ESSENTIALS OF DIAGNOSIS
Prompt diagnostic imaging is essential for any woman with a palpable dominant breast mass, regardless of her age.
Ultrasound is the initial test of choice for women under the age of 30.
In women between the ages of 30 and 39, ultrasound is the preferred initial imaging modality, although diagnostic mammography or digital breast tomosynthesis (DBT) may be considered in the setting of a concerning clinical exam or significant risk factors.
In women over the age of 40, diagnostic mammography with or without ultrasonography or DBT are the preferred imaging modalities.
Palpable breast masses may be detected by a patient during breast self-examination or may be identified by the provider during a routine physical examination. A breast mass may be a presenting symptom of breast cancer, and thus a thorough work-up of any palpable breast mass is essential, regardless of age and personal risk factors for breast cancer (see Chapter 17-07). Benign causes of palpable breast masses include fibroadenomas, cysts, and hamartomas.
Clinicians should ask patients about temporal changes in the mass shape and size, as well as associated symptoms, including pain, skin thickening, and nipple discharge. A patient’s personal risk for breast cancer should be assessed, including age, previous breast biopsies, family history, and age at menarche and first pregnancy.
The location of the mass should be described using the clock-face position and distance from the nipple, as this aids the radiologist in the diagnostic evaluation. Clinicians should note the size, site, mobility, and texture of the mass, as well as areas of skin dimpling, retraction, or erythema. A thorough examination of the axillary and supraclavicular lymph node areas is essential. Some women may have areas of indeterminate thickening in the absence of a discrete and well-defined palpable mass; if this finding is asymmetric, it should be evaluated further with diagnostic imaging.
B. Diagnostic Tests and Imaging
As noted above, all women with a dominant palpable breast mass require diagnostic imaging. Approved imaging techniques include diagnostic mammography, DBT, and ultrasonography. Diagnostic mammography consists of the standard views that are used in screening mammography plus additional views, such as spot-compression and magnification, to better delineate the area of concern. Unlike in screening mammography, diagnostic radiologists are typically present in real time during diagnostic mammography to guide the need for additional views. DBT provides a three-dimensional view of the breast and may be used in place of diagnostic mammography in centers that offer this imaging technique. The breast ultrasound is the most sensitive test for distinguishing a cystic from a solid lesion and also provides detailed information regarding the shape, borders, and acoustic properties of an identified mass. In addition, ultrasonography can be used to guide the biopsy of suspicious lesions.