ORIGINAL RESEARCH • BREAST IMAGING

US as the Primary Imaging Modality in the Evaluation

of Palpable Breast Masses in Breastfeeding Women,
Including Those of Advanced Maternal Age
Maggie Chung, MD  •  Jessica H. Hayward, MD  •  Genevieve A. Woodard, MD, PhD  •  Anna Knobel, MD  • 
Heather I. Greenwood, MD  •  Kimberly M. Ray, MD  •  Bonnie N. Joe, MD, PhD  •  Amie Y. Lee, MD
From the Department of Radiology and Biomedical Imaging, University of California, San Francisco, 1825 4th St, Room L3185, San Francisco, CA, 94107 (M.C.,
J.H.H., A.K., H.I.G., K.M.R., B.N.J., A.Y.L.); and Department of Radiology, Mayo Clinic, Rochester, Minn (G.A.W.). Received March 16, 2020; revision requested May
1; revision received June 30; accepted July 10. Address correspondence to A.Y.L. (e-mail: Amie.Lee2@ucsf.edu).

Conflicts of interest are listed at the end of this article.

See also the editorial by Newell in this issue.

Radiology 2020; 00:1–9 • https://doi.org/10.1148/radiol.2020201036 • Content codes:

Background:  Women are increasingly delaying childbearing, and thus lactation, into their 30s and 40s, when mammography would
typically be the initial imaging modality to evaluate palpable masses in the general population. Current guidelines recommend US
as the first-line imaging modality for palpable masses in pregnant and lactating women, but data regarding breastfeeding women
age 30 years and older are near nonexistent.

Purpose:  To evaluate the diagnostic performance of targeted US as the primary imaging modality for the evaluation of palpable
masses in lactating women, including those of advanced maternal age.

Materials and Methods:  Lactating women with palpable breast masses evaluated at targeted US over a 17-year period (January 2000
to July 2017) were retrospectively identified. All US evaluations were performed at diagnostic evaluation, and mammography was
performed at the discretion of the interpreting radiologist. Breast Imaging Reporting and Data System assessments, imaging, and
pathology results were collected. Descriptive statistics and 2 3 2 contingency tables were assessed at the patient level.

Results:  There were 167 women (mean age, 35 years 6 5 [standard deviation]), 101 of whom (60%) were of advanced maternal
age (35 years). All women underwent targeted US, and 98 (59%) underwent mammography in addition to US. The frequency
of malignancy was five of 167 (3.0%). Targeted US demonstrated a sensitivity and specificity of five of five (100%; 95% confidence
interval [CI]: 48%, 100%) and 114 of 162 (70%; 95% CI: 63%, 77%), respectively. Negative predictive value, positive predictive
value of an abnormal examination, and positive predictive value of biopsy were 114 of 114 (100%; 95% CI: 97%, 100%), five of
53 (9.4%; 95% CI: 3%, 21%), and five of 50 (10%; 95% CI: 3%, 22%), respectively. In the subset of 98 women who underwent
mammography in addition to US, mammography depicted seven incidental suspicious findings, which lowered the specificity from
62 of 93 (67%; 95% CI: 56%, 76%) to 57 of 93 (61%; 95% CI: 51%, 71%) (P = .02).

Conclusion:  Targeted US depicted all malignancies in lactating women with palpable masses. Adding mammography increased false-
positive findings without any additional cancer diagnoses.
© RSNA, 2020

