Role of Breast Ultrasound and Mammography in Evaluating Patients Presenting with Focal Breast Pain in the Absence of a Palpable Lump

Imaging for breast pain: A useful paradigm to promote breast cancer screening and reduce unnecessary breast imaging

OBJECTIVE

Identify the proportion of patients presenting for diagnostic breast imaging with clinically insignificant breast pain who are eligible for screening mammography and analyze the impact of routing these patients to screening on resource utilization, healthcare spending and cancer detection.

METHODS

We retrospectively reviewed 100 consecutive women ≥40 years old without a history of breast cancer who underwent diagnostic mammogram and breast ultrasound for clinically insignificant breast pain from 1/2022 to 4/2022. Patients were screen-eligible if their last bilateral mammogram was over 12 months prior to presentation. Patients with only screening views during diagnostic mammography were assumed to have a negative/benign screening mammogram. Costs were calculated using the Centers for Medicare & Medicaid Services Physician Fee Schedule.

RESULTS

68 of 100 patients with breast pain were screen-eligible at time of diagnostic imaging. With a screen first approach, 47/68 would have had negative/benign screening mammograms, allowing for the availability of 47 diagnostic breast imaging appointments. The current workflow led to 100 diagnostic mammograms and ultrasounds, 29 follow-up ultrasounds, and 10 image-guided biopsies, with a total cost of $42,872.41. With a screen first approach, there would have been 68 screening mammograms, 53 diagnostic mammograms and ultrasounds, 10 follow-up ultrasounds, and 9 image-guided biopsies, with a total cost of $34,231.60. Two cancers were identified, both associated with suspicious mammographic findings. None would have been missed in a screen-first approach.

DISCUSSION

Identifying screen-eligible patients with clinically insignificant breast pain and routing them to screening mammogram improves radiology resource allocation and decreases healthcare spending without missing any cancers.

ESR Essentials: diagnostic work-up in patients with symptomatic breast disease-practice recommendations by the European Society of Breast Imaging

Breast complaints are frequent reasons for consultations in primary care or breast clinics. Breast pain, breast lumps, and nipple discharge are the most common complaints. Less common symptoms such as skin changes and axillary abnormalities also require specific diagnostic approaches. Imaging the symptomatic breast should be performed by appropriately trained breast radiologists following the best practice guidelines and quality standards. Full-field digital mammography (FFDM), digital breast tomosynthesis (DBT), and breast ultrasound (US) are the main modalities used in this primary setting. The choice depends on the patient's age and symptoms. Women younger than 30-years-old are first imaged by US, whereas women over 40-years-old usually require both FFDM or DBT and US. For women between 30-years-old and 40-years-old, the US is the modality of choice, whereas FFDM or DBT might also be performed if needed. Pregnant or lactating women with palpable lesions or nipple discharge are imaged with US as the first method; FFDM or DBT can also be performed depending on the degree of suspicion as the dose to the fetus is minimal, and shielding may even further reduce the dose. More advanced techniques such as breast magnetic resonance imaging or contrast-enhanced mammography are not indicated in this first diagnostic setting and are reserved for cases of established malignancy (local staging) or rare cases of equivocal findings not otherwise resolved or inflammatory breast cancer. Last, but not least, male breast symptoms should also be addressed with US and/or FFDM. CLINICAL RELEVANCE STATEMENT: It is equally important to correctly diagnose an underlying malignancy and to avoid false positives that would lead to unnecessary biopsies, increased costs, and anxiety for the patient. Proper use of imaging modalities ensures optimal diagnostic approach and minimizes false negatives. KEY POINTS: Ultrasound, full-field digital mammography, or digital breast tomosynthesis are the main imaging modalities in the diagnostic setting, while MRI or contrast-enhanced mammography should be reserved to selected cases. Initial imaging modality includes ultrasound combined with mammography or digital breast tomosynthesis depending on women's age and the presence (or not) of inconclusive findings. A negative imaging evaluation should not deter biopsy when a highly suspicious finding is found on physical examination.

