due to several factors. The cancer may be occult or missed on screening mammography, the woman may not be of screening age or is not undergoing routine screening, and interval cancers may arise in between scheduled screenings.
Diagnostic breast imaging is always indicated in women with a new concerning breast symptom, such as a palpable abnormality, suspicious nipple discharge, other nipple changes such as inversion/retraction or rash, or unilateral breast swelling. The breast radiologist plays a central role in the management of these symptomatic women, with the workup and diagnosis often fully completed within the breast imaging facility.
Knowledge of the appropriate imaging workup of breast signs and symptoms can help you, the radiologist, better triage the symptomatic woman and more accurately diagnose malignancy.
Palpable Breast Lump
A palpable breast abnormality is the most common presenting breast symptom. A lump may be found on clinical breast examination or self-identified by the patient. While most palpable lumps are benign in etiology, a palpable finding remains the most common symptom of a breast malignancy. Furthermore, palpable breast cancers are often more advanced and aggressive than asymptomatic cancers detected by screening. Therefore, prompt workup and diagnosis upon symptom recognition are critical.
Diagnostic imaging with mammography and/or ultrasound should be used to appropriately and safely triage women with a palpable lump. These two imaging modalities can determine whether the cause of the palpable lump is benign (Breast Imaging Reporting and Data System [BI-RADS] 1 or 2), probably benign (BI-RADS 3), suspicious (BI-RADS 4), or highly suggestive of malignancy (BI-RADS 5). The specific imaging and management algorithm used is outlined in the American College of Radiology (ACR) Appropriateness Criteria and is largely dictated by the patient’s age. Other factors to consider include pregnancy status, lactational status, history of trauma, or suspected infection.
Palpable Lump ≥40 Years Old
For women aged 40 years or older with a palpable breast symptom ( Box 14.1 ), the first step in evaluation is diagnostic mammography with a radiopaque marker placed over the site of palpable concern on full-field views ( Fig. 14.1 ). This consists of craniocaudal and mediolateral oblique views, with additional supplemental views at the discretion of the interpreting radiologist or institutional policy. For conventional two-dimensional mammography, this should be followed by spot compression views at the site of concern with or without magnification. Magnification improves detection and characterization of associated calcifications ( Fig. 14.2 ). Breast tomosynthesis with a tomosynthesis-compatible skin marker may also be utilized. If the patient is due for screening of the contralateral breast or if it is the patient’s baseline mammogram, the contralateral breast should also be imaged. Including both breasts can allow for better detection of asymmetries and is also an opportunity to screen for contralateral asymptomatic cancers ( Fig. 14.3 ).
Box 14.1
Palpable Lump ≥40 Years Old a
a For age 30–39: The same algorithm may be followed. The ACR Appropriateness Criteria states ultrasound may also be the initial step for this age group, at the discretion of the radiologist.
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Start with diagnostic mammography.
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Almost always follow with ultrasound.
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Unless, clearly benign mammographic correlate.
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If only entirely fatty tissue, ultrasound is not mandatory.
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Screening mammography is not a substitute for diagnostic workup.
In nearly all cases, diagnostic mammography should be followed with an ultrasound targeted to the site of clinical concern. The rare exception is when there is a definitively benign mammographic lesion clearly corresponding to the palpable lump, such as a lipoma, hamartoma, fat necrosis, morphologically benign intramammary lymph node, or calcified involuting fibroadenoma ( Figs. 14.4–14.5 ). In addition, the ACR appropriateness criteria states that if there is only entirely fatty tissue at the site of the palpable lump, then ultrasound may not be necessary, although data in this particular scenario is sparse.
In all other scenarios, targeted ultrasound is required. If the mammogram is negative, ultrasound can identify mammographically occult lesions ( Fig. 14.6 ). If there is a suspicious mammographic finding, ultrasound can further characterize the lesion and determine whether ultrasound-guided percutaneous biopsy is feasible.
When both diagnostic mammography and targeted ultrasound are negative with no suspicious correlate to the palpable lump, the negative predictive value is very high (97%–100%). The patient may be reassured of the negative examination with recommendation for clinical follow-up. However, if the clinical breast examination is highly suspicious, palpation-guided percutaneous biopsy should be considered.
Palpable Lump in Women 30 to 39 Years Old
The ACR Appropriateness Criteria advises that for women 30 to 39 years old, either diagnostic mammography or targeted ultrasound may be used as the first step in imaging evaluation of a palpable lump ( Fig. 14.7 ). Ultrasound alone has been shown, in a few studies, to have high sensitivity for detection of malignancy in this age group. Whether to begin with mammography or ultrasound is at the discretion of the radiologist or institutional policy.
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