D elayed childbearing is an increasingly common trend

in the United States. In 2018, 18.3% of births were to
mothers of advanced maternal age, which is defined by the
American College of Obstetricians and Gynecologists as
age 35 years or older (1,2). The birth rate for women age
40 years or older has more than doubled since 1989 (3).
As more women have delayed childbirth, and therefore
lactation, the prevalence of pregnancy-associated breast
cancer (PABC) has also increased (4–6). PABC is defined
as breast malignancy occurring during pregnancy, within
12 months postpartum, or anytime while lactating (7). Di-
agnosis of PABC in a lactating woman may prove more
challenging because breast engorgement and increased
breast tissue density can limit clinical and mammographic
evaluation of breast cancer (8). Lack of awareness of breast
cancer during pregnancy and lactation may lead to delayed
referral and diagnosis (9). PABC is associated with more
aggressive histologic profile, especially in women who are
postpartum and women older than 35 years (10). Conse-
quently, PABCs tend to be larger and more advanced at
the time of diagnosis (8). Accurate imaging evaluation and
diagnosis of breast cancer in this population is of growing
importance.
A palpable breast mass is the most common manifest-
ing symptom of breast cancer (8). There are limited data
regarding the appropriate imaging modality for evaluation
of palpable breast masses in lactating women. The Ameri-
can College of Radiology Appropriateness Criteria state
that US should be the first imaging modality to help evalu-
ate palpable masses in lactating women because increased
breast tissue density limits mammographic evaluation
(11,12). However, more women are delaying lactation into
their 30s and 40s, which is when mammography would
typically be the initial imaging modality in the general
population. There is a critical gap in evidence-based crite-
ria to guide imaging evaluation of palpable breast masses

This copy is for personal use only. To order printed copies, contact reprints@rsna.org
Evaluation of Palpable Breast Masses in Breastfeeding Women

Abbreviations
BI-RADS = Breast Imaging Reporting and Data System, CI = confi-
dence interval, PABC = pregnancy-associated breast cancer

Summary
Targeted US depicted all malignancies (sensitivity, 100%) in lactating
women with palpable masses, including those of advanced maternal
age, and therefore should be the first-line modality for evaluation.

Key Results
n Targeted US evaluation of lactating women with palpable breast
masses demonstrated sensitivity and specificity of 100% and 70%,
respectively. Positive predictive value of an abnormal examina-
tion and positive predictive value of biopsy were 9.4% and 10%,
respectively.
n In those who underwent mammography in addition to US, mam-
mography added seven false-positive findings without additional
cancer diagnoses. Specificity was lowered with the addition of
mammography from 67% to 61% (P = .02).

in the growing population of lactating women of advanced ma-

ternal age. To date, there are only two small retrospective studies
(with 27 and 81 lactating women, respectively) that evaluated
diagnostic imaging in predominantly young lactating women
(13,14). In the cohort studied by Obenauer et al (13), most
women were younger than 30 years, and only one woman was of
advanced maternal age.
The purpose of our study was to evaluate the diagnostic per-
formance of targeted breast US as the primary imaging modal-
ity in the evaluation of palpable masses in lactating women,
including those of advanced maternal age. Our secondary aim
was to evaluate the added benefit of mammography.
Materials and Methods
Our institutional review board approved this Health Insur-
ance Portability and Accountability Act–compliant study and
waived the requirement for written informed consent.
Patient Sample
A retrospective search of the radiology database identified all
lactating women who underwent targeted breast US with or
without mammography for diagnostic evaluation of palpable
breast masses over a 17-year period (January 2000 to July
2017) at a single academic institution. Exclusion criteria in-
cluded pregnancy, nonpalpable breast masses, exclusively
nonbreast findings, known breast malignancy at the time of
imaging, previous evaluation for the same palpable lump, and
less than 2 years of imaging or clinical follow-up to establish
benignity in absence of biopsy.
Data Collection
Demographics, clinical history, and radiology reports were
obtained from the electronic medical record. Data collected
included age, sonographic and/or mammographic imaging
findings, Breast Imaging Reporting and Data System (BI-
RADS) assessment, mammographic density, pathology results,
imaging follow-up, and clinical follow-up. In women who pre-
Figure 1:  Study flowchart.
sented with more than one palpable area of concern, the BI-
RADS assessment for the most suspicious finding at palpable
US was recorded. For those with more than one palpable area
of concern, no woman had more than one suspicious finding
at imaging.
Imaging Protocol and Interpretation
Breast US evaluations were performed by using a US system
(Epiq; Philips, Best, the Netherlands) and a broadband linear-
array transducer (L18–5; Philips). All US evaluations were per-
formed in real time at the time of diagnostic evaluation by the
interpreting radiologist, radiology resident, or fellow under the
direct supervision of the interpreting attending radiologist. US
examinations were performed by using standard technique tar-
geted to the site of palpable concern. For each lesion identified,
radial, antiradial, and color Doppler images were obtained.
Spatial compounding and harmonic imaging are not part of
the default imaging settings when performing breast US at our
institution. However, these techniques may occasionally be
used by the radiologist for problem solving or image optimiza-
tion on a case-by-case basis.
Diagnostic mammography was performed at the discretion
of the interpreting radiologist. If obtained, mammography was
performed on a digital mammography device (Selenia; Hologic,
Marlborough, Mass). Craniocaudal, mediolateral oblique, and
true lateral digital images were obtained with a radiopaque
marker placed over the site of palpable concern per institu-
tional protocol. Additional spot compression magnification