An Image-Rich Educational Review of Breast Pain

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.

Problem-solving Breast MRI

Breast MRI has high sensitivity and negative predictive value, making it well suited to problem solving when other imaging modalities or physical examinations yield results that are inconclusive for the presence of breast cancer. Indications for problem-solving MRI include equivocal or uncertain imaging findings at mammography and/or US; suspicious nipple discharge or skin changes suspected to represent an abnormality when conventional imaging results are negative for cancer; lesions categorized as Breast Imaging Reporting and Data System 4, which are not amenable to biopsy; and discordant radiologic-pathologic findings after biopsy. MRI should not precede or replace careful diagnostic workup with mammography and US and should not be used when a biopsy can be safely performed. The role of MRI in characterizing calcifications is controversial, and management of calcifications should depend on their mammographic appearance because ductal carcinoma in situ may not appear enhancing on MR images. In addition, ductal carcinoma in situ detected solely with MRI is not associated with a higher likelihood of an upgrade to invasive cancer compared with ductal carcinoma in situ detected with other modalities. MRI for triage of high-risk lesions is a subject of ongoing investigation, with a possible future role for MRI in decreasing excisional biopsies. The accuracy of MRI is likely to increase with the use of advanced techniques such as deep learning, which will likely expand the indications for problem-solving MRI. ©RSNA, 2023 Quiz questions for this article are available in the supplemental material.

Patient-centered Care: Value Added by Breast Radiologists in the Management of Breast Pain

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.

Role of breast ultrasonography in predicting accurate tumor dimensions in correlation with histopathology and its impact on staging of breast carcinoma

BACKGROUND AND OBJECTIVES

Estimation of the preoperative size of a breast tumor is of primary importance in deciding the treatment modality. Hence, clinical examination of the lump aided by the imaging is necessary. Our study is instrumental in correlating the size of breast tumor by high-resolution ultrasonography (USG) with the morphological size and also in comparing clinical staging of breast carcinoma against the gold standard pathological staging.

METHODS

It is a cross-sectional study of correlating the size of tumor on USG with the morphological size of biopsy proven invasive ductal carcinoma when received after excision. The size of the tumor was measured grossly and was compared with the USG measurements and palpatory findings.

RESULTS

Seventy percent of cases had good correlation between the USG and morphological size. In 50% of cases, the size on physical examination corroborated with the USG findings and only in 40% of the cases size on physical examination matched with morphological findings. In 65% of cases, the clinical staging of the breast carcinoma matched with the pathological staging. Our study reflected that USG promised to be the most useful radiological tool in predicting the accurate preoperative size of the tumor.

INTERPRETATION AND CONCLUSION

We observed that USG has proved to be a very useful conjunct to clinical examination as only palpation was not found to be very accurate in predicting the actual tumor size. It proved to be safer and cheaper and effectively instrumental in meting out an effective management at pre- and postoperative level to the patient.

No association between breast pain and breast cancer: a prospective cohort study of 10 830 symptomatic women presenting to a breast cancer diagnostic clinic

BACKGROUND

Women with breast pain constitute >20% of breast clinic attendees.

AIM

To investigate breast cancer incidence in women presenting with breast pain and establish the health economics of referring women with breast pain to secondary care.

DESIGN AND SETTING

A prospective cohort study of all consecutive women referred to a breast diagnostic clinic over 12 months.

METHOD

Women were categorised by presentation into four distinct clinical groups and cancer incidence investigated.

