Recall from breast screening — assessment of a screen-detected abnormality
BI-RADS assessment principles; ACR AC Palpable Breast Masses (2022 rev)A screen-detected finding is an incomplete assessment, not a diagnosis. The pathway is targeted problem-solving mammographic views with tomosynthesis and targeted ultrasound, proceeding to image-guided biopsy where the finding persists.
An asymptomatic woman recalled from a population screening programme for a mass, asymmetry, distortion or microcalcification.
Referenced decision support — confirm against your local protocol.
Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.
Accept as requested
Diagnostic mammography (± tomosynthesis)
Mammography
What we'd amend, and why
- Supplementary views — spot compression, magnification, true lateral and tomosynthesis — are what separate a summation artefact from a real lesion, and they characterise calcification morphology and distribution, which is the single most useful feature for deciding on biopsy. Targeted ultrasound is added for a mass or asymmetry that persists, both to characterise it and to give a route for sampling.
Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.
How was this decided?
- pathwayany — Screening assessment
- rulerule-pregnancy-ionising — Pregnancy status before an ionising exposure; checked by Radiographer at the scanner
Decision support only. Local protocol takes precedence.
Handled at the scanner(1)nothing for you to do
Settled and owned downstream. Each returns to a radiologist only on the stated trigger.
- Pregnancy status before an ionising exposureMake the pregnancy enquiry immediately before the exposure and record the answer. In the UK this is a statutory operator duty discharged at the time of exposure under the employer’s written procedures required by IR(ME)R 2017 — it is not something the vetting radiologist can perform or pre-empt, and a request is complete without it.Radiographer at the scannerAt the scannerFlags back if: The patient states that she is, or may be, pregnant AND the uterus is in or near the primary beam. The exposure is then paused for re-justification by the IR(ME)R practitioner before it proceeds.
Worth asking the referrer (1)
None of these hold the request up. They sharpen the protocol or the plan that follows.
- What was seen on the screening mammogram, on which side, and in which quadrant?It determines which supplementary views are performed and where the ultrasound is targeted. Without it the assessment cannot be planned.
Pathways
Big forks are separate pathways; the first whose conditions match is the one used.
Screening assessment
Matches your inputsDefault| Role | Study & protocol | Why this answers the question |
|---|---|---|
| First line | Mammography Diagnostic mammography (± tomosynthesis) | Supplementary views — spot compression, magnification, true lateral and tomosynthesis — are what separate a summation artefact from a real lesion, and they characterise calcification morphology and distribution, which is the single most useful feature for deciding on biopsy. Targeted ultrasound is added for a mass or asymmetry that persists, both to characterise it and to give a route for sampling. |
| Problem solving | MRI Breast MRI Breast — full dynamic contrast-enhanced | Used after conventional assessment, not instead of it: to determine disease extent once malignancy is proven, or in the uncommon case of a persistent mammographic finding that ultrasound cannot localise for biopsy. Used earlier it generates additional lesions that themselves require work-up, which is precisely what an assessment clinic is trying to avoid. |
Pitfalls
- Repeating standard screening views instead of performing targeted problem-solving views — the recall is not answered by the same pictures again.
- Using ultrasound alone to dismiss a mammographic finding, particularly calcification, which ultrasound frequently cannot demonstrate.
- Assessing without the screening images to hand, and working up the wrong site.
- Recording a benign outcome without documenting the mammographic-pathological concordance where a biopsy was taken.
- Working a symptomatic woman up as a screening recall. If she has a palpable lump, nipple discharge or skin change, she is a symptomatic patient who happens to have been recalled, and she belongs on the triple assessment pathway — a normal assessment of the screen-detected finding says nothing about the lump she can feel.
Priors — what to pull first
- The previous screening round is the most valuable comparison available; a stable finding across rounds is often the whole answer.
- Any prior surgery or benign biopsy at the site explains distortion that would otherwise be suspicious.
What makes a good request
- The recalled finding, its side and its location should travel with the request; assessment without knowing what was seen on the screening film is guesswork.
- A large majority of recalls resolve as normal or benign once the finding is worked up, which is why the assessment pathway is designed to be completed in one visit.
- Calcification is a mammographic problem: magnification views characterise it, ultrasound frequently cannot see it at all.
Scoring this once it is done
The classification and risk tools this question ends in.
How these studies are acquired
Contrast, phases and timing for every study on the pathways above.
Confirm locally
- Diagnostic mammography (± tomosynthesis): timings are typical — confirm against local protocol.
- Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
- Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.
References
- ACR Appropriateness Criteria — Palpable Breast Masses: 2022 Update · ACR Appropriateness Criteria
- BI-RADS assessment categories and the incomplete (category 0) work-up · Primary literature
- The Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) — Schedule 2 requires written procedures for making enquiries of individuals of childbearing potential to establish whether they are or may be pregnant or breastfeeding; the operator is responsible for the practical aspects they carry out. · RCR
- Society of Radiographers — The impact of IR(ME)R 2017 / IR(ME)R (NI) 2018 on pregnancy checking procedures · RCR
- ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation — Fetal dose <50 mGy not shown to increase risk of pregnancy loss or malformation; attributable cancer risk approximately 0.4% per 10 mGy · Other
- IAEA Radiation Protection of Patients — pregnancy enquiry is not needed for examinations in which the uterus is remote from a properly collimated primary beam (head, extremities) · Other
Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.