Evaluating breast pain following negative mammogram: Is US needed?
Should a patient with breast pain and a normal mammogram also have a breast ultrasound examination? Unless the patient presents with multiple symptoms, such as nipple discharge or palpable concerns, research conducted at Columbia University Medical Center in Manhattan suggests not. In a study published online in Current Problems in Diagnostic Radiology in January, radiologists reported that mammography alone effectively excluded malignancy in over 500 women with isolated complaints of breast pain.
Mastalgia -- cyclic and noncyclic breast pain -- generates concern that it may be a symptom of malignancy, especially if it is persistent, localized, and unilateral. While rates of malignancy in patients presenting with mastalgia have been reported in multiple studies as less than 4%, a mammogram is usually performed, followed by targeted ultrasound examination in the area of indicated pain.
The authors conducted a study to evaluate the diagnostic value of breast ultrasound following a normal mammogram ordered for all patients with breast pain during a calendar year. The study included 559 women who ranged in age from 27 to 97 (median 46 years). The majority (70%) had no other symptoms, but one-fourth also reported skin changes, nipple discharge, and/or had concerns about palpable masses.
Patients’ breast pain was categorized into five types: focal, diffuse, cyclical, unilateral or bilateral. Mammographic breast density scores and Breast Imaging-Reporting and Data System (BI-RADS) final assessments were recorded and analyzed. Nearly half of the patients had heterogeneously dense breasts (46%) and 8.6% had dense breasts. The overwhelming majority (79%) had BI-RADS 1 or 2 scores, with 12.9% having BI-RADS 3, and 8.1% having BI-RADS 4.
Twenty-six patients underwent tissue biopsy. This included only one patient in the group of 374 women who did not have additional symptoms (0.0003%). Lead author Eralda Mema, MD, reported that malignancy was identified in 2 patients, one who also had nipple discharge (1 out of 22 patients, or 4.5%) and the other with palpable concern (1 out of 134 patients, or 0.7%).
“Our results suggest that ultrasound evaluation in the setting of a negative mammogram is not indicated. No malignancies were identified with the addition of ultrasound examination in mammographically normal patients presenting with mastalgia. Furthermore, malignancy was not impacted by bone density,” wrote the authors. “We believe that obtaining an ultrasound examination in these patients may increase the number of follow-ups of probably benign (BI-RADS 3) lesions and subsequently increase the rate of benign biopsies. Mammography alone was effective in excluding malignancy in our cohort of patients with isolated complaints of breast pain.”
The authors recommend that similar, larger studies be performed to validate their findings. They also recommend that long-term multi-year studies of women who present with breast pain be initiated, noting that none have yet been performed.
REFERENCE
- Mema E, Cho E, Ryu Y-K, et al. In the setting of negative mammogram, is additional breast ultrasound necessary for evaluation of breast pain? Curr Probl Diagn Radiol. Published online January 9, 2018. doi: 10.1067/j.cpradiol.2017.12.007.