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Bui AH, Smith GJ, Dyrstad SW, Robinson KA, Herman CR, Owusu-Brackett N, Fowler AM. An Image-Rich Educational Review of Breast Pain. JOURNAL OF BREAST IMAGING 2024; 6:311-326. [PMID: 38538078 PMCID: PMC11129617 DOI: 10.1093/jbi/wbae001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Indexed: 05/28/2024]
Abstract
Breast pain is extremely common, occurring in 70% to 80% of women. Most cases of breast pain are from physiologic or benign causes, and patients should be reassured and offered treatment strategies to alleviate symptoms, often without diagnostic imaging. A complete clinical history and physical examination is key for distinguishing intrinsic breast pain from extramammary pain. Breast pain without other suspicious symptoms and with a negative history and physical examination result is rarely associated with malignancy, although it is a common reason for women to undergo diagnostic imaging. When breast imaging is indicated, guidelines according to the American College of Radiology Appropriateness Criteria should be followed as to whether mammography, US, or both are recommended. This review article summarizes the initial clinical evaluation of breast pain and evidence-based guidelines for imaging. Additionally, the article reviews cyclical and noncyclical breast pain and provides an image-rich discussion of the imaging presentation and management of benign and malignant breast pain etiologies.
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Affiliation(s)
- Anthony H Bui
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | | | | | | | | | - Nicci Owusu-Brackett
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Amy M Fowler
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin Carbone Cancer Center, Madison, WI, USA
- Department of Medical Physics, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Dodelzon K, Shah S, Prasad L, Atallah J, Katzen JT. Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain. JOURNAL OF BREAST IMAGING 2023; 5:591-596. [PMID: 38416914 DOI: 10.1093/jbi/wbad023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Indexed: 03/01/2024]
Abstract
With the shift of the healthcare system toward patient-centered, value-based care, the role of the breast radiologist is essential and increasingly multifaceted. Beyond sole image interpreters, breast radiologists serve as subject matter experts within multidisciplinary care teams, acting as advocates and initiators into the healthcare system and providing patient-centered care through effective communication and patient education. These vital roles are well demonstrated through the imaging evaluation and management of the most common breast symptom that affects the majority of the patient population-mastalgia. By leveraging the opportunities provided during the evaluation of the symptomatic breast to optimize patient communication and education, as well as integration of care delivery, breast radiologists add significant value to patient care and ultimately improve patient outcomes.
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Affiliation(s)
| | - Shreena Shah
- Weill Cornell Medicine at NewYork-Presbyterian Brooklyn Methodist Hospital, Department of Radiology, Brooklyn, NY, USA
| | - Lona Prasad
- Weill Cornell Medicine, Department of Obstetrics and Gynecology, New York, NY, USA
| | - Juliana Atallah
- Weill Cornell Medicine, Department of Radiology, New York, NY, USA
| | - Janine T Katzen
- Weill Cornell Medicine, Department of Radiology, New York, NY, USA
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Concerns About Breast Pain: How Useful Is Imaging? HEALTH SCOPE 2022. [DOI: 10.5812/jhealthscope-121702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Breast pain is one of the most common reasons for referral to breast imaging. Objectives: This study aimed to determine the diagnostic yield of mammography and sonomammography in women complaining of breast pain in a teaching hospital in Southeast Nigeria. Methods: This descriptive study analyzed the mammographic/sonomammographic images and records of 241 consecutive adult women aged 18 - 81 years with breast pain who presented to the radiology department over three years. A non-random sampling method was employed to select the participants. The extracted variables were patient’s age, positive clinical history of breast pain, laterality of breast pain, type of imaging, presence or absence of lesion, type, and laterality of lesions if present, and Breast Imaging Reporting and Data System (BI-RADS) assignment of imaging findings on mammography and sonomammography. The descriptive analysis of continuous variables and inferential statistics of ordinal data were performed with Microsoft Excel and chi-squared test, respectively. In this study, P < 0.05 was set as the significance level. Results: Most women (20%) with a complaint of breast pain were in the 40 - 44-year age group. Moreover, 32.3%, 33.2%, and 34.4% of the participants had left-sided, right-sided, and bilateral breast pain, respectively. Among the participants, 118 and 123 women had mammography and sonomammography, respectively. Furthermore, 76.3% had normal findings on mammography or sonomammography, and only 23.7% had positive imaging findings on breast imaging. These lesions were mostly observed among the women in the age group of 45 - 49 years. Of those with lesions detected on imaging, 79.2% and 20.8% demonstrated benign and malignant attributes, respectively. Masses with definite benign attributes assigned BI-RADS II were mostly fibroadenomata and cysts. Inferential statistics indicated that unilateral mastalgia was more likely to be associated with a breast lesion, while bilateral mastalgia usually resulted in normal breast imaging findings. Conclusions: Women referring to the Radiology Department with a complaint of breast pain alone are unlikely to have any significant breast imaging finding; hence, imaging serves as a tool for assuaging the anxiety of these patients and reassuring the referring physician. Unilateral but not bilateral mastalgia is likely to yield positive imaging findings, which are largely benign.
