Integrating salient imaging findings with clinical history is crucial when approaching the diagnosis of subcutaneous soft-tissue masses. The diagnosis of endometriosis should be entertained when soft-tissue masses are seen in the distribution of a cesarean section scar in a woman of reproductive age. Pain, particularly with a cyclic pattern, is highly suggestive of endometriosis. If endometriosis is suspected on CT or ultrasound, MRI can be performed for further evaluation. Definitive diagnosis is made with biopsy. Because subcutaneous nodules are so amenable percutaneous biopsy, imaging features, although of interest, are somewhat ancillary to the diagnostic workup.

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The purpose of the study was to determine the long-term clinical outcomes of women with breast pain in the absence of additional symptoms or signs (isolated breast pain), and the utility of mammography in their work-up. IRB approved, HIPAA compliant study retrospectively reviewed 1,386 patients referred for breast imaging with ICD-9 code for breast pain between 1/1/2006 and 12/31/2007. Of these, 617 consecutive women (mean age, 49 years) with isolated breast pain, mammogram, and follow-up (mean, 51 months) constituted the study group. Clinical data, mammographic and sonographic BI-RADS assessments, and geographic relationship between the site of cancer and pain were evaluated. The frequency of malignancies and of specific benign outcomes, both at and subsequent to the time of presentation, was determined. Breast cancer and specific benign outcomes were diagnosed in the painful breast of 11/617 (1.8 %) and 63/617 (10.2 %) women, respectively. Majority of the cancers (9/11, 81.8 %) were diagnosed subsequent (5-52 months) to initial imaging evaluation, whereas the majority of benign outcomes (52/63, 82.5 %) were diagnosed at initial presentation. Diagnostic mammography at initial presentation had a negative predictive value of 99.8 % (95 % CI 99.1 %, 100 %), specificity of 98.5 % (95 % CI 97.2 %, 99.3 %), and sensitivity of 66.7 % (95 % CI 11.6 %, 94.5 %). Three cancers were subsequently diagnosed in the contralateral (non-painful) breast. Eleven of 14 (78.6 %) cancers were in the symptomatic breast, of which 9 (81.8 %) geographically corresponded to the same area of focal pain. Thus, infrequently, breast cancer may clinically present as or be preceded by isolated breast pain and diagnostic mammography is useful for assessment.

The finding of a palpable breast mass on physical examination often warrants a radiologic workup including directed ultrasonography, diagnostic mammography, and, at times, biopsy with ultrasonographic guidance. The choice of initial imaging study is most often guided by the patient's age at presentation. Communicating the clinical findings to both the patient and the radiologist helps ensure the selection of the most appropriate imaging studies and helps in the interpretation of those studies. Every woman with a palpable breast mass, regardless of her age, should undergo imaging to exclude or establish the diagnosis of cancer.