Diagnostic Imaging Pathways - Breast Symptom (New)
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This pathway provides guidance on the imaging of adult female patients presenting with new breast symptoms.
Date reviewed: January 2012
Date of next review: 2017/2018
Published: January 2012
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
 | None | 0 |
 | Minimal | < 1 millisieverts |
 | Low | 1-5 mSv |
 | Medium | 5-10 mSv |
 | High | >10 mSv |
Images
Image GalleryNote: These images open in a new page | ||
|---|---|---|
| 1 |  |
Fibroadenoma Image 1 (Ultrasound): Within the upper outer quadrant of the left breast at the 2 o'clock position is a well circumscribed, ovoid hypoechoic lesion measuring 137mm maximally. No contained calcification or vascularity is identified. The appearance is consistent with, but not diagnostic of, a fibroadenoma. |
| 2 |  |
Fibroadenoma
Image 2 (H&E, x2.5): Histological section of a fibroadenoma showing compressed ducts (intra-canalicular growth pattern) surrounded by mild and bland stromal hypercellularity. The ducts are lined by a dual population of uniform epithelial and myoepithelial cells. |
| 3a |  |
Breast Carcinoma Image 3a (Mammogram, right breast): A non-calcified 22mm mass is present in the upper inner quadrant of the right breast. |
| 3b |  |
Image 3b (Ultrasound, right breast): Ultrasound of the same lesion showed an ill-defined solid mass with irregular margins, distortion of adjacent stroma and posterior acoustic shadowing, features which are suspicious for malignancy. Biopsy confirmed an invasive ductal carcinoma. |
| 4a |  |
Breast Carcinoma
Image 4a: Mastectomy showing an irregular pale tumour (arrow) with surrounding fibrosis consistent with a breast carcinoma. |
| 4b |  |
Image 4b (H&E, x2.5): Histological section of a moderately differentiated (Grade 2) invasive ductal carcinoma, type not otherwise specified, infiltrating through the breast parenchyma and surrounded by desmoplastic stroma. Occasional poorly formed tubules can be seen at the periphery (arrows). |
| 5 |  |
Breast Carcinoma Image 5 (H&E, x10): Histological section of a typical invasive lobular carcinoma showing the classical alignment of single cells in rows. |
Teaching Points
Teaching Points
- Imaging of a new breast symptom is dependent on the age of the woman and whether she is currently pregnant or lactating
- Young (<35), pregnant and lactating females should have a breast ultrasound
- For women over 35, depending on further clinical symptoms a Mammogram and/or a breast ultrasound may be the initial imaging modalities of choice
mammo
Mammography
- Standard mammography involves two views: cranio-caudal and medio-lateral oblique 1
- The diagnostic accuracy of mammography is enhanced through the use of magnification views (magnified, coned compression views), which visualise only a small area of breast tissue but gives better contrast resolution and spatial detail 1-5
- Abnormalities on mammography are generally categorised as 1
- Mass lesions
- Asymmetric densities
- Architectural disturbances
- Calcifications
- A combination of these
- Although it is an excellent tool for evaluating breast lesions, mammography does have an inherent false-negative rate 6
- Mammography is not as sensitive in detecting abnormal lesions in dense breast tissue and for this reason, ultrasound is preferred over mammography in women younger than 35 1
- The radiation exposure and hence risk of malignancy secondary to mammography is believed to be extremely low 7
symptom
Imaging a New Breast Symptom
- This pathway outlines some general principles for the evaluation of women with a new breast symptom such as a lump, thickening of the skin, asymmetrical prominence or pain
- It has been adapted from the NHMRC National Breast Cancer Centre guidelines 8
us
Ultrasound
- Is an important diagnostic tool in the evaluation of breast lesions
- Often used complementary to mammography but may be the initial and only imaging modality required for women younger than 35 1
- Is the preferred initial imaging modality in pregnant and lactating women 8
- Situations where ultrasound is useful include 1
- For evaluating palpable masses not seen on mammography
- For further evaluation of indeterminate lesions seen on mammography
- For detection of any underlying mass or altered architecture associated with calcification or asymmetric densities seen on mammography
- For implant evaluation
- For guidance of percutaneous biopsy
References
References
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Breast imaging: a guide for practice. National Breast Cancer Centre, 2002. (Review article)
- Echlund GW. The art of mammographic positioning, in radiological diagnosis of breast diseases. Berlin: Springer, 1997
- Faulk RM, Sickles EA. Efficacy of spot compression-magnification and tangential views in mammographic evaluation of palpable breast masses. Radiology. 1992;185:87-90. (Level III evidence)
- Feig SA. The importance of supplementary mammographic views to diagnostic accuracy. AJR Am J Roentgenol. 1988;151:40-1. (Review article)
- Berkowitz JE, Gatewood OM, Gayler BW. Equivocal mammographic findings: evaluation with spot compression. Radiology. 1989;171:369-71. (Level IV evidence)
- Foxcroft LM, Evans EB, Joshua HK, Hirst C. Breast cancers invisible on mammography. Aust N Z J Surg. 2000;70:162-7. (Level III evidence)
- Feig SA, Hendrick RE. Radiation risk from screening mammography of women aged 40-49 years. J Natl Cancer Inst Monogr. 1997;22:119-24. (Review article)
- NHMRC National Breast Cancer Centre. The investigation of a new breast symptom: a guide for general practitioners. Woolloomooloo (NSW): NHMRC National Breast Cancer Centre, 1997. (Evidence based guideline)
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
|
Consent to Procedure or Treatment Radiation Risks of X-rays and Scans |
Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
copyright
Copyright
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