Management of Palpable Abnormalities in the Breast Katerina Dodelzon, MD July 31, 2018, 7:00pm ET

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1 Management of Palpable Abnormalities in the Breast Katerina Dodelzon, MD July 31, 2018, 7:00pm ET SAM Questions year old female presenting with left breast palpable mass, what is the most appropriate initial imaging evaluation? A. Unilateral left mammogram B. Bilateral diagnostic mammogram C. Left breast ultrasound D. Bilateral screening mammogram E. MRI Rationale: Due to a low incidence of breast malignancy in women younger than 30 { < 1%}, ( 1) and the fact that most benign breast lesions in young women are not visualized on mammography (2 4), ultrasound is the main modality for initial imaging assessment of a palpable mass in women 30 years of age or younger. In several series the sensitivity of an ultrasound in symptomatic women younger than 40 was % and NPV of 100% (5 7). References: Anders CK, Johnson R, Litton J, Phillips M, Bleyer A. Breast Cancer Before Age 40 Years. Seminars in oncology. 2009;36(3): doi: /j.seminoncol Ciatto S, Bravetti P, Bonardi R, Rosselli del Turco M. The role of mammography in women under 30. Radiol Med. 1990;80(5): Feig SA. Breast masses. Mammographic and sonographic evaluation. Radiol Clin North Am. 1992;30(1): Harris VJ, Jackson VP. Indications for breast imaging in women under age 35 years. Radiology. 1989;172(2):

2 Loving VA, DeMartini Wb, Eby PR, Gutierrez RL, Peacock S, Lehman CD. Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol Dec;195(6): doi: /AJR Lehman CD, Lee CI, Loving VA, Portillo MS, Peacock S, DeMartini WB. Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women years of age. AJR 2012; 199: palpable and nonpalpable breast cancer in women aged 30 to 39 years. Breast Cancer 2007; year old woman presented with a palpable left breast abnormality. Targeted ultrasound demonstrated an irregular, poorly circumscribed, not parallel mass correlating to palpable area of concern. What is the most appropriate BIRADS and further recommendations? A. BIRADS 3, 6 months follow up ultrasound B. BIRADS 2, clinical correlation C. BIRADS 4, Diagnostic bilateral mammogram and biopsy D. BIRADS 3, 6 months clinical follow up Rationale: The above described sonographic features denote a higher risk of malignancy than 2%, therefore short interval follow up would not be appropriate and tissue sampling is recommended (1). Although it would not obviate the need for tissue sampling, given suspicion of malignancy, it is prudent to perform a bilateral diagnostic mammogram to evaluate for extent and additional ipsilateral and contralateral disease (2,3). References: Mendelson EB, Böhm Vélez M, Berg WA, et al. ACR BI RADS Atlas, Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; ACR BIRADS Ultrasound. Ciatto S, Bravetti P, Bonardi R, Rosselli del Turco M. The role of mammography in women under 30. Radiol Med. 1990;80(5): Appleton Dc, Hackeny L, Narayanan S., Ultrasonography alone for diagnosis of breast cancer in women under 40, Ann R Coll surg Engl 2014 Apr; 96 (3):202 6.

3 3. 25 year old presenting with right breast palpable area of concern. Ultrasound was performed and demonstrated no sonographic correlate for palpable area of concern. BIRADS and recommendations? A. BIRADS 3, follow up ultrasound in 6 months B. BIRADS 0, diagnostic mammogram C. BIRADS 1, diagnostic mammogram D. BIRADS 1, clinical correlation Answer: D Rationale: Unless the clinical findings are suspicious no further evaluation with imaging is warranted given the high sensitivity of sonography for palpable masses in young women (1 3). Clinical correlation is always recommended. In the setting of clinical findings highly suspicious for malignancy without an imaging correlate, biopsy under palpation can be performed (4). References: Loving VA, DeMartini Wb, Eby PR, Gutierrez RL, Peacock S, Lehman CD. Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications. AJR Am J Roentgenol Dec;195(6): doi: /AJR Lehman CD, Lee CI, Loving VA, Portillo MS, Peacock S, DeMartini WB. Accuracy and value of breast ultrasound for primary imaging evaluation of symptomatic women years of age. AJR 2012; 199: palpable and nonpalpable breast cancer in women aged 30 to 39 years. Breast Cancer 2007; Moy L, Heller SL, Bailey L, et al. ACR Appropriateness Criteria Palpable Breast Masses Journal of the American College of Radiology, Volume 14, Issue 5, S203 S year old female with left breast palpable area of concern. Initial evaluation? A. Ultrasound B. Diagnostic mammogram C. Either ultrasound or diagnostic mammogram D. MRI Rationale: Either diagnostic mammography or US can be used as initial means of image evaluation for women ages with a palpable mass and is at the discretion of the radiologist or referring clinician. The incidence of breast cancer remains low, and series demonstrate high

4 sensitivity ( 96%) and NPV ( 100%) of ultrasound with little added value from adjunct mammography ( 1 4), with one study demonstrating higher sensitivity of US compared with mammography in this age group ( 95.7% versus 60.9%), with similar specificity ( 89.2% and 94.4%, respectively) ( 1). References: Lehman CD, Lee CI, Loving VA, Portillo MS, Peacock S, DeMartini WB. Accuracy and value ofbreast ultrasound for primary imaging evaluation of symptomatic women years of age. AJR 2012; 199: Georgian Smith D, Taylor KJ, Madjar H, et al.sonography of palpable breast cancer. J Clin Ultrasound 2000; 28: palpable and nonpalpable breast cancer in women aged 30to 39 years. Breast Cancer 2007; Rahbar G, Sie AC, Hansen GC, et al. Benign versus malignant solid breast masses: US differentiation. Radiology 1999; 213: year old presented with left breast palpable mass. Mammogram was performed first and revealed no abnormalities and no mammographic correlate for palpable area of concern. What is the BIRADS and next step? A. BIRADS 1, clinical correlation B. BIRADS 1, return to screening C. BIRADS 3, short term follow up mammogram D. BIRADS 1, targeted ultrasound Answer: D Rationale: The addition of sonography detects % of cancers that are occult on mammography ( 1 4), and has been shown to be superior in detection of benign palpable findings. In one series, 40% of benign palpable masses were seen only on sonography (5). Negative predictive value of combined mammogram and ultrasound for evaluation of palpable abnormality is > 97% ( 1, 3, 6). Therefore, in a female older than 30 years of age a targeted ultrasound should be performed in the setting of a negative mammogram evaluating palpable abnormality. References: Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology. 2002;225(1):

5 Shetty MK, Shah YP. Prospective evaluation of the value of negative sonographic and mammographic findings in patients with palpable abnormalities of the breast. J Ultrasound Med. 2002;21(11): Soo MS, Rosen EL, Baker JA, Vo TT, Boyd BA. Negative predictive value of sonography with mammography in patients with palpable breast lesions. AJR Am J Roentgenol. 2001;177(5): Murphy IG, Dillon MF, Doherty AO, et al. Analysis of patients with false negative mammography and symptomatic breast carcinoma. J Surg Oncol. 2007;96(6): Shetty MK, Shah YP, Sharman RS. Prospective evaluation of the value of combined mammographic and sonographic assessment in patients with palpable abnormalities of the breast. J Ultrasound Med. 2003;22(3): Gumus H, Gumus M, Mills P, et al. Clinically palpable breast abnormalities with normal imaging: is clinically guided biopsy still required? Clin Radiol. 2012;67(5):