The radiologic workup of a palpable breast mass
ABSTRACTThe finding of a palpable breast mass on physical examination often warrants a radiologic workup including directed ultrasonography, diagnostic mammography, and, at times, biopsy with ultrasonographic guidance. The choice of initial imaging study is most often guided by the patient’s age at presentation. Communicating the clinical findings to both the patient and the radiologist helps ensure the selection of the most appropriate imaging studies and helps in the interpretation of those studies. Every woman with a palpable breast mass, regardless of her age, should undergo imaging to exclude or establish the diagnosis of cancer.
KEY POINTS
- Typically, in women under age 30, ultrasonography is the first or the only test ordered to evaluate the abnormality. In women age 30 or older, diagnostic mammography is typically the first test ordered.
- On mammography, a suspicious palpable mass has an irregular shape with spiculated margins. A benign mass typically has a round shape with well-circumscribed margins.
- When mammography is required during pregnancy, the patient can be reassured that it will not jeopardize her fetus because the radiation dose is very low and the abdomen and pelvis can be shielded.
IF A PREGNANT WOMAN HAS A PALPABLE BREAST MASS
Most publications on breast cancer in pregnancy report a prevalence of 3 per 10,000 pregnancies, accounting for 3% of all breast cancers diagnosed.5 Therefore, imaging evaluation of a palpable mass should not be postponed.
Hormonal changes throughout pregnancy may increase the nodularity of breast tissue, raising the concern of palpable masses. Additionally, there is a higher prevalence of galactoceles and lactating adenomas in these patients. Because contrasting fatty breast tissue is lost during pregnancy and because of the need to minimize radiation exposure, ultrasonography is often the imaging test of first choice. If mammography is required, the radiation dose is very low and the patient’s abdomen and pelvis can be shielded.6 In this situation, the patient can be reassured that the imaging test is not jeopardizing her fetus.
WHAT WORKUP IS REQUIRED IN MEN?
Breast cancer in men is rare, accounting for less than 0.5% of all cases.7 Most often, a palpable breast mass in a man presents as unilateral gynecomastia. Gynecomastia occurs in a bimodal age distribution (in the 2nd and 7th decades) and has a variety of hormonal and drug-related causes. Despite the low prevalence of breast cancer in men, the combination of mammography and ultrasonography is recommended for evaluation at all ages.