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Taylor-Cho MW, Peacock S, Wolf S, Thomas S, Grimm LJ, Johnson KS. Role of digital breast tomosynthesis in the evaluation of focal breast pain. Clin Imaging 2021; 82:73-76. [PMID: 34798561 DOI: 10.1016/j.clinimag.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 10/11/2021] [Accepted: 11/04/2021] [Indexed: 11/25/2022]
Abstract
RATIONAL AND OBJECTIVE To investigate the utility of digital breast tomosynthesis (DBT) in the evaluation of focal breast pain, considering breast density and breast cancer risk. METHODS Ninety-one cases of focal breast pain evaluated with DBT and ultrasound (US) from 12/30/2014 to 11/9/2017 with 2-year follow-up were identified. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of ipsilateral cancer, trauma, or infection. Demographic data, Tyrer-Cuzick Score (TCS), medical history, breast density, imaging results, and pathology were recorded. Descriptive statistics were reported. RESULTS Eighteen percent (16/91) of cases demonstrated findings, all benign. Of these, 6% (1/16) were detected by DBT only, 88% (14/16) by US only, and 6% (1/16) by DBT and US. US resulted in 3 benign biopsies. Ninety-nine percent (75/76) of cases with no findings at the site of pain on US also had no findings on DBT. Ninety-eight percent (89/91) of cases with no cancer detected at the site of pain on US also did not have cancer on DBT. DBT detected 2 incidental cancers not associated with pain. DBT and US agreed that there was no finding at the site of pain in 82% (75/91) of cases. A high degree of agreement between DBT and US was seen when stratified by breast density and TCS. CONCLUSION DBT may be appropriate for the evaluation of focal pain. Low breast cancer incidence was observed at the site of focal pain across all mammographic breast densities and breast cancer risks.
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Affiliation(s)
- Michael W Taylor-Cho
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA.
| | - Stephanie Peacock
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA
| | - Steven Wolf
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA
| | - Samantha Thomas
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA
| | - Lars J Grimm
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA
| | - Karen S Johnson
- Duke University Medical Center, Department of Radiology, DUMC Box 3808, Durham, NC 27701, USA
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Mathelin C. [The HRT follow-up consultation. What to do in case of breast pain. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2021; 49:493-499. [PMID: 33757920 DOI: 10.1016/j.gofs.2021.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Breast pain is a concern in perimenopausal and postmenopausal women, quantifiable using validated tools, and may pre-exist or appear after initiation of a HRT. OBJECTIVES A review of the literature was conducted to evaluate the frequency of breast pain, its evolution with age, its changes under HRT, its link with a possible risk of subsequent breast cancer, and the diagnostic (breast imaging) or therapeutic management modalities (pharmacological or other) in women taking HRT. METHOD A review of the literature was carried out by consulting Medline, Cochrane Library data and international recommendations in French and English up to the end of 2019. RESULTS Published data confirm the importance of breast pain in relation to breast cancer risk. Women with breast pain prior to or related to the use of HRT have a significantly increased risk of breast cancer compared to women without breast pain. The risk is increased in cases of moderate to severe breast pain. In the presence of diffuse breast pain without abnormalities on clinical examination, it is not recommended to change the usual indications for screening, whether organized or individual. For focal breast pain, breast imaging (mammography and possibly ultrasound) is recommended. In the absence of abnormalities on breast imaging, a reassuring dialogue has to take place. With regard to HRT, doses of estrogens should be reduced until the breast pain decreases, or even stop the HRT if this symptom persists despite the use of low doses. Wearing a bra brassiere-type can also reduce breast pain.
