What is the yield of breast MRI in the assessment of palpable breast findings?

ACR Appropriateness Criteria® Imaging of Invasive Breast Cancer

As the proportion of women diagnosed with invasive breast cancer increases, the role of imaging for staging and surveillance purposes should be determined based on evidence-based guidelines. It is important to understand the indications for extent of disease evaluation and staging, as unnecessary imaging can delay care and even result in adverse outcomes. In asymptomatic patients that received treatment for curative intent, there is no role for imaging to screen for distant recurrence. Routine surveillance with an annual 2-D mammogram and/or tomosynthesis is recommended to detect an in-breast recurrence or a new primary breast cancer in women with a history of breast cancer, and MRI is increasingly used as an additional screening tool in this population, especially in women with dense breasts. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Palpable Breast Masses: 2022 Update

Palpable masses in women are the most common symptom associated with breast cancer. This document reviews and evaluates the current evidence for imaging recommendations of palpable masses in women less than 30 to over 40 years of age. There is also a review of several different scenarios and recommendations after initial imaging. Ultrasound is usually the appropriate initial imaging for women under 30 years of age. If ultrasound findings are suspicious or highly suggestive of malignancy (BIRADS 4 or 5), it is usually appropriate to continue with diagnostic tomosynthesis or mammography with image-guided biopsy. No further imaging is recommended if the ultrasound is benign or negative. The patient under 30 years of age with a probably benign ultrasound may undergo further imaging; however, the clinical scenario plays a role in the decision to biopsy. For women between 30 to 39 years of age, ultrasound, diagnostic mammography, tomosynthesis, and ultrasound are usually appropriate. Diagnostic mammography and tomosynthesis are the appropriate initial imaging for women 40 years of age or older, as ultrasound may be appropriate if the patient had a negative mammogram within 6 months of presentation or immediately after mammography findings are suspicious or highly suggestive of malignancy. If the diagnostic mammogram, tomosynthesis, and ultrasound findings are probably benign, no further imaging is necessary unless the clinical scenario indicates a biopsy. 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 process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Palpable Breast Findings in High-risk Patients: Are Self- and Clinical Breast Exams Worthwhile?

OBJECTIVE

To assess breast imaging findings, biopsy rates, and malignancy rates in areas of palpable concern in women at high risk for breast cancer.

METHODS

An IRB-approved retrospective review of a tertiary cancer center's breast imaging database was performed. Breast imaging and electronic medical records of high-risk women with palpable findings detected on self- or clinical breast examination from January 1, 2010, to January 1, 2016, were reviewed. Descriptive statistical analyses were conducted.

RESULTS

Imaging correlates for 322 palpable findings in 238 high-risk women included 55/203 (27.1%) on mammography, 183/302 (60.6%) on US, and 20/47 (42.6%) on MRI. Biopsies were performed for 104/322 (32.3%) palpable findings: 95/104 (91.3%) under imaging guidance and 9/104 (8.7%) under palpation after negative imaging. Of 322 palpable findings, 16 (5.0%) were malignant in 16/238 (6.7%) women, yielding a positive predictive value of biopsy of 16.8% (95% CI: 9.2%-24%). Women diagnosed with cancer had 16/16 (100%) sonographic, 9/14 (64.3%) mammographic, and 7/7 (100%) MRI correlates. Cancer histopathology included 12 invasive ductal carcinomas, 1 ductal carcinoma in situ, 1 invasive lobular carcinoma, 1 malignant phyllodes tumor, and 1 metastatic carcinoid tumor. Over two years of follow-up imaging in 183/238 (76.9%) women were reviewed; 7/183 (3.8%) were diagnosed with breast cancer at least one year after presenting with a palpable concern in a different location.

CONCLUSION

High-risk women with palpable findings exhibit a 6.7% malignancy rate, indicating the value of imaging workup in this population. In our cohort, imaging demonstrated a high negative predictive value.