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 Chung et al

Each examination was

Table 1: Patient, Imaging, and Lesion Characteristics
reviewed by an interpreting
Parameter All US with Mammography Cohort radiologist, who was one of
No. of women 167 98 14 attending academic radi-
Age (y) ologists (including J.H.H.,
 Mean 35.1 6 5.3 36.6 6 4.5 K.M.R., H.I.G., B.N.J., and
 Median* 36 (32–38) 36 (34–39) A.Y.L.), who subspecialize in
  20 1 (0.6) 0 breast imaging with Mam-
 20–29 21 (12.6) 2 (2.0) mography Quality Standards
 30–39 114 (68.3) 74 (75.5) Act certification and experi-
 40–49 30 (18) 21 (21.4) ence ranging from 2 years
  .50 1 (0.6) 1 (1) to longer than 30 years. The
  Advanced maternal age (35) 101 (60.4) 70 (71.4) interpreting radiologist inde-
Imaging modality pendently reviewed examina-
  US alone 69 (41.3) … tions in real time and reported
  US and mammography 98 (58.7) 98 (100) findings prospectively by us-
US correlate ing the most current edition
 Yes 111 (66.5) 57 (58.2) of the American College of
 No 56 (33.5) 41 (41.8) Radiology BI-RADS atlas at
US finding time of the interpretation.
  Solid mass 44 (39.6) 29 (50.9)
BI-RADS 1, 2, and 3 were
  Solid and cystic mass 10 (9.0) 6 (10.5)
considered negative imaging
 Cysts 20 (18.0) 10 (17.5)
examinations, and BIRADS
  Inflammatory or infectious 14 (12.6) 2 (3.5)
4 and 5 were considered posi-
 Duct 4 (3.6) 0 (0)
tive imaging examinations.
 Galactocele 11 (9.9) 5 (8.8)
  Focal normal tissue 3 (2.7) 1 (1.8)
 Other 5 (4.5) 4 (7.0) Percutaneous Sampling
BI-RADS assessment for palpable lesion US-guided core biopsies, US
 1 56 (33.5) 41 (41.8) fine-needle aspirations, and
 2 54 (32.3) 19 (19.4) stereotactic core biopsies were
 3 4 (2.4) 2 (2.0) performed at the discretion
 4 51 (30.5) 34 (34.7) of the procedural radiologist.
 5 2 (1.2) 2 (2.0) US-guided core biopsies were
Mammographic breast density most commonly performed
  Almost entirely fatty 0 (0) 0 (0) with 14-gauge spring-loaded
  Scattered areas of fibroglandular density 2 (2.0) 2 (2.0) automatic biopsy device. US-
  Heterogeneously dense 25 (25.5) 25 (25.5) guided fine-needle aspirations
  Extremely dense 71 (72.5) 71 (72.5) were performed by using a
Note.—Unless otherwise indicated, data are numerators and data in parentheses are percentages. Mean 25-gauge needle with a cy-
age is 6 standard deviation. topathologist present in real
* Data in parentheses are interquartile range. time for rapid on-site inter-
pretation to determine diag-
views of the palpable mass were obtained at the discretion of nostic adequacy. Stereotactic core biopsies were performed by
the interpreting radiologist. Tomosynthesis was not performed. using a 9-gauge vacuum-assisted device. Per our institutional
Per the policy at our institution for the evaluation of palpable policy, the procedural radiologists reviewed all percutaneous
lumps, we start with targeted US in all women younger than age biopsies for radiologic-pathologic concordance. There were no
30 years. For those age 30 years and older, our policy is to start discordant radiologic-pathologic results. Excisional biopsies
with diagnostic mammography followed by US. Our institution were performed by a breast surgeon. The decision to perform a
does not have a specific separate policy for breastfeeding women palpation-guided percutaneous fine-needle aspiration or open
who are age 30 and older. In most cases, the same algorithm surgical biopsy was on the basis of clinical presentation, physi-
used for nonlactating patients is followed, although this is at the cal examination, and imaging findings.
discretion of the interpreting radiologist at the time of the ex-
amination. In some women in whom US is performed first (eg, Statistical Analysis
in women age ,30 years), mammography may be performed Descriptive statistics and imaging performance metrics were
after US; for example, if there is an indeterminate finding at US performed at the patient level. Performance metrics included
or if there are negative findings at US but suspicious findings at positive predictive value of an abnormal examination, positive
clinical examination. predictive value of biopsy, negative predictive value, sensitivity,