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Affiliation(s)
- C Mathelin
- Service de chirurgie, Institut de cancérologie Strasbourg Europe (ICANS), 17, rue Albert-Calmette, 67200 Strasbourg, France; IGBMC, Institut de génétique et de biologie moléculaire et cellulaire, biologie du cancer, CNRS UMR 7104, INSERM U964, Université de Strasbourg, Illkirch, France.
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Sivarajah R, Welkie J, Mack J, Casas RS, Paulishak M, Chetlen AL. A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment. JOURNAL OF BREAST IMAGING 2020; 2:101-111. [PMID: 38424883 DOI: 10.1093/jbi/wbz082] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Indexed: 03/02/2024]
Abstract
Over two-thirds of women will experience breast pain in their lifetime. As one of the leading breast symptoms for which women seek medical attention, breast pain is suspected to be underreported and under-studied. Cyclical breast pain is related to hormonal changes. Noncyclical breast pain is independent of the menstrual cycle and can be idiopathic and related to chronic pain syndromes, infections, ill-fitting bras, musculoskeletal abnormalities, pregnancy, perimenopause, and postsurgical causes. Breast pain can also present in transgender patients and may require additional considerations as to the underlying cause. Imaging of mastalgia depends upon the suspected etiology. Inappropriate imaging for breast pain is associated with significant utilization of health care resources. Cyclical breast pain does not require an imaging work-up. The work-up of focal, noncyclical breast pain includes ultrasound for women aged younger than 40 years, and mammography and ultrasound for women aged 40 years and older. Management of breast pain is often supportive, as most breast pain resolves spontaneously. If pain persists, imaging and management should follow a step-wise approach. If conservative measures fail, second-line therapy is topical nonsteroidal anti-inflammatory drugs. If breast pain is severe and resistant to conservative methods, additional third-line therapies can be added by breast care specialists with specific knowledge of the potential deleterious side effects of these medications. While the causes of mastalgia are overwhelmingly benign, breast pain can significantly impact quality of life, and the breast radiologist should be familiar with causes, management, and treatment recommendations from a multidisciplinary approach.
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Affiliation(s)
- Rebecca Sivarajah
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
| | - Janelle Welkie
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
- Penn State College of Medicine, Hershey, PA
| | - Julie Mack
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
| | - Rachel S Casas
- Penn State Health-Hershey Medical Center, Department of General Internal Medicine, Hershey, PA
| | - Melody Paulishak
- Penn State Health-Hershey Medical Center, Department of Surgery, Hershey, PA
| | - Alison L Chetlen
- Penn State Health-Hershey Medical Center, Department of Radiology, Hershey, PA
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Holbrook AI, Zhang J, D'amico K, Liu Y, Newell MS. The Association of Breast Pain with Malignancy. JOURNAL OF BREAST IMAGING 2019; 1:177-181. [PMID: 38424755 DOI: 10.1093/jbi/wbz029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Indexed: 03/02/2024]
Abstract
OBJECTIVE Breast pain is a common reason for imaging evaluation; however, the limited literature available suggests a low incidence of malignancy with isolated pain. The goal of this study is to calculate the risk of cancer in patients with breast pain, and to compare to the screening mammography cancer detection rates. METHODS This retrospective, institutional review board-approved study included all patients for whom a breast pain history sheet was filled out between November 3, 2013, and July 28, 2016. Those without at least two years of follow-up were excluded. From the medical record, any malignancy found at the site of pain at presentation or within two years was noted. Screening cancer detection rate was calculated from the mammography tracking software, and the Chi-square test was used to evaluate the significance of the difference between the cancer detection rates in patients with pain versus that detected by screening. RESULTS Of 421 patients who met the inclusion criteria, 4 (1.0%) had cancer at the site of pain, with a rate of malignancy of 9.5/1000 (95% CI: 3.5/1000 to 25.2/1000). The screening cancer detection rate was 7.3/1000 (P = 0.403), which was not significantly different. All cancers occurred in patients with coexisting palpable abnormalities; none was found when pain was the only symptom. CONCLUSION The rate of malignancy in patients with breast pain did not differ significantly from that detected by screening mammography. In patients with isolated breast pain without a palpable abnormality, there were no cases of malignancy. Imaging patients for the sole purpose of evaluating breast pain may not be necessary.
