Palpable breast lump

ACR AC Palpable Breast Masses (2022 update); NICE NG12; NICE NG101

A palpable lump is assessed by clinical examination, imaging and — where indicated — needle biopsy, together, not sequentially. Which imaging test leads depends on age: targeted ultrasound in the dense young breast under 30, either study between 30 and 39 where the guidance genuinely does not choose, and diagnostic mammography with targeted ultrasound from about 40 onwards.

A discrete palpable lump found by the patient or on examination, referred through a symptomatic breast clinic or an urgent suspected-cancer pathway.

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.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

Diagnostic mammography (± tomosynthesis)

Mammography

What we'd amend, and why

From about the age of 40, diagnostic mammography leads because breast density falls, sensitivity rises, and mammography detects the calcification and architectural distortion of disease beyond the palpable lump — including in the opposite breast, which no targeted study will look at. It is performed with targeted ultrasound of the palpable finding and the axilla, which is what characterises the lump itself and guides biopsy: the answer at this age is both studies, and the mammogram is the one that must not be left out.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayforty-and-over — 40 and over (and where age is not stated)
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 exposure
Make 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 scanner
Flags 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.
Pregnancy does not remove the need to assess a palpable lump. Ultrasound leads, and where mammography is required for a suspicious finding it is performed: the fetus lies far outside the primary beam and the dose to it from two-view mammography is a tiny fraction of any threshold for harm, which is negligible against the cost of a delayed breast cancer diagnosis. Note that this is no longer a shielding conversation — patient-side lead aprons for fetal protection have been withdrawn from recommended practice, because they do not reduce the internal scatter that constitutes the fetal dose and they can degrade the examination. If an apron is offered it is for reassurance, and it is never the condition on which the mammogram depends.

Worth asking the referrer (2)

None of these hold the request up. They sharpen the protocol or the plan that follows.

How old is the patient, and where exactly is the lump?
Age decides which imaging test leads — ultrasound under 30, either study between 30 and 39, mammography from 40 — and the site decides where the targeted ultrasound is performed, because a lump that is not scanned is not assessed. Where no age is stated the card falls back to the 40-and-over arm, so an unanswered age question can send a young woman for a mammogram she did not need.
Is the patient pregnant or breastfeeding?
It changes the imaging emphasis towards ultrasound and changes the differential, without removing the need to biopsy a suspicious lump.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Under 30

Role	Study & protocol	Why this answers the question
First line	Breast ultrasound Targeted breast ultrasound usually appropriate	Under about 30 two things point the same way: the breast is dense, so mammographic sensitivity for a mass is at its lowest, and the pre-test probability of cancer is low, so the study that is least likely to find disease is also the one being asked to reassure. Targeted ultrasound of the exact site the patient is pointing at answers the question the clinic is actually asking — cyst or solid, and if solid, whether the features are those of a fibroadenoma or of something that must be sampled — and it images the axilla and guides the needle in the same sitting, with no dose to radiosensitive glandular tissue. The ACR rates ultrasound usually appropriate as the initial study in this group and mammography only may-be-appropriate.
Second line	Mammography Diagnostic mammography (± tomosynthesis) may be appropriate	Problem-solving rather than initial imaging in this age group: performed where ultrasound is suspicious or highly suggestive of malignancy, where ultrasound is indeterminate or fails to explain a definite palpable abnormality, or where sampling has already confirmed cancer and the extent of disease, the calcification burden and the contralateral breast now matter. In each of those the mammogram is answering a question that has already been raised, which is what justifies the exposure in a young dense breast — and it is why it is a step here rather than the first step.
Problem solving	MRI Breast MRI Breast — full dynamic contrast-enhanced	Reserved for problems the standard pathway cannot close, and no more common in a young woman than in an older one: extent of disease before surgery in a proven cancer, an axillary nodal metastasis with no primary found, or a clinically suspicious lump with genuinely negative conventional imaging and non-diagnostic sampling. It is not a substitute for biopsy and does not resolve an indeterminate lump on its own.