Radiology: Volume 00: Number 0— 2020  n  radiology.rsna.org 3

Evaluation of Palpable Breast Masses in Breastfeeding Women

specificity, and rates of true-positive, true-negative, false-positive,

Table 2: Performance of Targeted US
and false-negative findings. A false-negative finding was defined
Performance Statistic Percentage (n = 167) as an imaging result negative for cancer (BI-RADS 1–3) with a
Biopsy recommended 32 (25, 39) [53/167] diagnosis of malignancy in the ipsilateral breast within 2 years.
Cancer yield 3 (1, 7) [5/167] All statistical analyses were completed by using statistical
True-positive findings 3 (1, 7) [5/167] software (SAS University Edition, version 9.4; SAS Institute,
True-negative findings 68 (61, 75) [114/167] Cary, NC). Performance metric point estimates and exact
False-positive findings 29 (22, 36) [48/167] confidence intervals (CIs) were calculated by using PROC
False-negative findings 0 (0, 2) [0/167] FREQ with the binomial option. Performances estimates
Sensitivity 100 (48, 100) [5/5] were compared by fitting a repeated measures model with
Specificity 70 (63, 77) [114/162] PROC GENMOD. Two-sided P values less than .05 were
PPV2 9 (3, 21) [5/53] considered to indicate statistical significance.
PPV3 10 (3, 22) [5/50]
NPV 100 (97, 100) [114/114] Results
Note.—Data in parentheses are 95% confidence intervals and
data in brackets are numerator/denominator. NPV = negative Patient and Imaging Characteristics
predictive value, PPV2 = positive predictive value of biopsies
recommended, PPV3 = positive predictive value of biopsies Among 186 identified women, six were excluded because of
performed. pregnancy, four because of nonpalpable breast masses, two

Figure 2:  Images in a 43-year-old breastfeeding woman

with strong family history of breast cancer and new palpable
lump in the right breast. There was no US correlate to the area of
palpable abnormality in the right breast. (a) Craniocaudal and
(b) mediolateral oblique mammograms of the bilateral breasts
and (c) spot-magnification mediolateral mammogram of the
left breast. There are scattered areas of fibroglandular density.
There is no mammographic correlate for palpable abnormal-
ity in the right breast. There is a group of coarse heterogenous
calcifications in the retroareolar left breast (area of interest in
a–c). Breast Imaging Reporting and Data System assessment
was category 4. Pathology from stereotactic core biopsy of the
left breast demonstrated benign fibroadenoma with associated
calcifications.

