Focal Breast Pain

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.

Introduction

Breast pain is one of the most common symptoms for which women seek medical care . Although up to 80% of women experience breast pain at some point in their lives, most commonly breast pain results from a benign etiology including idiopathic causes, simple cysts, trauma, infection, pregnancy, or lactation . In contrast, breast cancer is reported in up to 4% of women presenting with focal breast pain . Despite the uncommon association between breast cancer and focal breast pain, a diagnostic imaging workup can be requested . Current American College of Radiology Appropriateness Criteria guidelines rate the use of mammography and ultrasound for the evaluation of noncyclical, focal, unilateral, or bilateral breast pain in patients 30 years and older as “may be appropriate”; in women under 30, ultrasound is rated “may be appropriate” and mammography is rated “usually not appropriate” . Traditionally, both mammography and ultrasound are performed in women older than 30 years, who present with noncyclical, focal breast pain as imaging can often exclude a treatable benign cause of pain and/or provide reassurance .

However, current recommendations for imaging primary focal breast pain are controversial owing to the overall paucity of data limited by small sample sizes and short follow-up intervals . Furthermore, most studies include data obtained from film screen mammography, which has been replaced by digital mammography as the standard of care ( Table 1 ). One study to date has evaluated the utility of mammography over long follow-up intervals (average: 51 months), but this study included both screen film and digital mammograms . To our knowledge, there is no published work evaluating the utility of directed breast ultrasound in combination with digital mammography in a large study population over a long follow-up period. In addition, none of the previous work has assessed the utility of ultrasound in the setting of focal breast pain among women with different mammographic breast densities.

Table 1

Summary of Literature

Author Year Cohort Mean Duration of Follow-up No. of Cases with Benign Imaging Findings No. of Cases with Breast Cancer ( N ) (mo)N (%)N (%) Duijm et al. 1998 987 48 129(13) 4(0.4) Leddy et al. 2013 257 12 117(46) 3(1) Tumyan et al. 2005 86 26.5 82(95) \* 4(4.7) † Masroor et al. 2009 55(5 focal pain) 48 38(69) 0(0) Noroozian et al. 2015 617(304 focal pain) 51 63(10.2) 11(1.8) Leung et al. 2002 110 29 25(23) 0(0)

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Materials and Methods

Patient Inclusion and Exclusion Criteria

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Imaging Technique

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Data Collection

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Data Analysis

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Results

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Imaging

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Table 2

Imaging Findings in Women with Primary Focal Breast Pain

Modality Finding_N_ (%) Cases with imaging findings 76(100) Digital mammography 3(4) Calcifications 2(3) Asymmetry 1(1) Directed ultrasound 46(61) Cyst 32(42) Mass 8(11) Lymph node 3(4) Fibroadenoma 1(1) Fluid collection 1(1) Hypoechoic area 1(1) Digital mammography and directed ultrasound 27(36) Mass or asymmetry on digital mammogram found to be a cyst on directed ultrasound 14(18) Mass on digital mammogram found to be a milk duct on directed ultrasound 1(1) Postoperative change on digital mammography found to be a mass on directed ultrasound 1(1) Cyst 4(5) Mass 5(7) Silicone 2(3)

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Histology Results and Follow-up

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Table 3

Description of Breast Cancer Detected on Follow-up

Age (y) 64 50 68 Duration of follow-up (mo) 12 50 32 Imaging indication Routine screening Routine screening Palpable abnormality Imaging finding Mammogram Cluster of pleomorphic calcifications with an associated irregular spiculated mass None 8 mm area of grouped punctate, round calcifications Ultrasound 1.5 cm × 1.5 cm × 1.2 cm mass with angular margins 1 cm × 0.8 cm × 1 cm irregular mass None Histology Invasive ductal carcinoma Invasive ductal carcinoma Ductal carcinoma in situ Nodal status None None None Stage 1 1 0 Grade 3 1 Nuclear grade 2

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Breast Density

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Table 4

Mammographic Breast Density

Mammographic Density Nondense Breast Dense Breast Total Cohort ( N ) 180 233 413 Cases with imaging findings, N (%) 20(26) 56(74) 76(100) Cases with findings only on ultrasound, N (%) 6(13) 40(87) 46(100) Cases with subsequent cancer development, N (%) 0(0) 3(100) 3(100)

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Discussion

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References

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Focal Breast Pain

Rationale and Objectives

Materials and Methods

Results

Conclusions

Introduction

Materials and Methods

Patient Inclusion and Exclusion Criteria

Imaging Technique

Data Collection

Data Analysis

Results

Imaging

Histology Results and Follow-up

Breast Density

Discussion

References

Further Reading

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