A benign-looking, probably fibroadenomatous lesion in a young woman still needs a documented plan — short-interval follow-up or biopsy — rather than an open-ended discharge.
Ultrasound-first is not the same as imaging-only. A clinically suspicious lump is sampled whatever the ultrasound shows, and a young patient is not a reason to stop at reassurance.

30 to 39

Role	Study & protocol	Why this answers the question
First line	Breast ultrasound Targeted breast ultrasound usually appropriate	This is the decade where the guidance genuinely does not pick a winner: the ACR rates targeted ultrasound and diagnostic mammography both usually appropriate as the initial study, and the evidence does not separate them. Ultrasound characterises the palpable lesion and the axilla, works whatever the density, and provides the route for needle sampling in the same visit, which is why many one-stop clinics start here and add the mammogram on the same attendance when the ultrasound or the examination is not clearly benign.
First line	Mammography Diagnostic mammography (± tomosynthesis) usually appropriate	Equally endorsed as the initial study in this decade, and the better first move where a family history, a known genetic risk or a clinically suspicious lesion makes disease beyond the palpable finding — calcification, architectural distortion, a contralateral abnormality — the thing that most needs excluding. Targeted ultrasound of the palpable site and the axilla is performed alongside it, not instead of it. Requesting either study first is a defensible reading of the guidance; requesting imaging and then stopping short of tissue in a suspicious lump is not.
Problem solving	MRI Breast MRI Breast — full dynamic contrast-enhanced	Reserved for problems the standard pathway cannot close: extent of disease before surgery in a proven cancer, an axillary nodal metastasis with no primary found on mammography and ultrasound, or a clinically suspicious lump with genuinely negative conventional imaging and non-diagnostic sampling. It is not a substitute for biopsy and does not resolve an indeterminate lump on its own.

The two initial studies are listed in an order, but the order is not a ranking. Both are rated usually appropriate, both accept as requested, and which one the clinic performs first is a matter of local one-stop protocol and of what the examination has already suggested.
The consequential decision in this age band is the referral, not the modality: NICE NG12 puts an unexplained lump at 30 or over onto a suspected-cancer pathway regardless of which study is booked.

40 and over (and where age is not stated)

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	Mammography Diagnostic mammography (± tomosynthesis) usually appropriate	From about the age of 40, diagnostic mammography leads because breast density falls, sensitivity rises, and mammography detects the calcification and architectural distortion of disease beyond the palpable lump — including in the opposite breast, which no targeted study will look at. It is performed with targeted ultrasound of the palpable finding and the axilla, which is what characterises the lump itself and guides biopsy: the answer at this age is both studies, and the mammogram is the one that must not be left out.
Reasonable alternative	Breast ultrasound Targeted breast ultrasound usually appropriate	Targeted ultrasound is part of the answer at this age but not the whole of it. It is rated usually appropriate because it is performed with the mammogram — a request for ultrasound alone leaves the calcification, the architectural distortion and the contralateral breast unassessed in exactly the population where those findings are most likely to be present, so the sequencing advice is to add the mammogram rather than to substitute for it. Ultrasound alone is the reasonable first step only when the mammogram is already done, or during pregnancy and lactation.
Problem solving	MRI Breast MRI Breast — full dynamic contrast-enhanced	Reserved for problems the standard pathway cannot close: extent of disease before surgery in a proven cancer, an axillary nodal metastasis with no primary found on mammography and ultrasound, or a clinically suspicious lump with genuinely negative conventional imaging and non-diagnostic sampling. It is not a substitute for biopsy and does not resolve an indeterminate lump on its own.