4 radiology.rsna.org  n  Radiology: Volume 00: Number 0— 2020


Table 3: Breast Imaging Reporting and Data System 4 and 5
Palpable Lesion Pathology Results
Pathology and Cytologic Analysis (n = 50)
Lactational change
Cyst/fibrocystic change
Galactocele
Lactating adenoma
Malignancy
Fibroadenoma
Ectatic/occluded duct
Abscess/phlegmon
Inflammation/mastitis
Fibromatosis
Note.—Data in parentheses are percentages.
because of nonbreast masses, two because of known breast
malignancy, three because of previous evaluation for the same
palpable lump, and two because of less than 2 years of imag-
ing or clinical follow-up (Fig 1). After exclusions, 167 women
were included in the analysis (Table 1). The mean patient
age was 35 years 6 5 (standard deviation) (age range, 17–52
years) and the majority (101 of 167; 60%) were age 35 years
or older and classified as advanced maternal age.
Performance of Targeted US
Targeted US was performed in all women at the time of di-
agnostic evaluation. When assessing US findings alone, a
sonographic correlate to the palpable lump was identified
in 111 of 167 (66%) women, and no sonographic correlate
was identified in 56 of 167 (34%) women. Of the 111 sono-
graphic correlates, 58 (52.2%) were benign (BI-RADS 2; n =
54; 48.6%) or probably benign (BI-RADS 3; n = 4; 3.6%).
The most common benign or probably benign US findings
were cysts (n = 20; 34%), inflammatory or infectious changes
(n = 14; 24%), and galactoceles (n = 11; 19%).
In 53 of 167 women (32%), US depicted a suspicious cor-
relate (BI-RADS 4 or 5) in which biopsy was recommended,
and solid masses (40 of 53; 75%) and complex solid and
cystic masses (10 of 53; 19%) were the most common. Of
the 53 positive findings at US, five were true-positive find-
ings and 48 were false-positive findings (Table 2). There were
no false-negative findings at US. Targeted US performance
demonstrated sensitivity of five of five (100%, 95% CI: 48%,
100%) and specificity of 114 of 162 (70%, 95% CI: 63%,
77%). Biopsy was recommended in all 53 women with posi-
tive findings at US and was performed in 50 women. In the
three women who did not undergo biopsy, findings were pre-
sumed benign with at least 2 years of clinical and/or imaging
follow-up without diagnosis of malignancy in the symptom-
atic breast. Positive predictive value of an abnormal finding
and positive predictive value of biopsy were five of 53 (9.4%;
95% CI: 3.1%, 21%) and five of 50 (10%; 95% CI: 3.3%,
22%), respectively. Negative predictive value was 114 of 114
(100%; 95% CI: 97%, 100%).
Radiology: Volume 00: Number 0— 2020  n  radiology.rsna.org 5
Chung et al
No. of Lesions
13 (26)
7 (14)
6 (12)
6 (12)
5 (10)
4 (8)
3 (6)
3 (6)
2 (4)
1 (2)
Figure 3:  US image in 29-year-old breastfeeding woman with new
palpable lump in the right breast. Targeted gray-scale US at site of pal-
pable abnormality shows a 1.8-cm hypoechoic irregular solid mass with
indistinct margins. Breast Imaging Reporting and Data System assessment
was category 4. Fine-needle aspiration demonstrated benign lactational
changes.
All incidental lesions were identified at mammography.
Because only targeted US examinations directed to the site
of clinical concern were performed, no incidental lesions dis-
tinct from the site of the palpable mass were identified at US.
Addition of Mammography to US
Ninety-eight of 167 (59%) women underwent diagnostic mam-
mography in addition to US. In the majority of women (73 of
98; 74%), mammography was performed first. In 25 women
(25 of 98; 26%), US was performed first. All women who un-
derwent mammography first were older than age 30 years. Of
the two patients younger than age 30 years who underwent
mammography in addition to US, both underwent mammog-
raphy after US for further evaluation of US findings. Ninety-six
of 98 (98%) women had dense breast tissue; 25 of 98 (26%)
women had heterogeneously dense breast tissue and 71 of 98
(72%) women had extremely dense breast tissue (Table 1).
The addition of mammography to targeted US did not help
to identify any additional findings suspicious for cancer at the site
of palpable mass. Among the 53 women with suspicious findings
at targeted US at the site of the palpable mass, 36 women under-
went mammography, and mammography depicted a correlate
with suspicious findings at the site of palpable abnormality in 18
women. Mammography identified seven incidental suspicious
findings distinct from the site of palpable mass, and biopsy was
recommended for all seven findings. In four women, mammog-
raphy depicted calcifications suspicious for cancer (incidental
and remote from the palpable mass), all of which were proven
benign by stereotactic core biopsy (n = 3) or surgical excision (n
= 1) (Fig 2). In one woman, mammography depicted an inci-
dental mass with no sonographic correlate for which the patient
declined the recommended stereotactic biopsy, and this inci-
dental mass resolved at subsequent follow-up mammography.
In two women, mammography depicted incidental enlarged
axillary lymph nodes; US-guided biopsies were performed with
Evaluation of Palpable Breast Masses in Breastfeeding Women