RESULTS

Of 10 830 women, 1972 (18%) were referred with breast pain, 6708 (62%) with lumps, 480 (4%) with nipple symptoms, 1670 (15%) with 'other' symptoms. Mammography, performed in 1112 women with breast pain, identified cancer in eight (0.7%). Of the 1972 women with breast pain, breast cancer incidence was 0.4% compared with ∼5% in each of the three other clinical groups. Using 'breast lump' as reference, the odds ratio (OR) of women referred with breast pain having breast cancer was 0.05 (95% confidence interval = 0.02 to 0.09, P<0.001). Compared with reassurance in primary care, referral was more costly (net cost £262) without additional health benefits (net quality-adjusted life-year [QALY] loss -0.012). The greatest impact on the incremental cost-effectiveness ratio (ICER) was when QALY loss because of referral-associated anxiety was excluded. Primary care reassurance no longer dominated, but the ICER remained greater (£45 528/QALY) than typical UK National Health Service cost-effectiveness thresholds.

CONCLUSION

This study shows that referring women with breast pain to a breast diagnostic clinic is an inefficient use of limited resources. Alternative management pathways could improve capacity and reduce financial burden.

Transforming the 2-week wait (2WW) pathway: management of breast pain in primary care

Breast pain has no association with breast cancer yet is a frequent reason for referral from Primary to Secondary Care, often on an urgent (2-week wait) referral. The referral often causes significant patient anxiety, further heightened by screening mammograms and/or ultrasound scans in the absence of an associated red flag symptom or finding by the patient or general practitioner. This paper reports the pilot implementation of a specialist Primary Care Breast Pain Clinic in Mid-Nottinghamshire where patients were seen, examined without any imaging and assessed for their risk of familial breast cancer: numerous studies have reported 15%–>30% of patients with breast pain only have a family history of breast cancer.

177 patients with breast pain only were seen in this clinic between March, 2020 and April, 2021 with a 6-month interim suspension due to COVID-19. The mean age of patients was 48.4 years (range: 16–86). 172/177 (97.2%) patients required no imaging although there were three (1.7%) inappropriate referrals and two additional abnormalities (1.1%—hamartoma, thickening/tethering) that were referred onward. There were no cancers. 21 (12.4%) patients were identified to have an increased familial risk of breast cancer and were referred to the specialist familial cancer service. 170/177 patients completed an anonymous questionnaire on leaving the clinic. 167/169 (99%) were reassured regarding their breast pain, 155/156 (99%) were reassured of the Familial Risk Assessment, 162/168 (96%) were reassured regarding their personal risk assessment while 169/170 (99%) were ‘extremely likely/likely to recommend the service’.

This specialist Primary Care Breast Pain Clinic provides service improvement across all levels of care (Primary, Secondary and Tertiary). Patients were successfully managed in the community with high levels of patient satisfaction and together this obviated referral to secondary care. The familial breast cancer risk assessment also helped identify unmet need in the community.

Role of digital breast tomosynthesis in the evaluation of focal breast pain

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.

Persistent bilateral breast pain treated with traditional Kampo medicine

A 45-year-old woman presented with persistent bilateral breast and axillary pain lasting for more than 3 months. Lengthy work-up failed to identify the etiology. Physical examination was entirely normal, including breast examination. A traditional Kampo medicine, Goshaku-san, was tried, and the symptoms began to improve gradually. This case is characterized by persistent regional pain syndrome mainly on her breast yet not accompanied by other symptoms, and we would like to propose the current case as a novel unique disease entity. We also discuss the potential benefit of Kampo medicine for the symptoms.

[The HRT follow-up consultation. What to do in case of breast pain. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

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.

A Review of Breast Pain: Causes, Imaging Recommendations, and Treatment

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.

The Association of Breast Pain with Malignancy

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.

Breast pain and cancer: should we continue to work-up isolated breast pain?

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.

ACR Appropriateness Criteria® Breast Pain

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.

Focal breast pain: imaging evaluation and outcomes

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.

Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging

This article summarises the information that should be provided to women and referring physicians about breast ultrasound (US). After explaining the physical principles, technical procedure and safety of US, information is given about its ability to make a correct diagnosis, depending on the setting in which it is applied. The following definite indications for breast US in female subjects are proposed: palpable lump; axillary adenopathy; first diagnostic approach for clinical abnormalities under 40 and in pregnant or lactating women; suspicious abnormalities at mammography or magnetic resonance imaging (MRI); suspicious nipple discharge; recent nipple inversion; skin retraction; breast inflammation; abnormalities in the area of the surgical scar after breast conserving surgery or mastectomy; abnormalities in the presence of breast implants; screening high-risk women, especially when MRI is not performed; loco-regional staging of a known breast cancer, when MRI is not performed; guidance for percutaneous interventions (needle biopsy, pre-surgical localisation, fluid collection drainage); monitoring patients with breast cancer receiving neo-adjuvant therapy, when MRI is not performed. Possible indications such as supplemental screening after mammography for women aged 40-74 with dense breasts are also listed. Moreover, inappropriate indications include screening for breast cancer as a stand-alone alternative to mammography. The structure and organisation of the breast US report and of classification systems such as the BI-RADS and consequent management recommendations are illustrated. Information about additional or new US technologies (colour-Doppler, elastography, and automated whole breast US) is also provided. Finally, five frequently asked questions are answered.

TEACHING POINTS

• US is an established tool for suspected cancers at all ages and also the method of choice under 40. • For US-visible suspicious lesions, US-guided biopsy is preferred, even for palpable findings. • High-risk women can be screened with US, especially when MRI cannot be performed. • Supplemental US increases cancer detection but also false positives, biopsy rate and follow-up exams. • Breast US is inappropriate as a stand-alone screening method.

To image or not in noncyclic breast pain? A systematic review

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.

Mastalgia: Imaging Work-up Appropriateness

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.

[Not Available]

Zusammenfassung. Mastodynie ist ein häufig auftretendes Krankheitsbild, das uns im klinischen Alltag regelmässig begegnet. Da die Ursachenpalette äusserst breit von physiologischen Veränderungen bis Malignität reichen kann, ist die Diagnosefindung nicht immer einfach. Der Ausschluss der Malignität führt bereits bei vielen Betroffenen zu einer grossen Entlastung und zu besserem Umgang mit den Beschwerden. Nach einer sorgfältigen Abklärung kann die adäquate Therapie je nach Form der Mastodynie eingeleitet werden. Grundsätzlich lässt sich sagen: Die medikamentöse Therapie der zyklusunabhängigen Form ist unbefriedigend, operative Vorgehensweisen sind bei symptomatischen Befunden zu diskutieren. Grössere operative Massnahmen stellen hingegen bei der zyklischen Mastodynie keine erfolgversprechende Option dar und hier ist strenge Zurückhaltung geboten. Nicht jede Mastodynie benötigt zwingend ein therapeutisches Vorgehen. Das Konzept muss individuell angepasst an den Leidensdruck festgelegt werden. Bekannt sind Spontanremissionen von ca. 20–30 %. Dabei steht die Remission der zyklischen Mastodynie in Zusammenhang mit hormonellen Ereignissen (z.B. Beginn Einnahme einer Antibabypille, Schwangerschaft, Menopause).

Focal Breast Pain: Does Breast Density Affect the Need for Ultrasound?

RATIONALE AND OBJECTIVES

This study aimed to determine the utility of directed ultrasound and digital mammogram for evaluating focal breast pain in women with different mammographic breast densities.

MATERIALS AND METHODS

This institutional review board-approved and Health Insurance Portability and Accountability Act-compliant retrospective study included 413 cases of focal breast pain in 369 women (mean age 53 years). All cases were evaluated with both mammogram and ultrasound and had at least 2 years of imaging follow-up. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of trauma or infection. Breast density, imaging findings, and biopsy results were recorded. Specificity, positive predictive values, and negative predictive values were calculated.

