A multicentre review of the direct-access mammography programme in Ireland for women with breast pain.

AIM: To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort. MATERIALS AND METHODS: A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded. RESULTS: The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer. CONCLUSION: There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

Male patients with unilateral breast symptoms: an optimal imaging approach.

OBJECTIVES: To evaluate the usefulness of bilateral mammography in male patients with unilateral breast symptoms, including investigation of the diagnostic performance of unilateral and bilateral reviews and the average glandular dose (AGD) per exposure. METHODS: Two hundred seventy-one consecutive male patients (mean age, 57 years) with unilateral breast symptoms underwent bilateral mammography. Image interpretation was performed in two ways, first with a unilateral review of the symptomatic breast and then with a bilateral review. A modified BI-RADS scale (from 1 to 5) was used. The diagnostic performance of unilateral and bilateral reviews was compared, and contralateral breast abnormalities and the AGD per exposure were recorded. We also analyzed ultrasound (US) results and compared them with mammography. RESULTS: Of 271 male patients, 29 were pathologically diagnosed with breast cancer. There was no bilateral breast cancer. The sensitivity, specificity, positive and negative predictive values, and accuracy were 96.6%, 96.7%, 77.8%, 99.6%, and 96.7%, respectively, for unilateral review, and 96.6%, 95.9%, 73.7%, 99.6%, and 95.9% for bilateral review. Receiver operator characteristic analysis showed excellent diagnostic performance for both methods: the area under the curve (AUC) was 0.966 for unilateral review and 0.962 for bilateral review (p = 0.415). The mean AGD per exposure was 1.10 ± 0.29 mGy for symptomatic breast and 1.04 ± 0.30 mGy for contralateral breast (p < 0.001). Diagnostic performance parameters of US were not significantly different from bilateral or unilateral review of mammography. CONCLUSION: The diagnostic performance of unilateral mammography is comparable with bilateral mammography in male patients with unilateral breast symptoms. Unilateral mammography also has the advantage of reducing radiation exposure. KEY POINTS: • There is limited knowledge about standardized guidelines or recommendations for imaging the male breast. • Unilateral mammography for male patients with unilateral breast symptoms showed comparable diagnostic performance with bilateral mammography. • Both unilateral and bilateral mammography showed excellent diagnostic performance in the assessment of male patients with unilateral breast symptoms.

Breast Pain, A Common Grievance: Guidance to Radiologists.

OBJECTIVE. Breast pain is a common complaint among women and a frequent reason they seek health care, including imaging. However, breast pain is infrequently associated with breast cancer. This article reports and synthesizes the evidence about the risk of malignancy with breast pain, the use of imaging to evaluate breast pain, the detection of treatable symptomatic lesions by imaging, and the ability of negative examination findings to reassure patients. Evidence-based guidance for the imaging evaluation of breast pain is presented, and areas that warrant further research are described. CONCLUSION. The studies evaluating the role of imaging in breast pain are limited and conflicting. The clinician and patient should discuss the drawbacks and benefits of imaging to decide whether it is worth pursuing. If imaging is performed, ultrasound, mammography, or both should be done depending on the age of the patient. Areas worthy of further research include larger studies using modern techniques to evaluate the utility of imaging in patients with breast pain, the best way to assist clinicians in avoiding unnecessarily imaging patients with breast pain, and the utility of imaging results to reassure patients with breast pain.

Development of Breast Imaging Specific Entrustable Professional Activities Using a Double Delphi Technique.

RATIONAL AND OBJECTIVES: To develop subspecialty-specific entrustable professional activities for breast imaging radiology (EPA-BRs) through the use of a double consensus-driven, validity-enhancing methodology that may be relevant to other subspecialties in radiology and medicine in general. MATERIALS AND METHODS: A six-step methodology was used to develop EPA-BRs via a double Delphi process followed by educational theorist's refinement. Two groups of experts completed each Delphi process: the core group of breast imaging educators and an expert panel of national experts in breast imaging standards and appropriateness. RESULTS: Five EPA-BRs were developed, with eight nested EPA-BRs, one of which is elective. This comprehensive list of EPA-BRs covers the role of a breast imaging radiologist in the care of a patient from detection of breast cancer to post-treatment follow-up. CONCLUSION: A combined modified and classic double Delphi approach can be utilized by other graduate medical education (GME) specialties and subspecialties as a method by which GME education can be transformed into a clinical framework that more closely bridges individual competencies and real-world clinical practice.

