Mammography is the gold standard test for the diagnosis of breast lumps in women aged >40 years old. Ultrasound is the gold standard test for the diagnosis of breast lumps in women aged <40 years old. Management and medical therapy of breast lumps depends on women’s age (age> 40 or age <40) and mammography results in women aged > 40 years. In women aged > 40 years; no further evaluation is needed in case of clearly benign mass in mammography; however, ultrasound imaging is required for the rest of the findings mammography. Approach to breast lumps in women >40 years is depended on breast imaging reporting and data systems (BI-RADS) stages. Medical therapy of breast lumps in women< 40 years is depended on ultrasound results and BI-RADS categories.

Mammography is the gold standard test for the diagnosis of breast lumps in women aged >40 years old.^[1]

• If the patient had positive history of bilateral mammography within past 6 months, only ipsilateral mammography is needed.

Ultrasound is the gold standard test for the diagnosis of breast lumps in women aged <40 years old.^[1]

The comparison of various diagnostic studies for breast lumps:^[2]

Breast ultrasound has higher sensitivity and mammography has higher specificity. The accuracy of ultrasound reported as 84% and accuracy of mammography reported as 81% .^[2]

Diagnostic approach for breast lump:

• Women aged >40 years with palpable mass:^[3]
  • Diagnostic mammography is considered as the first step.
  • If the last screening test is related to more than previous 6 months, both breast mammography is required to rule out occult malignancy.
  • No further evaluation is needed in case of clearly benign mass in mammography.
  • Ultrasound imaging is required for the rest of cases appeared in mammography.
    • Stereotactic biopsy is recommended in negative ultrasound findings addition to suspicious mammographic results.
• Women aged< 40 years with palpable mass:^[1][4]
  • Ultrasound or mammography is suggested for initial management of women aged between 30 to 39 years.
  • Ultrasound is the first step for women < 30 years presenting with palpable mass.

Approach to breast lumps in women aged > 40 years based on mammographic results:^[3]

• If mammographic results become negative, the next step is targeted ultrasound.
  • Negative ultrasound results considered as breast imaging reporting and data system (BI-RADS) 1, then clinical follow-up is needed.
  • Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is needed.
  • Probably benign results considered as BI-RADS 3, then ultrasound short interval follow-up is needed.
  • Suspicious ultrasound results considered as BI-RADS 4 or 5, then core-needle biopsy is needed.
• If mammographic results show only fatty tissue:
  • Considered as BI-RADS 1, then clinical follow-up is needed.
• If mammographic results show benign mass:
  • Considered as BI-RADS 2, then clinical follow-up
• If mammographic results are in favor of probably benign lumps, the next step is targeted ultrasound.
  • Negative ultrasound results considered as BI-RADS 3, then mammographic short interval follow-up is required.
  • Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is required.
  • Probably benign ultrasound results considered as BI-RADS 3, then ultrasound short interval follow-up.
  • Suspicious ultrasound results is considered as BI-RADS 4 or 5, then core needle biopsy is required.
• If mammographic result is in favor of suspicious lesion, the next step is ultrasound to determine biopsy plan.
  • Considered as BI-RADS 4 or 5, then core needle biopsy is required.

Approach to breast lumps in women aged <40 years based on targeted ultrasound findings:^[3]

• If ultrasound results become negative, there are two approaches:
  • Considered as BI-RADS 1, then clinical follow-up is required ( if no palpable dominant suspicious mass found at clinical examination)
  • Perform diagnostic mammography:
    • Negative results are in favor of BI-RADS 1, then clinical follow-up is required.
    • Benign results are considered as BI-RADS 2, then clinical follow-up is required.
    • Probably benign results considered as BI-RADS 3, Mammographic short interval follow-up is required.
    • Suspicious results considered as BI-RADS 4 or 5, then core needle biopsy is required.
• If ultrasound results show benign findings:
  • Considered as BI-RADS 2, then clinical follow-up is required.
• If ultrasound results show probably benign findings:
  • Considered as BI-RADS 3, then short interval follow-up is required.
• If ultrasound results become suspicious:
  • Considered as BI-RADS 4 or 5, then core needle biopsy is required.

For more information on breast imaging reporting and data system (BI-RADS) system, click here.

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