Breast Symptom (New)
Pathway Home
Population Covered By The Guidance
This pathway provides guidance for women at any risk presenting with a new breast symptom including new breast lump, breast pain, breast or nipple asymmetry, skin changes or nipple changes. Imaging of new nipple discharge is covered separately.
Date reviewed: April 2018
Date of next review: March 2023
Published: November 2018
Quick User Guide
Move the mouse cursor over the PINK text boxes inside the flow chart to bring up a pop up box with salient points.
Clicking on the PINK text box will bring up the full text.
The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.
| SYMBOL | RRL | EFFECTIVE DOSE RANGE |
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None | 0 |
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Minimal | < 1 millisieverts |
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Low | 1-5 mSv |
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Medium | 5-10 mSv |
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High | >10 mSv |
Images
Image GalleryNote: These images open in a new page |
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|---|---|---|
| 1 |  |
Fibroadenoma Image 1 (Ultrasound): Within the upper outer quadrant of the left breast at the 2 o'clock position is a well circumscribed, ovoid hypoechoic lesion measuring 137mm maximally. No contained calcification or vascularity is identified. The appearance is consistent with, but not diagnostic of, a fibroadenoma. |
| 2 |  |
Fibroadenoma
Image 2 (H&E, x2.5): Histological section of a fibroadenoma showing compressed ducts (intra-canalicular growth pattern) surrounded by mild and bland stromal hypercellularity. The ducts are lined by a dual population of uniform epithelial and myoepithelial cells. |
| 3a |  |
Breast Carcinoma Image 3a (Mammogram, right breast): A non-calcified 22mm mass is present in the upper inner quadrant of the right breast. |
| 3b |  |
Image 3b (Ultrasound, right breast): Ultrasound of the same lesion showed an ill-defined solid mass with irregular margins, distortion of adjacent stroma and posterior acoustic shadowing, features which are suspicious for malignancy. Biopsy confirmed an invasive ductal carcinoma. |
| 4a |  |
Breast Carcinoma
Image 4a: Mastectomy showing an irregular pale tumour (arrow) with surrounding fibrosis consistent with a breast carcinoma. |
| 4b |  |
Image 4b (H&E, x2.5): Histological section of a moderately differentiated (Grade 2) invasive ductal carcinoma, type not otherwise specified, infiltrating through the breast parenchyma and surrounded by desmoplastic stroma. Occasional poorly formed tubules can be seen at the periphery (arrows). |
| 5 |  |
Breast Carcinoma Image 5 (H&E, x10): Histological section of a typical invasive lobular carcinoma showing the classical alignment of single cells in rows. |
Teaching Points
Teaching Points
- Imaging modality of a new breast symptom is dependent on the age of the woman and whether she is currently pregnant or lactating
- Young (<35), pregnant or lactating women should have a breast ultrasound first
- For women over 35, who are not pregnant or lactating, a mammogram is the initial imaging modality, followed by an ultrasound
- The most reliable way to diagnose breast cancer is through the ‘Triple Test’ consisting of:
- Medical history and breast examination
- Imaging (mammogram and/or ultrasound)
- Non-excisional biopsy (FNA and/or core biopsy)
- The Triple Test is positive if any component is indeterminate, suspicious or malignant. A positive triple test warrants specialist referral
- Although biopsy is not always required, it should be performed when the findings on clinical examination and/or breast imaging are not definitely benign
References
References
Date of literature search: August 2017 – April 2018
References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document
- Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000;61(8):2371-8, 85. View the reference
- Kharkwal S, Sameer, Mukherjee A. Triple test in carcinoma breast. Journal of Clinical and Diagnostic Research : JCDR. 2014;8(10):NC09-NC11. View the reference .
- National Health and Medical Research Council. National breast cancer centre. The investigation of a new breast symptom: a guide for general practitioners. Woolloomooloo (NSW)2006. View the reference
- The investigation of a new breast symptom: a guide for general practitioners 2017. Cancer Australia. 2017. View the reference
- Jackson VP, Reynolds HE, Hawes DR. Sonography of the breast. Seminars in Ultrasound, CT and MRI. 1996;17(5):460-75. View the reference
- American College of Radiology. ACR appropriateness criteria; breast pain. J Am Coll Radiol. Rockville MD: Agency for Healthcare Research and Quality (AHRQ); 2016. p. 11. View the reference
- Moy L, Heller SL, Bailey L, D'Orsi C, DiFlorio RM, Green ED, et al. ACR Appropriateness criteria. Palpable breast masses. J Am Coll Radiol. 2017;14(5s):S203-s24. View the reference
- Salzman B, Fleegle S, Tully AS. Common breast problems. Am Fam Physician. 2012;86(4):343-9. View the reference
- Bevers TB, Anderson BO, Bonaccio E, Buys S, Daly MB, Dempsey PJ, et al. Breast cancer screening and diagnosis. J Natl Compr Canc Netw. 2009;7(10):1060-96. View the reference
- Kösüs N, Kösüs A, Duran M, Simavli S, Turhan N. Comparison of standard mammography with digital mammography and digital infrared thermal imaging for breast cancer screening. J Turk Ger Gynecol Assoc. 2010;11(3):152-7. View the reference
- Gonzaga MA. How accurate is ultrasound in evaluating palpable breast masses? The Pan African medical journal. 2010;7:1. View the reference .
