طب الأشعة

PALPABLE BREAST MASSES

“last update: 13 May 2024” Download Guideline

– Executive Summary

This guideline is concerned with imaging of female patients in the adult age group >18 years presenting with palpable breast mass. The recommendations according to the age group are as follows:

ADULT FEMALE, 40 YEARS OF AGE OR OLDER, PALPABLE BREAST MASS:

Variant 1: Initial imaging.

1. Mammography diagnostic:

In women 40 years of age or older with palpable breast mass, mammography is the initial diagnostic imaging modality of choice. Both breasts should be imaged in two views; craniocaudal and mediolateral oblique views enabling the entire breast to be completely screened for any additional lesions. The exam should be done under the supervision of a radiologist and a small radiopaque marker can be placed at the site of the palpable abnormality to assess in localizing the lesion.

Strong recommendation

2. Digital breast tomosynthesis diagnostic:

Diagnostic digital breast tomosynthesis (DBT) is recommended as an initial diagnostic tool. A radio-opaque marker can be applied to the skin to indicate its location.

Strong recommendation

3. Ultrasound breast:

Ultrasound of the breast is used following DBT or DM in this age group particularly if the patient has had a negative DM or DBT in the previous six months.

Strong recommendation

Variant 2: Mammography findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study.

1. Ultrasound breast:

Breast ultrasound is the next imaging modality of choice to characterize suspicious findings detected by DM or DBT. The ultrasound should be performed using a high-resolution linear transducer with a minimum frequency of 12 MHz and an adjustable focal zone. Examination of the remainder of the breast and the contralateral breast is recommended to search for any additional suspicious findings.

Strong recommendation

2. Contrast studies (contrast enhanced mammography/contrast MRI):

In women with dense breasts, contrast mammography (CEM) or contrast MRI are recommended for proper staging and to exclude multicentricity/bilaterality.

Conditional recommendation

3. Image guided core biopsy:

Core biopsy should be done for assessment and histological evaluation of suspicious palpable breast abnormalities allowing for tumor receptor status. If a suspicious finding seen by mammography of DBT correlates with the palpable abnormality, biopsy is warranted even with a negative ultrasound. If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Strong recommendation

4. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done for the assessment and histological evaluation of suspicious palpable breast abnormalities allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Conditional recommendation

Variant 3: Diagnostic mammography, DBT, and US findings are probably benign (BI-RADS 3). Next imaging study.

1. Mammography:

Breast masses with mammographic features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. Following a 24-month stabilization, the patient will be categorized as definitively benign BIRADS II and resume her normal screening.

Strong recommendation

2. Ultrasound breast:

Breast masses with ultrasound features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. Following a 24-month stabilization, the patient will resume her normal screening. If the mass reduces in size or disappear during the 24-month surveillance, it can be downgraded to BIRADS II

Strong recommendation

3. Image guided core biopsy:

Core biopsy is recommended if the mass is newly developed or has shown a 20% increase in volume or single diameter size. If the lesion is detected by ultrasound, ultrasound-guided biopsy is the preferred approach as it is and more tolerated by the patient as it avoids breast compression and may allow biopsy for difficult to reach locations by stereotactic biopsy. A radio-opaque clip is placed and a post-biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Strong recommendation

4. Image guided fine needle aspiration:

Fine needle aspiration biopsy (FNAB) can be done if the mass is newly developed or has shown a 20% increase in volume or single diameter size allowing for faster pathology results but with no difference in therapy timing. A radio-opaque clip is placed and a post aspiration biopsy mammogram or DBT is done to confirm its location and correlation between the ultrasound and mammography/DBT findings.

Conditional recommendation

Variant 4: Mammography findings are benign (BI-RADS 2) at the site of palpable mass. Next imaging study.

1. Ultrasound breast:

When the mammogram shows a benign finding, ultrasound is not necessary considering that there is a certain correlation between the mammographic finding and the clinically palpable abnormality.

If the correlation is uncertain, a targeted ultrasound examination is recommended.

Strong recommendation

2. Image guided core biopsy:

If a suspicious finding is detected by ultrasound, biopsy is recommended. A suspicious clinical examination should warrant biopsy irrespective of the imaging findings.

Strong recommendation

Variant 5: Mammography findings are negative (BI-RADS 1). Next imaging study.

1. Ultrasound breast:

Ultrasound breast should be done in women with a palpable abnormality and a negative mammogram.

Strong recommendation

2. Image guided core biopsy:

If a suspicious finding is detected by ultrasound, biopsy is recommended, A suspicious clinical examination should warrant biopsy irrespective of the imaging findings.

Strong recommendation

ADULT FEMALE, 30 YEARS OF AGE OR YOUNGER, PALPABLE BREAST MASS:

Variant 1: Initial imaging.

1. Ultrasound breast:

Ultrasound is the initial imaging modality of choice preferably targeted to the palpable abnormality.

Strong recommendation

Variant 2: US findings are suspicious or highly suggestive of malignancy (BI-RADS 4 or 5). Next imaging study.

1. Mammography diagnostic:

Mammography is indicated if the suspicious ultrasound finding correlates with the clinically palpable abnormality.

Strong recommendation

2. Digital breast tomosynthesis diagnostic:

DBT is indicated if the suspicious ultrasound finding correlates with the clinically palpable abnormality. DBT demonstrates the true extent of the lesion and exclude contralateral abnormalities particularly in young women with dense breasts.