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Affiliation(s)
- Anna I Holbrook
- Emory University, Department of Radiology and Imaging Science, Emory University, Atlanta, GA
| | - James Zhang
- Emory University, Department of Neuroscience and Behavioral Biology, Atlanta, GA
| | | | - Yuan Liu
- Emory University, Rollins School of Public Health, Department of Biostatistics & Bioinformatics, Atlanta, GA
| | - Mary S Newell
- Emory University, Department of Radiology and Imaging Science, Emory University, Atlanta, GA
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Breast pain and cancer: should we continue to work-up isolated breast pain? Breast Cancer Res Treat 2019; 177:619-627. [PMID: 31309396 DOI: 10.1007/s10549-019-05354-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 07/07/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To assess the cancer detection rate (CDR) in patients presenting with isolated breast pain. METHODS A retrospective review was performed of consecutive patients presenting to a large tertiary care academic center or an affiliated hospital with isolated breast pain from October 1, 2013 to September 30, 2015. Medical records were reviewed for patient demographics, pain characteristics, imaging findings, and outcome. RESULTS The study cohort was comprised of 971 exams in 953 patients, with a median age of 50 years. A total of 62.5% (607/971) of the cases were assessed by mammography and ultrasound, 24.4% (237/971) by ultrasound only, and 13.1% (127/971) by mammography only. Including the abnormalities detected in the asymptomatic breast, 88.7% (861/971) of the cases were negative or had benign findings (BI-RADS 1 and 2), 6.8% (66/971) were probably benign (BI-RADS 3), 3.9% (38/971) were suspicious (BI-RADS 4), and 0.6% (6/971) were highly suggestive of malignancy (BI-RADS 5). CDR on initial work-up was 0.8% (8/953), of which 0.6% (4/690) was in average-risk patients while 1.5% (4/263) was in higher-than-average risk patients. CONCLUSIONS CDR in patients presenting with isolated breast pain overall was low, comparable to the expected incidence of breast cancer in asymptomatic women. Work-up for isolated breast pain may therefore be unnecessary and lead to overutilization of healthcare resources. Routine screening mammography should be encouraged and higher-than-average risk patients may benefit from additional tests.
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ACR Appropriateness Criteria ® Breast Pain. J Am Coll Radiol 2019; 15:S276-S282. [PMID: 30392596 DOI: 10.1016/j.jacr.2018.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Accepted: 09/07/2018] [Indexed: 11/23/2022]
Abstract
Breast pain is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Ho PJ, Bok CM, Ishak HMM, Lim LY, Liu J, Wong FY, Chia KS, Tan MH, Chay WY, Hartman M, Li J. Factors associated with false-positive mammography at first screen in an Asian population. PLoS One 2019; 14:e0213615. [PMID: 30856210 PMCID: PMC6411141 DOI: 10.1371/journal.pone.0213615] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/25/2019] [Indexed: 11/19/2022] Open
Abstract
Introduction False-positive recall is an issue in national screening programmes. The aim of this study is to investigate the recall rate at first screen and to identify potential predictors of false-positive recall in a multi-ethnic Asian population-based breast cancer screening programme. Methods Women aged 50–64 years attending screening mammography for the first time (n = 25,318) were included in this study. The associations between potential predictors (sociodemographic, lifestyle and reproductive) and false-positive recall were evaluated using multivariable logistic regression models. Results The recall rate was 7.6% (n = 1,923), of which with 93.8% were false-positive. Factors independently associated with higher false-positive recall included Indian ethnicity (odds ratio [95% confidence interval]: 1.52 [1.25 to 1.84]), premenopause (1.23 [1.04 to 1.44]), nulliparity (1.85 [1.57 to 2.17]), recent breast symptoms (1.72 [1.31 to 2.23]) and history of breast lump excision (1.87 [1.53 to 2.26]). Factors associated with lower risk of false-positive recall included older age at screen (0.84 [0.73 to 0.97]) and use of oral contraceptives (0.87 [0.78 to 0.97]). After further adjustment of percent mammographic density, associations with older age at screening (0.97 [0.84 to 1.11]) and menopausal status (1.12 [0.95 to 1.32]) were attenuated and no longer significant. Conclusion For every breast cancer identified, 15 women without cancer were subjected to further testing. Efforts to educate Asian women on what it means to be recalled will be useful in reducing unnecessary stress and anxiety.