Focal breast pain: imaging evaluation and outcomes.

OBJECTIVES: To determine the number and characteristics of cancers detected and the optimal imaging evaluation in women presenting with focal breast pain (FBP). MATERIALS AND METHODS: We performed a retrospective review of 4720 women who underwent imaging for FBP from 2001 to 2013. Women 18 and over with one or two foci of breast pain and no concurrent breast symptoms were included. 944 patients met criteria. We recorded the imaging work-up, presence and type of finding at the site of pain, BI-RADS® assessment, and pathological outcomes. Subsequent imaging and clinical follow up was recorded. RESULTS: Imaging evaluation consisted of sonogram alone in 286 women, mammogram alone in 231 women, and both in 427 women. 113 women had an imaging finding at the site of pain; 103 were designated benign or probably benign. 12 biopsies of corresponding findings were performed: 9 benign, 1 invasive lobular carcinoma, 1 invasive ductal carcinoma, 1 ductal carcinoma in situ. All three malignancies were seen mammographically; 2 had an ultrasound correlate. At initial evaluation, 4 incidental breast cancers were diagnosed remote from the site of FBP. All were seen on mammogram and 2 of 4 had an ultrasound correlate. On follow up evaluation, 9 cancers were diagnosed at the site of pain and 13 incidental cancers were diagnosed. CONCLUSION: FBP is rarely associated with malignancy. Targeted ultrasound may be deferred in women 40 and older with FBP, no other clinical findings, and a negative mammogram.

In the Setting of Negative Mammogram, Is Additional Breast Ultrasound Necessary for Evaluation of Breast Pain?

PURPOSE: To evaluate whether in the setting of negative diagnostic mammogram for breast pain additional ultrasound is necessary. METHODS: Retrospective IRB-approved review of our database identified 8085 women who underwent ultrasound evaluation for breast pain from 1/1/2013-12/31/2013. Of 8085 women, 559 women had mammogram evaluation preceding the ultrasound and these women comprise the basis of this study. The patient's age, type of mammogram examination (screening or diagnostic), Breast Imaging-Reporting and Data System (BI-RADS) breast density (BD), type of breast pain (focal, diffuse, cyclical, unilateral, bilateral), additional breast symptoms (palpable concern, nipple discharge, skin changes, others), mammogram or ultrasound findings and final BI-RADS assessment, follow-up imaging, and follow-up biopsy results were reviewed and recorded. RESULTS: The median age of patients was 46 years old (range: 27-97). Patients recalled from negative screening mammogram were 29.8% (167/559). Patients with preceding negative diagnostic mammogram were 70.2% (392/559). The BI-RADS BD distribution was BD1: 5.5%, BD2: 39.9%, BD3: 46.0%, BD4: 8.6%. Final BI-RADS assessments were BI-RADS 1/2 (79%), BI-RADS 3 (12.9%), BI-RADS 4 (8.1%), BI-RADS 5 (0%). Majority (66.9%, 374/559) of the patient had breast pain alone. Additional breast symptoms were also noted as follows: palpable concern (24%), nipple discharge (3.9%), skin changes or other (5.2%). On follow-up evaluation, 26 findings were recommended for tissue sampling yielding 2 malignancies (0.4%, 2/559) in 2 patients. In the setting of negative mammogram and clinical symptom of breast pain alone yielded no malignances (NPV, 100%, 374/374) and was not impacted by BD. In patients with additional symptoms accompanying pain, malignancies were present despite negative mammogram in 2 patients; nipple discharge (4.5%, 1/22), and palpable concern (0.7%, 1/134). CONCLUSION: In the setting of negative mammogram and breast pain alone, additional evaluation with ultrasound is likely low yield and may be unnecessary. However, with additional symptoms such as palpable concern or nipple discharge, ultrasound is likely an important adjunct modality for identifying mammographically occult tumors.

ACR Appropriateness Criteria® Breast Pain.

Breast pain is a common complaint. However, in the absence any accompanying suspicious clinical finding (eg, lump or nipple discharge), the association with malignancy is very low (0%-3.0%). When malignancy-related, breast pain tends to be focal (less than one quadrant) and persistent. Pain that is clinically insignificant (nonfocal [greater than one quadrant], diffuse, or cyclical) requires no imaging beyond what is recommended for screening. In cases of pain that is clinically significant (focal and noncyclical), imaging with mammography, digital breast tomosynthesis (DBT), and ultrasound are appropriate, depending on the patient's age. 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 include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Evaluation of 1294 Female Patients with Breast Pain: A Retrospective Study.