Figure 4:  Images in a 40-year-old breastfeeding woman with a new palpable lump in the right breast. (a) Targeted gray-scale US
image at the site of palpable abnormality shows a 2.4-cm hypoechoic irregular solid mass with indistinct margins (arrows). Breast Imaging
Reporting and Data System (BI-RADS) assessment was category 4. US-guided core biopsy showed invasive ductal carcinoma. (b) Cranio-
caudal, (c) mediolateral oblique, and (d) spot-magnification mediolateral mammograms show heterogeneously dense breast tissue and a
subtle obscured mass at the site of palpable abnormality in the right breast (regions of interest, b–d) with a few associated amorphous calci-
fications. BI-RADS assessment was category 4. US-guided core biopsy showed invasive ductal carcinoma.

benign results. Two of these seven mammographic findings were
in women who had suspicious palpable sonographic findings
that were also recommended for biopsy.
In this subset of 98 women who underwent mammography
in addition to US, there were no additional cancers identified;
cancer yield was five of 98 (5.1%; 95% CI: 1.7%, 12%) and
sensitivity was five of five (100%; 95% CI: 48%, 100%) for
both the targeted US portion of the examination alone and for
combined mammography with US. However, specificity was
lower with the addition of mammography compared with the
targeted US portion of the examination alone (62 of 93 [67%;
95% CI: 56%, 76%] vs 57 of 93 [61%; 95% CI: 51%, 71%],
respectively) (P = .02).
Pathologic and Cytologic Results of the Palpable Lesions
Of the 53 suspicious findings at imaging at the palpable site
(BI-RADS 4 or 5), 50 were biopsied, yielding five malig-
nant lesions (10%). The most common benign pathologic
findings included 13 diagnoses of lactational change (26%),
seven cysts and/or fibrocystic changes (14%), six galacto-
celes (12%), and six lactating adenomas (12%) (Table 3,
Fig 3).
Fifteen women with negative findings at imaging (BI-
RADS 1–3) underwent biopsy because of the level of concern
on the part of referring provider at clinical examination. Most
were palpation-guided percutaneous biopsies. None revealed
malignant pathology.
Malignant Lesions
Mean age of the five lactating women with malignancy was 41
years 6 6 (age range, 36–52 years). Among the five women,
one had a BRCA1 mutation. The remaining four women did
not have known genetic mutations or other strong risk factors
for breast cancer. All five malignancies were identified at both

6 radiology.rsna.org  n  Radiology: Volume 00: Number 0— 2020

 Chung et al

Figure 5:  Images in a 36-year-old breastfeeding woman with new palpable lump in the right breast. (a) Targeted gray-scale US evalu-
ation at site of palpable abnormality shows a 4.2-cm conglomerate of hypoechoic irregular solid masses with angular margins. (b) Cranio-
caudal, (c) mediolateral oblique, and (d) spot-magnification craniocaudal mammograms show heterogeneously dense breast tissue and
global asymmetry (arrow) involving predominantly the outer hemisphere of the right breast. There is marked breast soft-tissue edema and skin
thickening (arrowheads). BI-RADS assessment was category 5. US core biopsy showed invasive ductal carcinoma.

US and mammography. At US, all malignancies manifested
as hypoechoic irregular masses with indistinct or angular
margins (range, 1.2–4.8 cm) (Figs 4, 5). There were three ma-
lignancies in women with heterogeneously dense breasts and
two in women with extremely dense breasts. At mammogra-
phy, four malignancies manifested as an irregular or obscured
mass and one manifested as mammographic global asymme-
try. Three malignancies had associated mammographic cal-
cifications. All five malignancies were invasive ductal carci-
noma at surgical pathology. Four women had axillary nodal
metastasis and one had distant metastasis to the liver.
Discussion
There is a lack of research to guide imaging evaluation
of palpable breast masses in breastfeeding women, and
data in women older than age 30 years is near nonexis-
tent. Current guidelines recommend US as the first-line
imaging modality (11,12). Our aim was to determine
the diagnostic performance of US as the primary imag-
ing modality for the evaluation of palpable lumps in
breastfeeding women. To our knowledge, our study is
the largest to date and the first in which the majority of
women (60%) were of advanced maternal age. Our findings
support targeted US as the primary imaging modality in
this population. Frequency of malignancy was five of 167
(3.0%). Four of the five women with malignancy had axil-
lary metastasis at diagnosis, and one had liver metastasis,
stressing the importance of prompt diagnostic evaluation.
Targeted US depicted all malignancies, demonstrating sen-
sitivity and negative predictive values of 100% and specific-
ity of 70%. The addition of mammography did not yield
any additional cancers. Conversely, mammography added
seven incidental false-positive findings at imaging and low-
ered the specificity from 67% to 61% (P = .02).