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Affiliation(s)
- Peh Joo Ho
- Genome Institute of Singapore, Genome, Singapore, Singapore, Singapore
| | - Chek Mei Bok
- Genome Institute of Singapore, Genome, Singapore, Singapore, Singapore
| | | | - Li Yan Lim
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
| | - Jenny Liu
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | | | - Kee Seng Chia
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Min-Han Tan
- National Cancer Centre, Singapore, Singapore
- Institute of Bioengineering and Nanotechnology, Singapore, Singapore
| | | | - Mikael Hartman
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Jingmei Li
- Genome Institute of Singapore, Genome, Singapore, Singapore, Singapore
- Department of Surgery, University Surgical Cluster, National University Hospital, Singapore, Singapore
- Karolinska Institutet, Department of Medical Epidemiology and Biostatistics, Stockholm, Sweden
- * E-mail:
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Mema E, Cho E, Ryu YK, Jadeja P, Wynn R, Taback B, Ha R. In the Setting of Negative Mammogram, Is Additional Breast Ultrasound Necessary for Evaluation of Breast Pain? Curr Probl Diagn Radiol 2019; 48:117-120. [DOI: 10.1067/j.cpradiol.2017.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2017] [Revised: 11/05/2017] [Accepted: 12/12/2017] [Indexed: 11/22/2022]
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Owen WA, Brazeal HA, Shaw HL, Lee MV, Appleton CM, Holley SO. Focal breast pain: imaging evaluation and outcomes. Clin Imaging 2019; 55:148-155. [PMID: 30825809 DOI: 10.1016/j.clinimag.2019.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 01/15/2019] [Accepted: 02/11/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the number and characteristics of cancers detected and the optimal imaging evaluation in women presenting with focal breast pain (FBP). MATERIALS AND METHODS We performed a retrospective review of 4720 women who underwent imaging for FBP from 2001 to 2013. Women 18 and over with one or two foci of breast pain and no concurrent breast symptoms were included. 944 patients met criteria. We recorded the imaging work-up, presence and type of finding at the site of pain, BI-RADS® assessment, and pathological outcomes. Subsequent imaging and clinical follow up was recorded. RESULTS Imaging evaluation consisted of sonogram alone in 286 women, mammogram alone in 231 women, and both in 427 women. 113 women had an imaging finding at the site of pain; 103 were designated benign or probably benign. 12 biopsies of corresponding findings were performed: 9 benign, 1 invasive lobular carcinoma, 1 invasive ductal carcinoma, 1 ductal carcinoma in situ. All three malignancies were seen mammographically; 2 had an ultrasound correlate. At initial evaluation, 4 incidental breast cancers were diagnosed remote from the site of FBP. All were seen on mammogram and 2 of 4 had an ultrasound correlate. On follow up evaluation, 9 cancers were diagnosed at the site of pain and 13 incidental cancers were diagnosed. CONCLUSION FBP is rarely associated with malignancy. Targeted ultrasound may be deferred in women 40 and older with FBP, no other clinical findings, and a negative mammogram.
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Affiliation(s)
- Wendi A Owen
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA.
| | - Hilary A Brazeal
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA
| | - Hillary L Shaw
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA.
| | - Michelle V Lee
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA.
| | - Catherine M Appleton
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA.
| | - Susan O Holley
- Breast Imaging Division, Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S. Kingshighway Blvd, Campus Box 8131, St. Louis, MO 63110, USA.
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15
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Cohen E, Leung JWT. Problem-Solving MR Imaging for Equivocal Imaging Findings and Indeterminate Clinical Symptoms of the Breast. Magn Reson Imaging Clin N Am 2018; 26:221-233. [PMID: 29622127 DOI: 10.1016/j.mric.2017.12.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Breast MR imaging is commonly used for high-risk screening and for assessing the extent of disease in patients with newly diagnosed breast cancer, but its utility for assessing suspicious symptoms and equivocal imaging findings is less widely accepted. The authors review current literature and guidelines regarding the use of breast MR imaging for these indications. Overall, problem-solving breast MR imaging is best reserved for pathologic nipple discharge and sonographically occult architectural distortion with limited biopsy options. Further study is necessary to define the role of problem-solving MR imaging for calcifications, mammographic asymmetries, and surgical scarring.
