Contributed by: Steven J. Rockoff, MD and Diana L. Lam, MD - June 1, 2020
A 35-year-old woman with no increased risk factors for the development of breast cancer presents with a palpable right breast lump, underlying an area of skin discoloration. She reports being involved in a motor vehicle accident two weeks ago. The technologist asks you which type of exam to perform first. You answer:
A. Screening mammogram B. Diagnostic ultrasound and mammogram C. Screening ultrasound
B. Diagnostic ultrasound and mammogram
Explanation:
In this clinical scenario (a woman between 30-39 years old, with no known elevated risk factors for breast cancer, with a palpable mass), the most appropriate imaging exam to perform first is a diagnostic ultrasound and bilateral mammogram.
According to current American College of Radiology Appropriateness Criteria, for a woman between 30 and 39 years of age who presents with a palpable breast complaint, both mammography and ultrasound are usually appropriate modalities to use for diagnostic evaluation. At our institution, we usually perform ultrasound first in this demographic.
A screening exam, whether with mammogram or ultrasound, is not appropriate in the setting of a focal breast complaint.
The ultrasound was performed first and did not demonstrate any definite sonographic findings at the area of concern. A bilateral diagnostic mammogram was then performed. Only the affected right breast is shown here. A BB marker was taped over the palpable lump.
Whole right breast views:
Spot compression views:
What is the relevant finding?
A. The mammogram is negative B. A cyst C. A fat-containing mass D. Architectural distortion
Answer: C. A fat-containing mass
Explanation:
The images demonstrate several circumscribed fat-containing round and oval masses.
What is your assessment?
A. Fat necrosis: BI-RADS 2 B. Fat necrosis: BI-RADS 0 C. Fat necrosis: BI-RADS 4 D. Hamartoma: BI-RADS 4
Answer: A. Fat necrosis: BI-RADS 2
Explanation:
In the setting of recent trauma to the breast, these fat-containing masses are consistent with fat necrosis. This is a benign finding and no further work-up is indicated.
Of note, although there was no significant ultrasound finding in this case, fat necrosis can have a variable (and sometimes scary) sonographic appearance. In the setting of an uncertain ultrasound finding, mammography is quite valuable if it can unquestionably demonstrate a fat-containing mass.