INTRODUCTION: Mastalgia, or breast pain, is one of the most important complaints referred to outpatient clinics. The objective of this study was to evaluate the factors causing mastalgia. All patients who presented to our clinic with complaints of mastalgia were assessed along with their type of mastalgia symptoms, menopausal status, and radiology results. METHODS: A total of 3157 patients with mastalgia complaints visited our clinic between January 2015 and February 2018. Only 1294 of them were retrospectively screened. Age, sex, menopausal (premenopausal, postmenopausal) status, mastalgia type (cyclic, non-cyclic), and imaging findings of the patients were examined. RESULTS: The mean age was 43.8 ± 11.8 (13-86) years, with 453 (35%) patients younger than 40 years and 841 (65%) older than 40. Cyclic mastalgia was found in 207 (16%) patients, and non-cyclic mastalgia was seen in 1087 (84%) patients. A total of 786 (60.7%) patients were premenopausal, and 508 (39.3%) were postmenopausal. Mammography was used in 545 (42.1%) patients; 1190 (92.0%) women had breast ultrasonography. CONCLUSION: Although breast pain is a common symptom in women who are referred to breast outpatient clinics, we concluded that patients who complain of mastalgia should not be afraid of cancer. Despite this and for reassurance, clinical imaging may be necessary to alleviate these patients' suspicions.

Mastitis granulomatosa lobulillar idiopática: manejo radiológico a propósito de dos casos / Idiopathic lobular granulomatous mastitis: radiological management in two cases

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Overutilization of Health Care Resources for Breast Pain.

OBJECTIVE: The objective of this study is to analyze the incidence of women with breast pain who present to an imaging center and assess the imaging findings, outcomes, and workup costs at breast imaging centers affiliated with one institution. MATERIALS AND METHODS: Demographic characteristics of and imaging findings for female patients presenting with breast pain at three community breast imaging centers between January 1, 2014, and December 31, 2014, were reviewed. Patients who were pregnant, were lactating, had a history of breast cancer, or presented with palpable nipple or skin findings were excluded. RESULTS: A total of 799 patients met the study criteria. Pain was diffuse in 30%, was focal in 30%, and was not localized in 40%. Of the 799 patients with breast pain, 790 (99%) presented for a diagnostic evaluation; 759 (95%) of these evaluated patients had negative findings. A benign sonographic correlate was detected in the area of pain in 5% of patients (39/799). One patient had a single cancer detected in the contralateral asymptomatic breast. When correlations between breast pain and the presence of cancer in the study patients were compared with the concurrent cancer detection rate in the screening population (5.5 cases per 1000 examinations performed), breast pain was not found to be a sign of breast cancer (p = 0.027). Patients younger than 40 years (316/799) underwent a total of 454 workup studies for breast pain; all findings were benign, and the cost of these studies was $87,322. Patients 40 years or older (483/799) underwent 745 workup studies, for a cost of $152,732. CONCLUSION: Breast pain represents an area of overutilization of health care resources. For female patients who present with pure breast pain, breast imaging centers should consider the following imaging protocols and education for referring physicians: an annual screening mammogram should be recommended for women 40 years or older, and reassurance without imaging should be offered to patients younger than 40 years.

To image or not in noncyclic breast pain? A systematic review.

PURPOSE OF REVIEW: Investigation of noncyclic mastalgia in women without signs or risk factors for cancer is controversial. An initial imaging strategy can diagnose breast cancer early, potentially leading to better treatment and survival. However, cancer diagnosis is very uncommon in these cases, and this approach can be harmful, as false positives or suspicion results will lead to unneeded interventions and follow-up. The purpose of this review is to analyse the trade-offs between desirable and undesirable consequences of initial imaging tests against clinical follow-up. RECENT FINDINGS: We found seven relevant studies, all observational, with some methodological limitations and very low-quality evidence. They showed low breast cancer prevalence (around 1-2%, increasing with age), high sensitivity to rule out disease but moderate specificity to rule it in using mammography and echography, and lacked evidence on follow-up and final outcomes. SUMMARY: There is a low prevalence of breast cancer in patients with painful breast with negative physical examination, and very little research to inform about the effect of performing or avoiding initial imaging test on outcomes of interest. With such limited evidence, only a weak recommendation to reinforce shared decision making about what should be done in the primary care setting can be made, with the backup of a specialized breast unit.

