Ultrasound is the initial test of choice in evaluating a lump in a young woman (under 30 years old).70 The most common cause of a palpable mass in a woman under age 30 is a fibroadenoma.71 A palpable, circumscribed, oval mass with no posterior features or minimal posterior enhancement is most likely a fibroadenoma. If such a mass, in a woman under 30 years of age, has clinically been known to the patient and stable for a period of at least 6 to 12 months, then follow-up is a reasonable alternative to biopsy. Because 15% of fibroade-nomas are multiple, bilateral whole breast ultrasound is reasonable in initial imaging evaluation. Many women prefer excision of a palpable lump, and direct excision of a probable fibroadenoma is reasonable in a young woman. The finding of a sonographically suspicious mass should prompt bilateral mammographic evaluation to better define the extent of presumed malignancy. A clinically suspicious mass without a sonographic correlate merits further evaluation with mammography.

At age 30 and over, breast cancer is increasingly common, and mammography is the initial test of choice for symptomatic women. When a lump appears highly suggestive of malignancy on mammography, US is useful in guiding biopsy, with 95% sensitivity on initial core biopsy and no delayed false negatives.36,72,73 A spot compression tangential mammo-graphic view over a palpable mass can improve visibility of the mass and demonstrate overlying skin thickening or retraction.74 Moderate evidence supports the use of US in addition to mammography in the evaluation of women with palpable masses or thickening (Table 28.3). In the multiinsti-tutional study of Georgian-Smith et al.,75 616 palpable lesions were evaluated sonographically and all 293 palpable cancers were depicted sonographically. Across several series (see Table 28.3), of 545 cancers in women with symptoms, 529 (97.1%) were depicted with the combination of mammogra-phy and US. A negative result after both mammographic and sonographic evaluation of a palpable abnormality is highly predictive of benign outcome, with 98.6% negative predictive value across these series.75-79 Nevertheless, final management of a clinically suspicious mass must be based on clinical grounds.

TABLE 28.3. Sensitivity and negative predictive value (NPV) of combined mammography and US in symptomatic women.
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