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Affiliation(s)
- Ethan Cohen
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA.
| | - Jessica W T Leung
- Department of Diagnostic Radiology, Division of Diagnostic Imaging, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1350, Houston, TX 77030-4009, USA
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Abstract
PURPOSE OF REVIEW Investigation of noncyclic mastalgia in women without signs or risk factors for cancer is controversial. An initial imaging strategy can diagnose breast cancer early, potentially leading to better treatment and survival. However, cancer diagnosis is very uncommon in these cases, and this approach can be harmful, as false positives or suspicion results will lead to unneeded interventions and follow-up. The purpose of this review is to analyse the trade-offs between desirable and undesirable consequences of initial imaging tests against clinical follow-up. RECENT FINDINGS We found seven relevant studies, all observational, with some methodological limitations and very low-quality evidence. They showed low breast cancer prevalence (around 1-2%, increasing with age), high sensitivity to rule out disease but moderate specificity to rule it in using mammography and echography, and lacked evidence on follow-up and final outcomes. SUMMARY There is a low prevalence of breast cancer in patients with painful breast with negative physical examination, and very little research to inform about the effect of performing or avoiding initial imaging test on outcomes of interest. With such limited evidence, only a weak recommendation to reinforce shared decision making about what should be done in the primary care setting can be made, with the backup of a specialized breast unit.
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Jokich PM, Bailey L, D’Orsi C, Green ED, Holbrook AI, Lee SJ, Lourenco AP, Mainiero MB, Moy L, Sepulveda KA, Slanetz PJ, Trikha S, Yepes MM, Newell MS. ACR Appropriateness Criteria ® Breast Pain. J Am Coll Radiol 2017; 14:S25-S33. [DOI: 10.1016/j.jacr.2017.01.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 01/18/2017] [Accepted: 01/20/2017] [Indexed: 12/31/2022]
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Chetlen AL, Kapoor MM, Watts MR. Mastalgia: Imaging Work-up Appropriateness. Acad Radiol 2017; 24:345-349. [PMID: 27916596 DOI: 10.1016/j.acra.2016.10.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2016] [Accepted: 10/10/2016] [Indexed: 11/25/2022]
Abstract
RATIONALE AND OBJECTIVES Radiologists frequently image women with the sole complaint of mastalgia (breast pain). We hypothesized that whereas the vast majority of women ultimately have no imaging explanation for their breast pain, a small percentage of patients may have a correlative imaging finding and confirm the current American College of Radiology Appropriateness Criteria recommendations. MATERIALS AND METHODS In this Health Insurance Portability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective review, we evaluated 236 women between the ages of 18 and 83 years who presented to our Breast Care Center in 2013 with the sole complaint of breast pain or tenderness. Patients' clinical presentation, diagnostic imaging work-up, and clinical and radiographic follow-up were documented. Outcomes of the diagnostic work-up were compared with the American College of Radiology Appropriateness Criteria recommendations. RESULTS Of the 236 patients, 10 women had cyclical breast pain, 116 had noncyclical, nonfocal breast pain, and 110 had noncyclical, focal breast pain. No imaging correlates were discovered to explain the etiology of cyclical pain, supporting the American College of Radiology Appropriateness Criteria rating values. A definitive imaging correlate for breast pain was identified in seven women (3%) with noncyclical, focal pain, one of which was a cancer diagnosis (0.4%), which correlates with the American College of Radiology Appropriateness Criteria ratings. No imaging correlates were found in women with noncyclical, nonfocal pain, supporting the American College of Radiology Appropriateness Criteria ratings. CONCLUSION There was no radiological imaging finding to explain the etiology of mastalgia in most women. Diagnostic imaging may be an appropriate diagnostic evaluation in patients with noncyclical, focal breast pain, supporting the American College of Radiology Appropriateness Criteria recommendations.
