DIAGNOTIC WORK UP

Compression of focal region of the breast to separate overlapping structures and provide better resolution.
- Pressure = force / area
Best for:
- True lesion vs superimposition
- Difficult to reach areas of the breast
Can be used w/ magnification
Almost always the next step in evaluating a focal suspicious abnormality
- Calcification? -> SC + Mag
- Mass or asymmetry? SC - Mag
  - If it presses out, likely superimposed normal FGT; can get US to further evaluate
  - No change = suspicious -> get spot mag view to assess margins and evaluate w/ US
- Architectural distortion? Worse w/ mag!

MAGNIFICATION

Indication
- Triangulate lesion seen on MLO but not CC view
- Suspect milk of Ca? -> ML/LM +/- mag
- Planning stereotactic procedure
Can be obtained in ML or LM projection
- ML view: xray travels medial -> lateral; detector placed laterally
  - Best for central or lateral lesions
- LM view: detectory is medial
  - Best for evaluating medial lesions
- Place the lesion in question closer to the detector if possible
Localization
- If lesion rises on lateral compared to MLO, lesion is located in medial breast (muffins rise)
- If lesion sinks on lateral compared to MLO, lesion is located in lateral breast (lead sinks)

Used to locate lesions seen only in the CC view
- Can also be used to spread-out overlapping tissue
In the CC position, roll the superior breast either medial (RCCM) or lateral (RCCL)
- If lesion moves medial w/ RCCM view = superior breast lesion
- If lesion moves lateral w/ RCCM view = inferior breast lesion
- Lesion does not move = central breast
Rolled views can also be done in the lateral projection

Lateral XCC (XCCL) pulls lateral breast tissue into detector.
Medial XCC (XCCM) pulls medial breast tissue into the detector.
May be the only way to see these far lesions.
Reduced compression
- Can be obtained to image far posterior lesions that may "slip out" of the detector when full compression is applied

Next steps depend on age
- If < 25 yo -> get US first
- If > 25 yo -> get mammo first

Combined evaluation w/ mammo and US for palpable findings has a sensitivity of 97%, NPV 98.6%
Get standard views of both breasts plus spot compression views of the area of concern
Exception
- recent mammogram w/n 6 months then spot compression CC and MLO vs tangential spot compression
- W/n 6 months to 1 year then standard views and spots of only the symptomatic breasts
If anything is found it is likely a FA
Only 1% of all breast CA are diagnosed in women under 30
Similar in frequency to male breast CA (<1%) and inflammatory breast CA (1-5%)
If no abnormality is detected at site of palpable finding, it is highly important to recommend clinical FU bc the sensitivity and NPV are not 100%
- Though rare, a CA can be initially occult by both modalities.
For palpable lump, ACR recommends...
- Under age 30, get US first
- Age 30-39, US or mammo first
- Age 40 and up, start w/ mammo, then US

Pathologic discharge: bloody, spontaneous, unilateral
- Causes: (1) papilloma (52%), (2) ductal ectasia (14-33%), CA (5-15%), infection
Physiologic (galactorrhea): bilateral, nonspontaneous, white/clear/yellow/green/brown/ gray, involves multiple ducts
- Causes: hyperprolactinemia 2/2 medications, pituitary tumors, other endocrine conditions
If not mammogram w/n 6 months, do full CC/MLO views w/ CC and lateral mag views of subareolar breast
If negative, proceed to targeted US of the retroareolar breast
If all are negative and nipple discharge has suspicious clinical features, recommend surgical consultation -> breast MRI or ductography.

Very common complaint.
The work up for focal, noncyclical breast pain (less than 1 quadrant) is the same as for palpable concern
Unlikely that breast CA causes pain
- May find cyst or abscess
- Very low chance of CA (0-3%)
ACR breast pain
- < 30 -> breast US first
- 30-39 -> US or mammo first
- >40 -> diagnostic mammo then US
DDX:
- Hormonal causes
- Cyst or multiple cysts
- Nerve related
- MSK

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