This is also the arm reached when the request states no age. The fallback is deliberate — under-imaging a woman of 55 is the more consequential error — but the age is asked for as a clarifier precisely because it moves the patient to a different arm.
A benign-looking, probably fibroadenomatous lesion still needs a documented plan — short-interval follow-up or biopsy — rather than an open-ended discharge, at any age.

Pitfalls

Sending a woman in her twenties for a mammogram as the first test — the dense young breast gives a low yield, and targeted ultrasound is the appropriate initial study.
Reading the age bands as hard cut-offs. They are where the balance tips, not a rule that overrides a hard fixed mass, a strong family history or a clinically suspicious examination.
Accepting a normal mammogram as reassurance for a clinically suspicious lump; sensitivity falls sharply in dense tissue, and this is the classic route to a missed cancer.
Accepting a normal targeted ultrasound as a complete assessment in a woman of 40 or over, which leaves calcification, architectural distortion and the contralateral breast unexamined.
Scanning the breast without scanning the site the patient is pointing at, or without assessing the axilla.
Deferring assessment in a pregnant or lactating woman. A lump in pregnancy is still a lump, and the mammogram, if the finding needs one, is not held up for a shielding discussion that current practice has retired.
Treating imaging as the end of triple assessment when clinical suspicion is high and no tissue has been obtained.
Reading the female age arms onto a man. An eccentric male breast mass from about 25 onwards is a mammographic question first, and sending him for ultrasound alone leaves the finding that distinguishes gynaecomastia from carcinoma unexamined.
Treating an area of skin thickening, peau d’orange or erythema as cellulitis or mastitis in a woman who is not lactating. Inflammatory breast cancer presents exactly like that, it is imaged rather than watched, and a course of antibiotics is the classic route to a weeks-late diagnosis.

Priors — what to pull first

Retrieve previous mammograms, including screening films: comparison with prior imaging is one of the strongest discriminators between a new mass and long-standing normal tissue.
A previous benign biopsy at the same site changes the interpretation of an unchanged lesion, but not of a growing one.

What makes a good request

Below about 30, targeted ultrasound is the initial imaging test and the ACR rates mammography only "may be appropriate" in that group; between 30 and 39 either ultrasound or diagnostic mammography is a reasonable start; from 40 onwards diagnostic mammography is the initial study, with targeted ultrasound of the palpable abnormality and the axilla alongside it.
The age thresholds are soft. They describe where the balance between breast density, pre-test probability and radiosensitivity tips, not a birthday on which the correct study changes — a 29-year-old with a strong family history and a hard fixed mass is imaged as the clinical picture demands, and that decision belongs to the breast radiologist rather than to a rule.
Imaging never overrides clinical suspicion. A clinically suspicious lump with normal imaging still needs tissue.
In the United Kingdom the referral decision and the imaging decision are separate: NICE NG12 puts anyone of 30 or over with an unexplained breast lump on a suspected-cancer pathway, and considers non-urgent referral under 30, but which study the clinic then performs first is the question this card answers.
A one-stop clinic model exists because the three components are meant to happen in the same visit; splitting them across weeks is where cancers get lost.
The age arms of this card describe the female breast. A MAN with a palpable breast lump is a different algorithm and the arms below will under-image him: from about 25 onwards, diagnostic mammography is the initial study for an indeterminate or eccentric male breast mass, with targeted ultrasound alongside it, because mammography separates gynaecomastia — which is a mammographic and clinical diagnosis needing no biopsy — from the eccentric, non-subareolar mass that does. Under 25, or where the examination is that of classic symmetrical subareolar gynaecomastia, ultrasound or no imaging at all is appropriate. Male breast cancer is uncommon and presents late, and "he is a man" is not a reason to stop short of tissue.

Scoring this once it is done

The classification and risk tools this question ends in.

BI-RADS Assessment Categories (Mammography / US / MRI)RECIST 1.1 Tumor Response

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Targeted breast ultrasound Diagnostic mammography (± tomosynthesis)MRI Breast — full dynamic contrast-enhanced

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

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.