- Lehman CD, Lee AY, Lee CI. Imaging management of palpable breast abnormalities. Am J Roentgenol. 2014;203(5):1142-53. View the reference
- National Breast Cancer Centre. Breast imaging: a guide for practice. 2002. View the reference
- Hauge IH, Pedersen K, Olerud HM, Hole EO, Hofvind S. The risk of radiation-induced breast cancers due to biennial mammographic screening in women aged 50-69 years is minimal. Acta Radiol. 2014;55(10):1174-9. View the reference
- Breast imaging: a guide for practice. National Breast Cancer Centre. 2002: View the reference
- Faulk RM, Sickles EA. Efficacy of spot compression-magnification and tangential views in mammographic evaluation of palpable breast masses. Radiology. 1992;185(1):87-90. View the reference .
- Berkowitz JE, Gatewood OM, Gayler BW. Equivocal mammographic findings: evaluation with spot compression. Radiology. 1989;171(2):369-71. View the reference
- Michell MJ, Iqbal A, Wasan RK, Evans DR, Peacock C, Lawinski CP, et al. A comparison of the accuracy of film-screen mammography, full-field digital mammography, and digital breast tomosynthesis. Clin Radiol. 2012;67(10):976-81. View the reference
- Houssami N, Skaane P. Overview of the evidence on digital breast tomosynthesis in breast cancer detection. The Breast. 2013;22(2):101-8. View the reference
- Waldherr C, Cerny P, Altermatt HJ, Berclaz G, Ciriolo M, Buser K, et al. Value of one-view breast tomosynthesis versus two-view mammography in diagnostic workup of women with clinical signs and symptoms and in women recalled from screening. AJR Am J Roentgenol. 2013;200(1):226-31. View the reference
- Phi X-A, Tagliafico A, Houssami N, Greuter MJW, de Bock GH. Digital breast tomosynthesis for breast cancer screening and diagnosis in women with dense breasts – a systematic review and meta-analysis. BMC Cancer. 2018;18:380. View the reference
- Gilbert FJ, Tucker L, Gillan MG, Willsher P, Cooke J, Duncan KA, et al. The TOMMY trial: a comparison of TOMosynthesis with digital MammographY in the UK NHS Breast Screening Programme--a multicentre retrospective reading study comparing the diagnostic performance of digital breast tomosynthesis and digital mammography with digital mammography alone. Health Technol Assess. 2015;19(4):i-xxv, 1-136. View the reference
- Bansal GJ, Young P. Digital breast tomosynthesis within a symptomatic "one-stop breast clinic" for characterization of subtle findings. Br J Radiol. 2015;88(1053):20140855. View the reference .
- Mariscotti G, Durando M, Houssami N, Zuiani C, Martincich L, Londero V, et al. Digital breast tomosynthesis as an adjunct to digital mammography for detecting and characterising invasive lobular cancers: a multi-reader study. Clin Radiol. 2016;71(9):889-95. View the reference .
- Foxcroft LM, Evans EB, Joshua HK, Hirst C. Breast cancers invisible on mammography. Aust N Z J Surg. 2000;70(3):162-7. View the reference .
- Leddy R, Irshad A, Zerwas E, Mayes N, Armeson K, Abid M, et al. Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump. Breast J. 2013;19(6):582-9. View the reference
- Kurita T, Tsuchiya S, Watarai Y, Yamamoto Y, Harada O, Yanagihara K, et al. Roles of fine-needle aspiration and core needle biopsy in the diagnosis of breast cancer. Breast Cancer. 2012;19(1):23-9. View the reference .
- Farshid G, Sullivan T, Jones S, Roder D. Performance indices of needle biopsy procedures for the assessment of screen detected abnormalities in services accredited by BreastScreen Australia. Asian Pac J Cancer Prev. 2014;15(24):10665-73. View the reference .
- Nagar S, Iacco A, Riggs T, Kestenberg W, Keidan R. An analysis of fine needle aspiration versus core needle biopsy in clinically palpable breast lesions: a report on the predictive values and a cost comparison. Am J Surg. 2012;204(2):193-8. View the reference .
- Al Nemer A. Combined use of unguided FNA and CNB increases the diagnostic accuracy for palpable breast lesions. Diagn Cytopathol. 2016;44(7):578-81. View the reference
- Apesteguía L, Pina LJ. Ultrasound-guided core-needle biopsy of breast lesions. Insights into Imaging. 2011;2(4):493-500. View the reference
Information for Consumers
Information for Consumers
Information from this website |
Information from the Royal Australian and New Zealand College of Radiologists’ website |
Consent to Procedure or Treatment Radiation Risks of X-rays and Scans |
Radiation Risk of Medical Imaging During Pregnancy Radiation Risk of Medical Imaging for Adults and Children |
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