ACR Appropriateness Criteria® Breast Pain.

Breast pain (or tenderness) is a common symptom, experienced by up to 80% of women at some point in their lives. Fortunately, it is rarely associated with breast cancer. However, breast pain remains a common cause of referral for diagnostic breast imaging evaluation. Appropriate workup depends on the nature and focality of the pain, as well as the age of the patient. Imaging evaluation is usually not indicated if the pain is cyclic or nonfocal. For focal, noncyclic pain, imaging may be appropriate, mainly for reassurance and to identify treatable causes. Ultrasound can be the initial examination used to evaluate women under 30 with focal, noncyclic breast pain; for women 30 and older, diagnostic mammography, digital breast tomosynthesis, and ultrasound may all serve as appropriate initial examinations. However, even in the setting of focal, noncyclic pain, cancer as an etiology is rare. 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 include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Mastalgia: Imaging Work-up Appropriateness.

RATIONALE AND OBJECTIVES: Radiologists frequently image women with the sole complaint of mastalgia (breast pain). We hypothesized that whereas the vast majority of women ultimately have no imaging explanation for their breast pain, a small percentage of patients may have a correlative imaging finding and confirm the current American College of Radiology Appropriateness Criteria recommendations. MATERIALS AND METHODS: In this Health Insurance Portability and Accountability Act (HIPAA)-compliant, institutional review board-approved retrospective review, we evaluated 236 women between the ages of 18 and 83 years who presented to our Breast Care Center in 2013 with the sole complaint of breast pain or tenderness. Patients' clinical presentation, diagnostic imaging work-up, and clinical and radiographic follow-up were documented. Outcomes of the diagnostic work-up were compared with the American College of Radiology Appropriateness Criteria recommendations. RESULTS: Of the 236 patients, 10 women had cyclical breast pain, 116 had noncyclical, nonfocal breast pain, and 110 had noncyclical, focal breast pain. No imaging correlates were discovered to explain the etiology of cyclical pain, supporting the American College of Radiology Appropriateness Criteria rating values. A definitive imaging correlate for breast pain was identified in seven women (3%) with noncyclical, focal pain, one of which was a cancer diagnosis (0.4%), which correlates with the American College of Radiology Appropriateness Criteria ratings. No imaging correlates were found in women with noncyclical, nonfocal pain, supporting the American College of Radiology Appropriateness Criteria ratings. CONCLUSION: There was no radiological imaging finding to explain the etiology of mastalgia in most women. Diagnostic imaging may be an appropriate diagnostic evaluation in patients with noncyclical, focal breast pain, supporting the American College of Radiology Appropriateness Criteria recommendations.

Focal Breast Pain: Does Breast Density Affect the Need for Ultrasound?

RATIONALE AND OBJECTIVES: This study aimed to determine the utility of directed ultrasound and digital mammogram for evaluating focal breast pain in women with different mammographic breast densities. MATERIALS AND METHODS: This institutional review board-approved and Health Insurance Portability and Accountability Act-compliant retrospective study included 413 cases of focal breast pain in 369 women (mean age 53 years). All cases were evaluated with both mammogram and ultrasound and had at least 2 years of imaging follow-up. Exclusion criteria were non-focal, axillary, or radiating pain; palpable or skin changes; pregnancy or lactation; and history of trauma or infection. Breast density, imaging findings, and biopsy results were recorded. Specificity, positive predictive values, and negative predictive values were calculated. RESULTS: Eighteen percent (76 of 413) of cases demonstrated an imaging correlate. Of these, 74% (56 of 76) occurred in dense breasts and 26% (20 of 76) in nondense breasts. Seventy percent (14 of 20) of lesions in nondense breasts were seen with mammography and ultrasound, whereas 30% (6 of 20) were detected only with ultrasound. Of lesions detected in dense breasts, 29% (16 of 56) were seen with mammography and ultrasound, whereas 71% (40 of 56) were detected only with ultrasound. Thirty-one percent (24 of 76) of cases were biopsied, 42% (10 of 24) of which were detected by ultrasound only. No cancer was detected in initial workup. At 2-year follow-up, three women, all with dense breasts, developed cancer in the same quadrant as the initial pain. CONCLUSIONS: Directed ultrasound, when performed in conjunction with digital mammography for the evaluation of focal breast pain in women with nondense breasts, is of low utility and may contribute to unnecessary intervention as a result of incidental findings.

