Breast Screening and Imaging Appropriateness Criteria
On this page you will find best practice breast screening and imaging appropriateness criteria for the following:
Palpable Breast Lumps
Most palpable breast lumps are benign, but a new palpable breast mass is a common presenting sign of breast cancer. Imaging evaluation is necessary in almost all cases to characterize the palpable lesion. Recommended imaging options include diagnostic mammography and targeted breast ultrasound (US), and are dependent on patient age and degree of radiologic suspicion. Any highly suspicious mass detected by imaging or palpation should undergo image-guided core biopsy (US guided, stereotactic, or digital breast tomosynthesis guided) unless contraindicated.
Diagnostic Mammography and Digital Breast Tomosynthesis
Diagnostic mammography (DM) is indicated for women age 30 and over who are presenting with a palpable lump. If a clearly benign correlate for a palpable finding (oil cyst, lipoma, etc.) can be identified on DM, this modality alone may be sufficient, and clinical follow-up would be appropriate. If DM is negative or an imaging correlate is identified that is not clearly benign, targeted ultrasound (US) directed to the palpable finding should be performed. Digital breast tomosynthesis is can improve address some of the limitations encountered with standard DM views. DM or digital breast tomosynthesis may also be helpful in women ages 30 to 39 with palpable lumps and in women younger than 30 with palpable lumps and suspicious findings on US.
Ultrasound (US) is recommended as the first-line investigation for a palpable lump in women under age 30, and in pregnant and lactating women. In the event of a suspicious finding on ultrasound, digital Mammography is warranted even in younger women in order to better delineate disease and identify features of malignancy that may be seen on digital mammography alone. US is also an essential next step in evaluating women ≥30 years with a palpable mass and either a negative mammogram or a finding not unequivocally characterized as benign on mammogram.
Palpable Breast Lumps Summary Recommendations
- Women age 30 and over: DM initially, followed by targeted US.
- Suspicious or negative findings → US
- Probably benign findings → US or mammography/digital breast tomosynthesis short interval follow-up
- Women age 30-39: DM and targeted US → next steps as above.
- Women younger than 30, pregnant or lactating → US initially. Suspicious findings → biopsy > diagnostic mammography
- Probably benign findings → US or DM short term follow-up
- Negative findings → clinical follow up, DM or digital breast tomosynthesis rarely helpful
- Any highly suspicious breast mass detected by imaging should have core biopsy, whether or not it is a palpable finding.
- Any highly suspicious breast mass detected by palpation should be biopsied, irrespective of imaging findings.
Nonpalpable Mammographic Findings
Screening mammography allows the detection of early, clinically occult cancers. Most lesions detected on screening mammograms are benign. Lesions that are concerning include masses, focal asymmetries, architectural distortions, and some types of calcifications. Diagnostic mammography (DM) and/or ultrasound (US) is necessary for further evaluation.
Ultrasound (US) can be used to differentiate cystic from solid masses. Round or oval masses can be further investigated with US for more characterization. US is not required for evaluation of suspicious or likely malignant mammographic findings. US can also evaluate architectural distortions found on mammography. Negative US evaluation of suspicious mammographic findings should not dissuade the decision to biopsy.
MRI evaluation of nonpalpable noncalcified mammographic lesions is controversial and should not be used when established methods can confidently evaluate a finding.
Final assessment of mammographically detected suspicious lesions should be assigned according to the ACR Breast Imaging, Reporting and Data System (BI-RADS) Atlas. If a lesion is a BI-RADS category 4 or 5, a percutaneous core biopsy is warranted, with either mammographic or US guidance. Percutaneous biopsy should be done to shorten the diagnostic process and/or provide a more cost-effective method of diagnosis as compared with excisional biopsy. Percutaneous biopsy of suspicious lesions can provide accurate tissue diagnosis at decreased cost, precluding the need for surgery in specific benign cases and allowing definitive, single-stage surgical treatment in cases that are as malignant.
Nonpalpable Mammographic Summary Recommendations
- Architectural distortion seen on screening mammogram → DM, US as needed
- Mass (indistinct, obscured or microlobulated margins) seen on screening mammogram → DM and then US
- Mass (circumscribed without suspicious features) seen on screening mammogram → US (DM may also be needed)
- Multiple bilateral nonsuspicious masses seen on screening mammogram → Return to screening mammography
- Multiple bilateral masses seen on screening mammogram with dominant or suspicious mass → DM and US
- Focal asymmetry or asymmetry (single-view finding) seen on screening mammogram → DM, possibly with US
- Grouped calcifications → DM with magnification views
Breast pain or tenderness occurs in 70 to 80 percent of women during their lifetime. It is not a common symptom of underlying malignancy. Breast imaging often provides reassurance if negative, but it may also lead to further clinical and imaging evaluation. Nevertheless, a persistent or focal area of pain or tenderness is an indication for imaging according to the American College of Radiology (ACR) practice guidelines. Imaging recommendations under these circumstances focus on non-high-risk patients assumed to have appropriate routine screening mammography according to the ACR guidelines.
- Hormonal medicines
- Selective serotonin reuptake inhibitors
- Psychological causes
- Duct ectasia with periductal inflammation
- Mastitis or breast abscess
- Surgery or implants
- Pregnancy and breast-feeding
- Nerve irritation
- Musculoskeletal causes
- Coronary, pulmonary, esophageal or gallbladder pathology
Breast Cancer Causes
- Advanced breast cancer with significant tissue invasion
- Invasive lobular carcinoma
- Anaplastic carcinoma
- Adenoid cystic carcinoma
Types of Breast Pain
Cyclical (most common, diffuse, unilateral or bilateral, third decade)—sensitivity to normal hormonal levels, these women undergo more frequent breast investigations
Noncyclical (25 percent, focal, unilateral, fourth decade)—inflammatory, may need evaluation to exclude malignancy
Breast Pain Summary Recommendations
- Women with cyclical and/or bilateral nonfocal pain or tenderness usually do not require nonroutine imaging.
- Women with noncyclical, unilateral or focal breast pain that is not extramammary in origin may benefit from imaging to exclude breast cancer, determine benign but treatable etiology, or to offer reassurance that there is no causative abnormality. Ultrasound is the first test used in symptomatic women < 30 years old, or pregnant or lactating women.
- Diagnostic mammography (unilateral or bilateral) may be added to ultrasound in symptomatic women < 30 years old with suspicious ultrasound, at the radiologist’s discretion.
- Digital Mammography and ultrasound in symptomatic women 30 and older, or in any patient qualifying for mammography, based on risk factors and the date of the last mammogram.
- There is no evidence to suggest that breast MRI or nuclear imaging (molecular breast imaging or positron emission mammography) meet risk/benefit or cost-effectiveness criteria to be used in the work-up of breast pain or tenderness.
Breast Imaging Codes: