Diagnostic Imaging Pathways - Breast Symptom (New)
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Population Covered By The Guidance
This pathway provides guidance for women at any risk presenting with a new breast symptom including new breast lump, breast pain, breast or nipple asymmetry, skin changes or nipple changes. Imaging of new nipple discharge is covered separately.
Date reviewed: April 2018
Date of next review: April 2021
Published: November 2018
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 modality of a new breast symptom is dependent on the age of the woman and whether she is currently pregnant or lactating
- Young (<35), pregnant or lactating women should have a breast ultrasound first
- For women over 35, who are not pregnant or lactating, a mammogram is the initial imaging modality, followed by an ultrasound
- The most reliable way to diagnose breast cancer is through the ‘Triple Test’ consisting of:
- Medical history and breast examination
- Imaging (mammogram and/or ultrasound)
- Non-excisional biopsy (FNA and/or core biopsy)
- The Triple Test is positive if any component is indeterminate, suspicious or malignant. A positive triple test warrants specialist referral
- Although biopsy is not always required, it should be performed when the findings on clinical examination and/or breast imaging are not definitely benign
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 1,2
- Breast symptoms in women encompass a spectrum of benign and malignant conditions 1,2
- Women being investigated for a new breast symptom should be assessed using the Triple Test approach involving breast examination, imaging tests and biopsy 3,4
- If there are any concerning findings in any component of the Triple Test, further action is needed, e.g. palpable mass with negative imaging should have a ‘direct’ fine needle aspiration (FNA) by a pathologist
- If there is concern regarding possible discordance between the components of the Triple Test, then specialist referral is recommended
- The choice of primary breast imaging in examining women with symptoms is partly based on age
- The Cancer Australia Guideline for investigation of a new breast symptom recommends that women younger than 35 years be imaged first with ultrasound and women 35 years and older be imaged first with mammography. 4 Most guidelines recommend that younger women be initially investigated with ultrasound, and the recommended age cut-off ranges from 30 to 40 years 5-9
- This pathway has been adapted from the NHMRC National Breast Cancer Centre guidelines 3 and the Cancer Australia Guideline for investigation of a new breast symptom 4
mammo
Mammography
- Standard mammography involves two views: cranio-caudal and medio-lateral oblique 13
- The radiation dose from digital mammography (DM) is extremely low and the risk of radiation-induced breast cancer is minimal 14
- The diagnostic accuracy of mammography is enhanced through the use of further views and/or tomosynthesis
- Magnified and coned compression views image a target area of breast tissue rather than the whole breast, resulting in better spatial and contrast resolution than the baseline mammogram of the whole breast 15-17
- Digital breast tomosynthesis (DBT) is a type of mammography that uses a low-dose x-ray system and computer reconstructions to create layered images of the breasts 18
- In DBT, multiple images of the compressed breast are taken from different angles and reconstructed to a 3D volume using mathematical algorithms 18, 19
- Adding DBT may increase the sensitivity and specificity of DM for diagnosing cancer in symptomatic women, particularly with dense and fatty breasts, 20, 21 and improve the assessment of screen-detected abnormalities 18, 20, 22
- Although further research is required, early evidence suggests that DBT has the potential to increase workflow efficiency in a diagnostic setting by reducing benign biopsy rates 23, 24
- Abnormalities on mammography are generally categorised as 15
- Masses
- Asymmetric densities
- Architectural distortions
- Calcifications
- A combination of these
- Although mammography is an excellent tool for evaluating breast lesions, it has a false-negative rate. 25 The reported false-negative rates of mammography are variable and depend on multiple factors including the presence of symptoms, breast density, age and modality used 4, 13, 26
us
Ultrasound
- Is an important and relatively inexpensive diagnostic tool in the evaluation of breast lesions 10,11
- Ultrasonography of the breast is useful because of its high sensitivity, specificity and diagnostic value 12
- Often used complementary to mammography but may be the initial and only imaging modality required for women younger than 35 1, 6
- Breast ultrasound is the preferred initial imaging modality for women with palpable lumps who are pregnant or lactating as it does not expose the patient to ionising radiation 3, 10
- Situations where ultrasound is useful include 6, 10
- 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
fna
FNA or Core biopsy
- FNA or core biopsy is a reliable alternative to surgical biopsy for a histological diagnosis
- Core biopsy can provide more information than FNA as tissue structure is preserved
- FNA and core biopsy have comparable diagnostic accuracy, however a disadvantage of FNA is that a considerable proportion of biopsies are non-diagnostic. 27-30 Another limitation of FNA is that cytology cannot discern between DCIS and invasive cancer 28
- Percutaneous biopsy is minimally invasive, quick and leaves minimal scarring. Complications such as haematoma and infection are rare 31
References
References
Date of literature search: August 2017 – April 2018
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000;61(8):2371-8, 85. View the reference
- Kharkwal S, Sameer, Mukherjee A. Triple test in carcinoma breast. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(10):NC09-NC11. View the reference .
- National Health and Medical Research Council. National breast cancer centre. The investigation of a new breast symptom: a guide for general practitioners. Woolloomooloo (NSW)2006. View the reference
- The investigation of a new breast symptom: a guide for general practitioners 2017. Cancer Australia. 2017. View the reference
- Jackson VP, Reynolds HE, Hawes DR. Sonography of the breast. Seminars in Ultrasound, CT and MRI. 1996;17(5):460-75. View the reference
- American College of Radiology. ACR appropriateness criteria; breast pain. J Am Coll Radiol. Rockville MD: Agency for Healthcare Research and Quality (AHRQ); 2016. p. 11. View the reference
- Moy L, Heller SL, Bailey L, D'Orsi C, DiFlorio RM, Green ED, et al. ACR Appropriateness criteria. Palpable breast masses. J Am Coll Radiol. 2017;14(5s):S203-s24. View the reference
- Salzman B, Fleegle S, Tully AS. Common breast problems. Am Fam Physician. 2012;86(4):343-9. View the reference
- Bevers TB, Anderson BO, Bonaccio E, Buys S, Daly MB, Dempsey PJ, et al. Breast cancer screening and diagnosis. J Natl Compr Canc Netw. 2009;7(10):1060-96. View the reference
- Kösüs N, Kösüs A, Duran M, Simavli S, Turhan N. Comparison of standard mammography with digital mammography and digital infrared thermal imaging for breast cancer screening. J Turk Ger Gynecol Assoc. 2010;11(3):152-7. View the reference
- Gonzaga MA. How accurate is ultrasound in evaluating palpable breast masses? The Pan African medical journal. 2010;7:1. View the reference .
- Lehman CD, Lee AY, Lee CI. Imaging management of palpable breast abnormalities. Am J Roentgenol. 2014;203(5):1142-53. View the reference
- National Breast Cancer Centre. Breast imaging: a guide for practice. 2002. View the reference
- Hauge IH, Pedersen K, Olerud HM, Hole EO, Hofvind S. The risk of radiation-induced breast cancers due to biennial mammographic screening in women aged 50-69 years is minimal. Acta Radiol. 2014;55(10):1174-9. View the reference
- Breast imaging: a guide for practice. National Breast Cancer Centre. 2002: View the reference
- Faulk RM, Sickles EA. Efficacy of spot compression-magnification and tangential views in mammographic evaluation of palpable breast masses. Radiology. 1992;185(1):87-90. View the reference .
- Berkowitz JE, Gatewood OM, Gayler BW. Equivocal mammographic findings: evaluation with spot compression. Radiology. 1989;171(2):369-71. View the reference
- Michell MJ, Iqbal A, Wasan RK, Evans DR, Peacock C, Lawinski CP, et al. A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis. Clin Radiol. 2012;67(10):976-81. View the reference
- Houssami N, Skaane P. Overview of the evidence on digital breast tomosynthesis in breast cancer detection. The Breast. 2013;22(2):101-8. View the reference
- Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, et al. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226-31. View the reference
- Phi X-A, Tagliafico A, Houssami N, Greuter MJW, de Bock GH. Digital breast tomosynthesis for breast cancer screening and diagnosis in women with dense breasts – a systematic review and meta-analysis. BMC Cancer. 2018;18:380. View the reference
- Gilbert FJ, Tucker L, Gillan MG, Willsher P, Cooke J, Duncan KA, et al. The TOMMY trial: a comparison of TOMosynthesis with digital MammographY in the UK NHS Breast Screening Programme--a multicentre retrospective reading study comparing the diagnostic performance of digital breast tomosynthesis and digital mammography with digital mammography alone. Health Technol Assess. 2015;19(4):i-xxv, 1-136. View the reference
- Bansal GJ, Young P. Digital breast tomosynthesis within a symptomatic "one-stop breast clinic" for characterization of subtle findings. Br J Radiol. 2015;88(1053):20140855. View the reference .
- Mariscotti G, Durando M, Houssami N, Zuiani C, Martincich L, Londero V, et al. Digital breast tomosynthesis as an adjunct to digital mammography for detecting and characterising invasive lobular cancers: a multi-reader study. Clin Radiol. 2016;71(9):889-95. View the reference .
- Foxcroft LM, Evans EB, Joshua HK, Hirst C. Breast cancers invisible on mammography. Aust N Z J Surg. 2000;70(3):162-7. View the reference .
- Leddy R, Irshad A, Zerwas E, Mayes N, Armeson K, Abid M, et al. Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump. Breast J. 2013;19(6):582-9. View the reference
- Kurita T, Tsuchiya S, Watarai Y, Yamamoto Y, Harada O, Yanagihara K, et al. Roles of fine-needle aspiration and core needle biopsy in the diagnosis of breast cancer. Breast Cancer. 2012;19(1):23-9. View the reference .
- Farshid G, Sullivan T, Jones S, Roder D. Performance indices of needle biopsy procedures for the assessment of screen detected abnormalities in services accredited by BreastScreen Australia. Asian Pac J Cancer Prev. 2014;15(24):10665-73. View the reference .
- Nagar S, Iacco A, Riggs T, Kestenberg W, Keidan R. An analysis of fine needle aspiration versus core needle biopsy in clinically palpable breast lesions: a report on the predictive values and a cost comparison. Am J Surg. 2012;204(2):193-8. View the reference .
- Al Nemer A. Combined use of unguided FNA and CNB increases the diagnostic accuracy for palpable breast lesions. Diagn Cytopathol. 2016;44(7):578-81. View the reference
- Apesteguía L, Pina LJ. Ultrasound-guided core-needle biopsy of breast lesions. Insights into Imaging. 2011;2(4):493-500. View the reference
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