Mastalgia Due to Degenerative Changes of the Spine.

BACKGROUND: Mastalgia is a common and enigmatic condition; the cause and optimal treatment are still inadequately defined. Cervical radiculopathy, which is the result of cervical nerve root pathology often caused by spaceoccupying lesions such as cervical disc herniation, spondylosis, or osteophytosis, is frequently encountered in physical therapy. OBJECTIVES: The aim of the study was to evaluate the incidence of vertebral pathologies in patients with non-cyclic mastalgia and the efficacy of conservative treatment of these pathologies on relieving breast pain. MATERIAL AND METHODS: One hundred patients were included in the study, all with breast pain continuing throughout the day and lasting at least three months. Breast and axillary physical examinations, mammographic and/or ultrasonographic evaluations were normal in all the patients. The patients' pain levels were scored using a visual analog scale (VAS). Cervical and thoracic spine magnetic resonance imaging (MRI) was performed on all the participants. RESULTS: Among 96 patients that had pathological findings on magnetic resonance imaging (96%), 49 women had diffuse annular bulging of the cervical spine, and 47 had cervical disc protrusion. Additionally, 12 patients had thoracic disc protrusion. At the end of the three-month period, the patients who were given only conservative treatment returned for follow-up evaluations. According to the VAS scores, five patients had mild to moderate improvement, 55 showed significant improvement, and 29 achieved complete remission. CONCLUSIONS: The authors concluded that if none of the known causes of breast pain are found in a patient, the patient should be evaluated for vertebral pathologies.

Breast tenderness after initiation of conjugated equine estrogens and mammographic density change.

We examined the association between new-onset breast tenderness and change in mammographic density after initiation of conjugated equine estrogens (CEE). We analyzed baseline, year 1 and 2 data from 695 participants of the Women's Health Initiative Estrogen + Progestin (daily CEE 0.625 mg + medroxyprogesterone acetate 2.5 mg [MPA] or placebo) and Estrogen-Alone (CEE 0.625 mg or placebo) trials who participated in the Mammogram Density Ancillary Study. Using multivariable repeated measures models, we analyzed the association between new-onset breast tenderness (i.e. absence of baseline tenderness and presence of tenderness at year 1 follow-up) and change from baseline in percent mammographic density. Active therapy increased the odds of new-onset breast tenderness (CEE + MPA vs. placebo risk ratio [RR] 3.01, 95% confidence interval [95% CI] 1.96-4.62; CEE vs. placebo RR 1.70, 95% CI 1.14-2.53). Among women assigned to CEE + MPA, mean increase in mammographic density was greater among participants reporting new-onset of breast tenderness than among participants without new-onset breast tenderness (11.3 vs. 3.9% at year 1, 9.4 vs. 3.2% at year 2, P < 0.001). Among women assigned to CEE alone, increase in mammographic density at year 1 follow-up was not significantly different in women with new-onset breast tenderness compared to women without new-onset breast tenderness (2.4 vs. 0.6% at year 1, 2.2 vs. 1.0% at year 2, P = 0.30). The new-onset of breast tenderness after initiation of CEE + MPA, but not CEE alone, is associated with greater increases in mammographic density.

Mammographic breast pattern in Nigerian women in Ibadan, Nigeria.

INTRODUCTION: Mammographic breast density is dependent on the relative proportion of radiolucent fat and radio-dense connective and glandular tissue. This breast density is said to be a marker of risk for breast cancer and has received widespread interest in many countries in recent years. AIMS AND OBJECTIVES: The main objective of this study is to estimate the prevalence of the various mammographic breast density patterns and seeks to find any association between the reported breast patterns and various demographic variables in women in Ibadan, South West Nigeria. METHODS: A prospective descriptive study of mammographic breast pattern in 498 women at the Department of Radiology, University College Hospital Ibadan. Two screening views and additional views when necessary were done on each breast with the Senographe DMR+ Mammographic Unit. Participants also completed an assisted administered questionnaire which was used to obtain data on their socio-demographic characteristics. RESULTS: The study confirmed significant association with age and parity as in previous reports in the diaspora. CONCLUSION: The study confirmed denser mammographic breast pattern in younger and nulliparous women. Future work on mammographic density and other variables is contemplated for complete cancer related data in our peculiar setting.