The radiologic workup of a palpable breast mass

Do Primary Care Physician Perform Clinical Breast Exams Prior to Ordering a Mammogram?

Both the American Cancer Society and National Comprehensive Cancer Network recommend annual clinical breast examination (CBE) along with screening mammogram (SM) for patients starting at 40 years of age. However, patients with a palpable breast mass should have a diagnostic mammogram (DM) during workup. Review at our institution demonstrated that 11% of patients with newly diagnosed breast cancer and self-identified breast mass had SM instead of DM. This led us to question whether primary care physicians (PCP) perform CBE prior to ordering mammography. As part of the routine preimaging screening, patients were asked if they had undergone breast examination by a medical provider prior to mammogram order. Data on mammogram type, ordering physician specialty, and presence of symptoms on day of mammogram were recorded. Of 6,109 mammograms, 4,823 were ordered by PCPs. CBE was performed prior to 67.2% SM and 64.8% DM (p = 0.12). OB/GYN performed statistically significantly higher CBE (81.6%) compared to internal (45.4%) and family (50.5%) medicine physicians (p < 0.001). Of patients with self-reported breast symptoms, 8.7% had SM ordered rather than DM. Despite recommendations, approximately 1/3 of women report not having CBE prior to mammogram. The chances of having a CBE varied significantly by PCP specialty. Lack of CBE can lead to incorrect type of mammogram, with possibly increased cost and delay in diagnosis. Further evaluation is needed to understand why CBE was not performed in some patients.

Use of simulators to explore specialty recommendation for a palpable breast mass

BACKGROUND

The aim of this study was to evaluate recommendation patterns of different specialties for the work-up of a palpable breast mass using simulated scenarios and clinical breast examination models.

METHODS

Study participants were a convenience sample of physicians (n = 318) attending annual surgical, family practice, and obstetrics and gynecology (OB/GYN) conferences. Two different silicone-based breast models (superficial mass vs chest wall mass) were used to test clinical breast examination skills and recommendation patterns (imaging, tissue sampling, and follow-up).

RESULTS

Participants were more likely to recommend mammography (P < .001) and core biopsy (P < .0001) and less likely to recommend needle aspiration (P < .043) and 1-month follow-up (P < .001) for the chest wall mass compared with the superficial mass. Family practitioners were less likely to recommend ultrasound (P < .001) and obstetrics and gynecologists were less likely to recommend mammogram (P < .006) across models. Surgeons were more likely to recommend core biopsy and less likely to recommend needle aspiration across models (P < .001).

CONCLUSIONS

Recommendation patterns differed across the 2 models in line with existing practice guidelines. Additionally, differences in practice patterns between primary care and specialty providers may represent varying clinician capabilities, healthcare resources, and individual preferences. Our work shows that simulation may be used to track adherence to practice guidelines for breast masses.

Is there a role for magnetic resonance imaging in diagnosing palpable breast masses when mammogram and ultrasound are negative?

BACKGROUND

The use of breast magnetic resonance imaging (MRI) for screening high-risk patients is well established. However, the role of MRI as a diagnostic problem-solving tool is less well studied. With the increasing availability of MRI, its use for problem solving has increased. This small retrospective study examines the use and utility of breast MRI in evaluating palpable breast masses with negative diagnostic mammogram and ultrasound studies.

METHODS

We reviewed our breast MRI database, selecting breast MRI studies performed to assess palpable abnormalities with negative mammogram and ultrasound findings. Evidence of cancer was determined by biopsy.

RESULTS

Seventy-seven studies were included, comprising 1.3% of all breast MRI studies performed at our institution during the study period (2005-2011). Twenty-two patients underwent biopsy, and 55 were followed clinically without biopsy. Approximately half (27 of 55) of the patients without biopsy were lost to follow-up after negative MRI, and the rest had no evidence of cancer on imaging or clinical examination at 1 year. Of the 22 patients who underwent biopsy, 2 were diagnosed with cancer, both with positive MRI studies. Sensitivity of MRI when compared to tissue diagnosis was 100%, and specificity was 70%. Positive and negative predictive values were 25% and 100%, respectively.

CONCLUSIONS

When used for evaluation of a palpable breast mass with negative traditional imaging, breast MRI likely offers low yield of cancer diagnosis and low specificity. Negative MRI results may cause a low compliance rate for recommended follow-up. Because a biopsy is indicated for persistent palpable masses, the addition of diagnostic MRI only adds another step, with associated costs and burdens.

[Diagnosis of breast cancer in women age 40 and younger: mammography and breast ultrasound]

Breast cancer is the leading cause of mortality among women aged 25 to 44 years in Serbia. The purpose of this study was to determine basic clinical and radiological features of breast cancer in young women. 93 women aged 31.0 +/- 3.5 years with breast cancer were identified. The analysis included clinical characteristics (TNM classification) and radiological features (mammography and breast ultrasound). 53.8% of the patients had locoregional disease. The mean diameter of breast cancer was 2.6 +/- 6 cm. Carcinoma in situ was found in 2.2%. Mammography was performed in 25.8% of the patients and breast ultrasound in 68.8%. The results of our study indicate that the diagnosis of breast cancer in young women is late, in the stage with palpable breast tumor and lymph node metastases. Mammography or breast ultrasound are not routinely used. The implementation of algorithms for breast cancer detection and diagnosis in young women helps in earlier detection of breast cancer and consequently improves outcomes.