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Breast screening and work-up: density, tomosynthesis, MRI and biopsy
Mammography is the basic screening test; in dense breasts its sensitivity falls and US or MRI is added by risk, annual MRI is for high-risk women, and biopsy is done with the modality in which the finding is seen best.
Why it matters in the exam
In Israel the national screening programme invites women aged 50–74 for mammography every 2 years; women at increased risk start earlier and more often. BRCA carriers and a lifetime risk of 20% or more, or chest radiation at age 10–30 — annual MRI plus mammography. ACR breast density: a — almost entirely fatty; b — scattered fibroglandular areas; c — heterogeneously dense, which may hide small masses; d — extremely dense, and lowers the sensitivity of mammography. In density c and d, US or MRI can be added as a supplementary test.
Tomosynthesis (DBT) produces thin slices of the breast from several angles: it detects more cancers and reduces recalls caused by tissue overlap, at a dose similar to or slightly higher than two-dimensional mammography. Contrast-enhanced mammography (CESM) uses iodine and two energies; its sensitivity approaches MRI, but it carries the risks of iodinated contrast. Indications for breast MRI: high-risk screening, extent of disease in a new cancer, an occult primary with an axillary metastasis, assessment of response to neoadjuvant treatment and silicone implant integrity (the "linguine" sign in intracapsular rupture). MRI does not replace biopsy of a suspicious finding and is not a test for non-focal pain. Signs of malignancy on MRI: an irregular mass with spiculated margins, rim enhancement and a washout curve.
Work-up of a palpable mass: under age 30 — US first; from age 40 — diagnostic mammography and US; at 30–39 — either. In pregnancy — US first. Biopsy: a mass seen on US — US-guided core needle biopsy; calcifications — stereotactic vacuum biopsy, with a specimen radiograph to confirm that the calcifications were removed; a finding seen only on MRI — MRI-guided biopsy. At the end of each biopsy a clip is left and imaging–pathology concordance is checked. ADH on needle biopsy — surgical excision. Pathological nipple discharge — spontaneous, unilateral, single-duct, bloody or clear; the commonest cause — intraductal papilloma; work-up — mammography and US. In a lactating woman, biopsy may cause a milk fistula.
Key points
- Israel: 50–74 every 2 years.
- Density d lowers sensitivity.
- Annual MRI at high risk.
- Tomosynthesis — more detection, fewer recalls.
- Calcifications — stereotactic biopsy with specimen radiograph.
Summary table
| Situation | Test | Note | Recommendation |
|---|---|---|---|
| Average risk | Mammography | In Israel 50–74 every 2 years | In density c and d consider supplement |
| High risk (BRCA, 20% or more) | Annual MRI and mammography | Starts at a young age | By risk protocol |
| Palpable mass under 30 or in pregnancy | US | Mammography as needed | US-guided biopsy |
| Suspicious calcifications | Stereotactic biopsy | Specimen radiograph | Clip and pathology concordance |
| Silicone implant | MRI without contrast | Linguine sign | By symptoms |
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Sources
- ACR Appropriateness Criteria: Breast Cancer Screening, 2023 — Average, intermediate and high risk
- Israeli Ministry of Health: National Breast Cancer Early Detection Programme, 2023 — Screening ages and intervals
- ACR Practice Parameter for the Performance of Contrast-Enhanced Breast MRI, 2023 — Indications
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.