In the presence of breast symptoms such as a palpable lump, blood stained nipple discharge, breast pain that requires investigation, mammography is used in the investigation of women aged 30 years or more, with the addition of ultrasound when indicated.
Mammography is not indicated as the first investigation for the majority of patients aged < 30 years.
Ultrasound is the imaging method of choice for the majority of women aged 30 years or less, and during pregnancy and lactation. However Mammography should be carried out in all patients with proven malignancy or a worrying appearance on ultrasound or clinical examination even if aged < 30years.
Breast pain that needs investigation is often a nonspecific breast symptom. In symptomatic women less than 30 years of age, Ultrasound is more accurate in making a diagnosis than mammography, and hence ultrasound is recommended as the first investigation.
In the 30- to 39-year-old age group, adding unilateral or bilateral mammography may be appropriate, because some of the small cancers found at the site of pain as reported in several studies were only visible mammographically. Mammography may also be indicated in patients under the age of 30 if a suspicious lesion is found on the initial Ultrasound examination, or if the patient’s history or risk status justifies the
Above the age of 40 years, mammography is recommended as the first investigation, followed by ultrasound, if required.
In women presenting with a lump, diagnostic mammography is recommended as the initial investigation, if age is 30 years or more.
Ultrasonography is more sensitive than mammography in detecting lesions in women with dense breasts, and it is the preferred imaging modality in women younger than 30 years with a palpable breast mass .
If ultrasound identifies a suspicious lesion,mammography is advised for the under 30 years age group also.
There are other guidelines which advise a cut off age of 40 years or 35 years, for performing mammography in ladies presenting with breast symptoms .
Given the early onset of breast cancer in India, and given that the Indian data we have is mostly from symptomatic women (rather than cancer picked up at breast screening), a lower cut off age of 30 years has been deemed appropriate for women with symptoms in our country.
COMMON BREAST SYMPTOMS
Common breast symptoms include breast lump, pain, nipple discharge, inflammation; either alone or in combination.
Breast imaging performed in this group of patients is called diagnostic breast imaging.
Purpose of clinical and imaging evaluation is to determine the cause of symptoms so that appropriate treatment can be given and secondly, to determine if the symptom is caused by underlying breast cancer.
Accordingly, evaluation of patient with any breast symptom should begin with detailed history and good clinical breast examination (CBE).
Breast lump is the most common breast symptom. Although most breast lumps are benign, it is alsothe most worrisome complaint as it the most common presentation of a breast cancer.All patients presenting with breast lump should undergo Triple assessment . It is a combination ofclinical breast examination, imaging test and pathological test. It is a standard and accurate methodto diagnose breast cancer in symptomatic breast .
Up to 30 years of age ultrasound of both breasts is the primary modality.Mammogram in this age group is performed only if there is strong clinical suspicion of breast cancer.If age is more than 30 years, then both mammography and ultrasound of both breasts arerecommended .
Further management is according to imaging results as follows
Simple cyst or Complicated cyst
with debris, thin septation etc (BIRADS 2)
No further imaging. Cyst may or may not be aspirated if not responsible for symptoms. If aspirated, fluid cytology is not required. No imaging follow-up is recommended.
(having suspicious solid component) – image guided aspiration and core biopsy.However, excision of the cyst and histopathology is preferred.
Solid benign mass (BIRADS 3)
Imaging follow-up only. Ultrasound guided core biopsy if there is a high risk factor or clinical suspicion for cancer or already diagnosed cancer in same or contralateral breast.
Suspicious mass (BIRADS 4 or 5)
Image guided core biopsy.
No further evaluation if typically benign. All calcifications which are not typically benign must be subjected to core biopsy. Specimen mammography of harvested cores is recommended to establish retrieval of calcification in harvested cores .
For BIRADS 4 lesions, if biopsy result is benign, then follow-up ultrasound and mammogram after 6 months.
If biopsy result is malignant then appropriate treatment.
If biopsy result is inconclusive (equivocal or atypia) then re-biopsy, preferably vacuum assisted biopsy is recommended .
For BIRADS 5 lesions, re-biopsy is must if histopathology result is not malignant on initial biopsy.
Mass on Clinical Breast Examination (CBE) but negative imaging
Palpation guided biopsy.
No mass on CBE as well on imaging
No further imaging. Follow-up with CBE may be considered
BREAST PAIN (MASTALGIA) AND MASTITIS
Mastalgia alone is generally not a feature of breast cancer. It may be due to aberrant response of breast tissue to the hormonal variations, especially if it is cyclic, bilateral and associated with vague nodularity of the breast.
Other causes may include infection, trauma and some drugs(spironolactone, Digoxin, haloperidol etc).
Age of the patient, history and CBE will guide the imaging protocol.
No imaging is required if pain is bilateral or diffuse, cyclic and CBE is normal.
If breast pain or tenderness is focal or associated with mass, then imaging is required.