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Ngô C, Seror J, Chabbert-Buffet N. [Breast pain: Recommendations]. JOURNAL DE GYNECOLOGIE, OBSTETRIQUE ET BIOLOGIE DE LA REPRODUCTION 2015; 44:938-46. [PMID: 26541567 DOI: 10.1016/j.jgyn.2015.09.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 09/18/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To evaluate the diagnostic value of clinical examination and additional tests in the exploration of breast pain, to evaluate the strategy of their care and to provide recommendations. METHODS A literature search in English and French carried out by consulting the databases PubMed, Cochrane Library and international recommendations. RESULTS Clinical examination and interrogation, with the use of visual analog scale used to differentiate non-cyclical breast pain from mastodynia (LE2). A calendar can be used to characterize the cyclical breast pain (LE3). Using a questionnaire can help to characterize the pain (LE3). In the absence of palpable abnormality, it is not recommended to modify systematic or individual screening modalities (LE2). MRI is not recommended in case of normal mammography and sonography. Explorations biopsy is guided by imaging. The therapeutic management includes reassurance after a normal clinical evaluation and/or normal radiological findings (LE2), and precise fitting of a brassière. In case of failure of this first approach, NSAIDs gel can be proposed (LE1-2).
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Affiliation(s)
- C Ngô
- Service de chirurgie cancérologique gynécologique et du sein, hôpital européen George-Pompidou, AP-HP, 75015 Paris, France; Université Paris-Descartes, 75005 Paris, France.
| | - J Seror
- Cabinet médical, 146, avenue Ledru-Rollin, 75011 Paris, France; Service d'échographie, hôpital Tenon, AP-HP, 4, rue de la Chine, 75020 Paris, France
| | - N Chabbert-Buffet
- Service de gynécologie obstétrique médecine de la reproduction, hôpital Tenon, AP-HP, 75020 Paris, France; UMR S 938, Université Pierre-et-Marie-Curie, 75006 Paris, France
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Long-term clinical outcomes in women with breast pain in the absence of additional clinical findings: mammography remains indicated. Breast Cancer Res Treat 2015; 149:417-24. [DOI: 10.1007/s10549-014-3257-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 12/21/2014] [Indexed: 10/24/2022]
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Abstract
Ultrasonography (US) is an indispensable tool in breast imaging and is complementary to both mammography and magnetic resonance (MR) imaging of the breast. Advances in US technology allow confident characterization of not only benign cysts but also benign and malignant solid masses. Knowledge and understanding of current and emerging US technology, along with the application of meticulous scanning technique, is imperative for image optimization and diagnosis. The ability to synthesize breast US findings with multiple imaging modalities and clinical information is also necessary to ensure the best patient care. US is routinely used to guide breast biopsies and is also emerging as a supplemental screening tool in women with dense breasts and a negative mammogram. This review provides a summary of current state-of-the-art US technology, including elastography, and applications of US in clinical practice as an adjuvant technique to mammography, MR imaging, and the clinical breast examination. The use of breast US for screening, preoperative staging for breast cancer, and breast intervention will also be discussed.
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Affiliation(s)
- Regina J Hooley
- Department of Diagnostic Radiology, Yale University School of Medicine, 333 Cedar St, PO Box 208042, New Haven, CT 06520-8042, USA.
