ACR Appropriateness Criteria Palpable Breast Masses

Abstract

A palpable breast mass is one of the most common presenting features of breast carcinoma. However, the clinical features are frequently nonspecific. Imaging performed before biopsy is helpful in characterizing the nature of the mass. For women with clinically detected breast masses, the vast majority will require evaluation with ultrasound. Diagnostic mammography is the initial imaging modality of choice for women aged ≥ 40 years; ultrasound is typically necessary unless a definitively benign mass is identified as the etiology of the clinical finding. For evaluating women aged <30 years and women who are pregnant or lactating, ultrasound is used for initial evaluation. For women aged 30 to 39 years, either ultrasound or diagnostic mammography may be used for initial evaluation. MRI is rarely indicated to evaluate a clinically detected finding. Biopsy is indicated for masses with suspicious features. Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma. Correlation between imaging and the clinical finding is essential. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Breast Ultrasound Past, Present, and Future

“…Ultrasound is an adjunct to mammography for mass characterization and is the next examination to perform for characterization of a mammographic mass, per ACR appropriateness criteria [26]. It is critical to establish the location and depth of the mass identified on mammography to ensure that the same area is imaged during breast ultrasound.…”

“…Ultrasound is the initial imaging modality used to evaluate a palpable mass in a patient less than 30 years old [26]. After an abnormality is detected with ultrasound, it is debatable as to whether the next examination to perform is a unilateral mammogram imaging the breast with the sonographic abnormality, a bilateral mammogram, or an ultrasound guided biopsy of the abnormality.…”

“…After an abnormality is detected with ultrasound, it is debatable as to whether the next examination to perform is a unilateral mammogram imaging the breast with the sonographic abnormality, a bilateral mammogram, or an ultrasound guided biopsy of the abnormality. Per ACR appropriateness criteria, either mammography or a biopsy is appropriate and the determination of the next examination is likely patient dependent [26]. Masses often found in this patient population include cysts, fibroadenomas, and very infrequently breast cancer.…”

Breast Ultrasound: Indications and Findings

“…Sonography should be carried out even if the mammogram is negative. 8 In symptomatic women, 10% to 15% of cancers are not observed on mammography but are detected on sonography. 7 In a study, 97.5% of palpable cancers and 67.9% of nonpalpable cancers were observed on sonography.…”

“…If there is a high suspicion for the palpable lesion and the mammogram and ultrasound are both negative, non-image-guided biopsy should be performed. 8 For women between 30 and 39 years of age, ACR Appropriateness Criteria indicate that either a mammogram or an ultrasound examination is the correct first step. 8 At our facility we perform mammographyasthefirststeponmostsymptomatic women over 30 years old.…”