Radiology: Volume 00: Number 0— 2020  n  radiology.rsna.org 7

Evaluation of Palpable Breast Masses in Breastfeeding Women
Prior literature on this topic is sparse, consisting of a few
small studies with a limited number of lactating women of
advanced maternal age. The study by Obenauer et al (13)
supports US as the initial imaging modality; however, the
study was limited to 27 lactating women with palpable
masses. The majority were younger than age 30 years and
only one woman was of advanced maternal age. Among the
27 women, all underwent US and 18 also underwent mam-
mography. The study by Robbins et al (14) included 87 lac-
tating women (age range, 19–47 years); however, only 64%
of the women presented with a palpable lump. Overall, in
the study by Robbins et al of 134 lesions in 126 pregnant,
lactating, or postpartum women, 12 of 134 (9%) women
were evaluated at mammography alone, 49 of 134 (37%)
women were evaluated at US alone, and 73 of 134 (54%)
were evaluated at both US and mammography. Similar to our
study, this study showed a US sensitivity of 100% in detect-
ing PABC. Other studies, although not specifically evaluat-
ing symptomatic patients, assessed the imaging findings of
proven PABCs (15–17). These studies demonstrated that US,
when performed, revealed a corresponding lesion at the site
of the malignancy in all women.
Sensitivity of mammography may be limited by increased
breast density during lactation (8,13,15,18). Whereas mam-
mography depicted all five cancers in our study, previous
studies suggested that breast cancers in dense breasts dur-
ing pregnancy or lactation may be missed at mammography
(15,17). Retrospective reviews of mammographic correlates
of PABC found that sensitivity of mammography ranged
from 78% to 90% (15–17). Yang et al (17) and Ahn et al
(15) showed that the PABCs missed at mammography were
in women with dense breasts and were all identified at US.
Obenauer et al (13) also found that one breast cancer was
missed at mammography and was identified at US in the eval-
uation of palpable masses in lactating women. These findings
suggest that sensitivity of mammography is slightly limited
and inferior to that of US during pregnancy and lactation
because of increased breast density.
In our study, mammography increased false-positive find-
ings and biopsies recommended without identifying addi-
tional cancers. In the evaluation of lactating women younger
than age 40 years, our study supports US as the primary mo-
dality except in women with in women with highly suspected
or confirmed malignancy, when the addition of mammogra-
phy may be helpful in assessing extent of disease and screen-
ing of the contralateral breast. In the evaluation of women
age 40 years or older, bilateral mammography may be con-
sidered if screening mammography has not been performed
within the last year.
Our study had limitations. First, the decision to perform
adjunct mammography in addition to US was at the dis-
cretion of the interpreting radiologist and was not consis-
tent even within a single academic practice. This variabil-
ity reflects the current uncertainty and lack of evidence on
how to best evaluate lactating women with palpable masses
who are age 30 years or older. Mammography was usually
performed in women with higher clinical concern on the
8 radiology.rsna.org  n  Radiology: Volume 00: Number 0— 2020
basis of age, history, and/or US findings. Despite this selec-
tion bias, which likely overstates the performance of mam-
mography, we failed to find evidence of the added benefit
of mammography in a small group of patients thought to
benefit from mammography. Second, there were no women
with ductal carcinoma in situ alone. Mammography is more
sensitive in detecting ductal carcinoma in situ because of its
ability to depict subtle microcalcifications. Third, the ma-
jority of women in this study were between age 30 and 39
years. Mammography may be of greater benefit in lactat-
ing women age 40 years or older in whom the incidence of
breast cancer is higher. More data are needed to confirm the
best imaging algorithm in this small subset of patients. Fi-
nally, US evaluations may be limited by interoperator vari-
ability. In our study, all US examinations were performed by
physician radiologists, and outcomes may differ from other
practices. Furthermore, our small sample size was not ad-
equate to adjust for the different radiologists.
In conclusion, in this imaging series of symptomatic
breastfeeding women, which is to our knowledge the largest
to date, our findings support targeted US as the primary im-
aging modality for the evaluation of palpable breast findings
in lactating women, including those of advanced maternal
age. Adding mammography increased false-positive findings
without any additional cancer diagnoses.
Author contributions: Guarantors of integrity of entire study, M.C., A.Y.L.; study
concepts/study design or data acquisition or data analysis/interpretation, all authors;
manuscript drafting or manuscript revision for important intellectual content, all au-
thors; approval of final version of submitted manuscript, all authors; agrees to ensure
any questions related to the work are appropriately resolved, all authors; literature re-
search, M.C., J.H.H., G.A.W., K.M.R., B.N.J., A.Y.L.; clinical studies, M.C., B.N.J.,
A.Y.L.; experimental studies, M.C., B.N.J.; statistical analysis, M.C., G.A.W., A.Y.L.;
and manuscript editing, M.C., J.H.H., G.A.W., H.I.G., K.M.R., B.N.J., A.Y.L.
Disclosures of Conflicts of Interest: M.C. Activities related to the present arti-
cle: disclosed no relevant relationships. Activities not related to the present article:
disclosed money paid to author from University of California, San Francisco for
travel and accommodations to attend AUR 2019, RSNA 2019, and ARRS 2019.
Other relationships: disclosed no relevant relationships. J.H.H. disclosed no rel-
evant relationships. G.A.W. disclosed no relevant relationships. A.K. disclosed
no relevant relationships. H.I.G. disclosed no relevant relationships. K.M.R. dis-
closed no relevant relationships. B.N.J. Activities related to the present article:
disclosed no relevant relationships. Activities not related to the present article:
disclosed money to author’s institution for grant from Kheiron Medical Tech-
nologies; disclosed money paid to author for royalties from UpToDate; disclosed
travel/accommodations/meeting expenses paid to author’s institution from World
Class CME. Other relationships: disclosed no relevant relationships. A.Y.L. dis-
closed no relevant relationships.
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