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Kalantari BN, Dauphine CE, Khalkhali I. The Role of Imaging in the Evaluation of Focal Mastalgia. Breast J 2013; 19:569-70. [DOI: 10.1111/tbj.12179] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Babak N. Kalantari
- Department of Radiology; Harbor-UCLA Medical Center; David Geffen School of Medicine at UCLA; Torrance California
| | - Christine E. Dauphine
- Department of Surgery; Harbor-UCLA Medical Center; David Geffen School of Medicine at UCLA; Torrance California
| | - Iraj Khalkhali
- Department of Radiology; Harbor-UCLA Medical Center; David Geffen School of Medicine at UCLA; Torrance California
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Leddy R, Irshad A, Zerwas E, Mayes N, Armeson K, Abid M, Cluver A, Campbell A, Ackerman S, Lewis M. Role of Breast Ultrasound and Mammography in Evaluating Patients Presenting with Focal Breast Pain in the Absence of a Palpable Lump. Breast J 2013; 19:582-9. [DOI: 10.1111/tbj.12178] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Rebecca Leddy
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Abid Irshad
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Emily Zerwas
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Nicholas Mayes
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Kent Armeson
- Division of Biostatistics and Epidemiology; Medical University of South Carolina; Charleston South Carolina
| | - Maham Abid
- Division of Biology College of Charleston; Medical University of South Carolina; Charleston South Carolina
| | - Abbie Cluver
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Amy Campbell
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Susan Ackerman
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
| | - Madelene Lewis
- Department of Radiology; Medical University of South Carolina; Charleston South Carolina
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The effect of imaging on the clinical management of breast pain. J Gen Intern Med 2012; 27:817-24. [PMID: 22331398 PMCID: PMC3378742 DOI: 10.1007/s11606-011-1982-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2011] [Revised: 12/02/2011] [Accepted: 12/14/2011] [Indexed: 10/14/2022]
Abstract
BACKGROUND Breast pain is a common complaint to primary care and breast specialists. Literature recommends imaging to provide reassurance of benign etiology. The effect of imaging on reassurance and subsequent healthcare utilization has not been described. OBJECTIVE To determine if initial imaging for breast pain reduces subsequent utilization. DESIGN Retrospective cohort study at a hospital-based breast health practice. PATIENTS Women referred for breast pain from 2006-2009. MAIN MEASURES Imaging ordered at initial provider visit; clinical utilization, defined as the number of follow-up visits, diagnostic imaging studies, and biopsies completed within 12 months following initial visit. KEY RESULTS Sixty-percent of women were age 40 or younger, 87% were from racial/ethnic minority groups. Twenty-five percent had imaging ordered at initial visit. Of those who received initial imaging, 75% had normal radiographic findings, yet 98% returned for additional evaluation. In adjusted analyses, women with initial imaging had increased clinical services utilization (OR 25.4, 95% CI: 16.7, 38.6). Women with normal clinical breast exams who received initial imaging exhibited increased odds for subsequent clinical services utilization (OR 23.8, 95% CI: 12.9, 44.0). Six cancers were diagnosed; imaging in the absence of clinical breast exam abnormalities did not result in any cancer identification. CONCLUSIONS Initial imaging for women with breast pain increased the odds of subsequent clinical utilization and did not increase reassurance in ruling out malignancy.
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Breast Cancer Screening and Problem Solving Using Mammography, Ultrasound, and Magnetic Resonance Imaging. Ultrasound Q 2011; 27:23-47. [PMID: 21343800 DOI: 10.1097/ruq.0b013e31820e15ac] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
Breast concerns commonly occur in the outpatient setting and predominantly consist of breast pain, nipple discharge, and breast masses. Many of these concerns can be treated with reassurance and reevaluation, but not if the patient has risk factors for an underlying pathology. This article reviews the diagnosis and treatment of the three most common breast concerns encountered in primary care practices.
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Affiliation(s)
- Ann M Rodden
- Department of Family Medicine, Medical University of South Carolina, 295 Calhoun Street, Charleston, SC 29425, USA.
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Methods for the prediction of low-molecular-weight occupational respiratory sensitizers. Curr Opin Allergy Clin Immunol 2009; 8:103-9. [PMID: 18317016 DOI: 10.1097/aci.0b013e3282f4cadd] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW There is recognition that respiratory sensitization is an occupational hazard of high concern. Despite international regulatory requirements there is no established protocol for the efficient prospective identification of chemical respiratory sensitizers. We review the predictive behaviour of available methods and suggest a possible high-throughput protocol. RECENT FINDINGS Animal or in-vitro tests specific to respiratory exposure and resulting in direct asthma-related outcomes have not been developed, although the use of a local lymph node assay originally designed for skin sensitization has been advocated in a respiratory context. Various methods have been used to develop quantitative structure-activity relationship models for prediction of low-molecular-weight organic chemical respiratory sensitizers. The estimated negative predictive value for all of the published models is 1, but their differences in positive predictive value can be exploited. SUMMARY The most pragmatic as well as valid approach for screening large numbers of industrial chemicals for respiratory sensitization hazard is likely to consist of an algorithm starting with quantitative structure-activity relationship models. Further corroboration from animal or human data, however, may be required for chemicals with a positive result by quantitative structure-activity relationship.
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