RESULTS

Eighteen percent (76 of 413) of cases demonstrated an imaging correlate. Of these, 74% (56 of 76) occurred in dense breasts and 26% (20 of 76) in nondense breasts. Seventy percent (14 of 20) of lesions in nondense breasts were seen with mammography and ultrasound, whereas 30% (6 of 20) were detected only with ultrasound. Of lesions detected in dense breasts, 29% (16 of 56) were seen with mammography and ultrasound, whereas 71% (40 of 56) were detected only with ultrasound. Thirty-one percent (24 of 76) of cases were biopsied, 42% (10 of 24) of which were detected by ultrasound only. No cancer was detected in initial workup. At 2-year follow-up, three women, all with dense breasts, developed cancer in the same quadrant as the initial pain.

CONCLUSIONS

Directed ultrasound, when performed in conjunction with digital mammography for the evaluation of focal breast pain in women with nondense breasts, is of low utility and may contribute to unnecessary intervention as a result of incidental findings.

A cost-effective handheld breast scanner for use in low-resource environments: a validation study

Background

With the incidence of breast cancer rising worldwide, we are evaluating the iBreastExam (iBE) (UE LifeSciences Inc.), a handheld breast scanning device that can be utilized by community health workers to screen for breast abnormalities. The purpose of this study is to determine the sensitivity of the iBE in a population undergoing diagnostic breast imaging.

Methods

Adult patients presenting to a breast imaging center for a diagnostic workup were eligible. Patients underwent an iBE exam performed by a trained ultrasound technician followed by their indicated imaging. Demographic, imaging, and biopsy data were recorded.

Results

Seventy-eight iBE exams were completed, 77 females and one male with a mean age of 42 (21–79). All patients were evaluated by ultrasound, 52 had diagnostic mammography and 39 had biopsies. Imaging and/or biopsy confirmed a mass (fibroadenoma, cyst, papilloma, myofibroblastoma, fat necrosis, DCIS, or cancer) in 60 patients. Twelve patients had a cancer diagnosed. In total, 342 quadrants were scanned, 77 quadrants had lesions confirmed on imaging, and iBE correctly identified 66 lesions for a sensitivity of 86 % and specificity of 89 %.

Conclusions

This validation study demonstrated excellent sensitivity of iBE for the identification of clinically significant lesions in patients presenting for diagnostic imaging.

Trial registration

A Cost-Effective Handheld Breast Scanner for Use in Low Resource Environments: A Validation Study: NCT02814292.

[Breast pain: Recommendations]

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).

Mastalgia-Cancer Relationship: A Prospective Study

OBJECTIVE

Mastalgia is an important symptom affecting approximately 70% of women and it disrupts the quality of life especially due to the worry of having cancer. In our study, the type and severity of mastalgia symptom of patients who presented to the outpatient clinic with mastalgia complaint were assessed along with their physical examination findings and radiology results. The purpose of the study is to demonstrate the relationship between mastalgia and malignity when assessed in combination with the risk factors of patients.

MATERIALS AND METHODS

The age, family history, menopausal status, age at the first childbirth, menarche, presence/absence of hormone replacement therapy, type of mastalgia, comorbidities and examination findings of 104 patients, who presented to the General Surgery outpatient clinic with mastalgia symptom, were recorded and assessed in the light of radiological study results.

RESULTS

With respect to the mastalgia types of the patients, 38.5% had cyclic pain, 57.7% non-cyclic pain and 3.8% other types of pain. Mild mastalgia was present in 46.2% of the patients, moderate mastalgia in 24% and severe mastalgia in 29.8% of them. According to the BIRADS category, 48.1% of the patients were identified to have BIRADS 1 mass lesions, 39.4% BIRADS 2, 9.6% BIRADS 3 and 2.9% BIRADS 5 mass lesions. The patients who were identified to have BIRADS 5 mass lesions described non-cyclic and severe pain in the post-menopausal period. They had palpable masses along with the pain symptom.

CONCLUSION

Our study suggests that mastalgia symptom does not per se result in suspicion of malignancy, but physical examination and radiological imaging should also be used as needed for confirmation. Studies with a larger patient population are needed to shed light on the mastalgia epidemiology and its relationship with cancer.