Strong recommendation

3. Contrast studies (contrast mammography/contrast MRI):

In women with dense breasts, contrast mammography (CEM) or contrast MRI should be recommended for proper staging and to exclude multicentricity/bilaterality.

Conditional recommendation

4. Image guided core biopsy:

Strong recommendation

5. Image guided fine needle aspiration:

Conditional recommendation

Variant 3: US findings probably benign (BI-RADS 3). Next imaging study.

1. Ultrasound breast:

Breast masses with ultrasound features of BIRADS III morphology should undergo 6-, 12- and 24-month surveillance provided that the benign feature of the mass is persistent and there is no upgraded to BIRADS IV or V. If the mass reduces in size or disappear during the 24-month surveillance, it can be downgraded to BIRADS II

Strong recommendation

2. Image guided core biopsy:

Strong recommendation

3. Image guided fine needle aspiration:

Conditional recommendation

Variant 4: US findings benign (BI-RADS 2). Next imaging study.

No further imaging required.

Strong recommendation

Variant 5: US findings negative (BI-RADS 1). Next imaging study.

No further imaging required.

Strong recommendation

ADULT FEMALE, 30 to 39 YEARS OF AGE, PALPABLE BREAST MASS.

Same guidelines as adult female 40 years or older.

Strong recommendation

The Use of Coronary Computed Tomography Angiography for Patients Presenting with Acute Coronary Syndrome

“last update: 30 March 2026” Download Guideline

– Executive Summary

· The clinician properly evaluates the patient before requesting CTA guided by the patient’s history, clinical presentation, ECG, and initial biomarker assessment. Good Practice Statement

· The clinician should acquire ECG and review it for STEMI and Cardiac troponin should be measured as soon as possible. Good Practice Statement

· The clinician should categorize patients into low-, intermediate- and high-risk according to risk stratification tools. The clinician should indicate the appropriate criteria for performing CCTA. Good Practice Statement

· The clinician may request non-contrast coronary calcium scoring for asymptomatic individuals and intermediate-risk individuals (Framingham Risk Score 10%-20%) to document atherosclerotic cardiovascular disease risk stratification and guide preventive measures. Conditional recommendation

· The clinician should not request non-contrast coronary calcium scoring for high-risk individuals, patients already receiving statin treatment or asymptomatic low-risk adults: Strong recommendation.

· The radiologist should report non-contrast coronary calcium scoring and categorize patients as no CAC (Agatston score 0), mild (1-100), moderate (101-400), or severe (>400). Strong recommendation

· Clinicians should request CCTA as the first line test for evaluating patients with or without history of CAD who present with stable typical or atypical chest pain, or other symptoms that are thought to represent a possible anginal equivalent (e.g., dyspnea on exertion, jaw pain). Strong recommendation

· Clinicians should request CCTA following a non-conclusive functional test to obtain more precision regarding diagnosis and prognosis if such information will influence subsequent patient management. Strong recommendation

· Clinicians should request CCTA for patients at higher pretest risk for ACS, including patients with non-ST elevation myocardial infarction (NSTEMI) when the invasive strategy is not preferred (e.g., bleeding risk, vascular access issues, patient preference). Strong recommendation

· Clinicians should not recommend CTA for low-risk patients or patients with high probability (cardiac catheterization is recommended). Strong recommendation

· Clinicians should request CTA for the assessment of coronary stents in symptomatic patients with coronary stents >3mm, with current generation drug-eluting stents that have struts <3mm, and with current generation drug-eluting stents that have struts <100µm. Strong recommendation

· Clinicians may request CTA for the assessment of stents with smaller diameters (<3mm) as they are more challenging to assess, yet CTA may still be a reasonable test for assessing proximal, non-bifurcation thin strut stents that are <3mm. Conditional recommendation

· Clinicians should request CCTA for the assessment patency of coronary artery bypass grafts in symptomatic patients. Strong recommendation

· Clinicians should request CCTA for assessment of graft patency, anastomotic sites, and stenosis, in presurgical planning of redo bypass graft. Strong recommendation

· Clinicians should request CCTA for assessment of coronary grafts and not for assessment of the native coronary arteries in patients with prior CABG as it is of limited value due to severe calcification of the native coronary artery. Strong recommendation

· Clinicians may request CT-FFR for evaluation of lesion-specific physiology from a coronary CTA dataset using computational flow dynamic modeling and some hemodynamic assumptions, increasing the specificity of CCTA. Conditional recommendation

· Clinicians may request CCTA for measuring extracellular volume fraction (ECV), yet the gold standard test for measuring ECV is Cardiac MRI. Conditional Recommendation

· Clinicians may request CCTA for estimation of myocardial perfusion and viability as an alternative modality to Cardiac MR in patients with MRI contraindications. Conditional recommendation

· Clinicians should educate the patient about the nature of the examination, its objectives, possible risks including radiation dose, their required cooperation, and the sensations they are likely to feel. Patients should be given a chance to request an alternative diagnostic strategy if they feel unable or unwilling to proceed. Good Practice Statement

· The radiologist should repeat the educational process after premedication, just before scanning, to ensure patients remember instructions on breath-holding and are prepared for the sensations likely to occur from nitroglycerin and contrast administration. Good Practice Statement

· The radiologist/radiographer should obtain CTA in minimum CT scanner specifications as 64-detector row or greater or dual-source scanners, axial resolution ≤0.5×0.5mm, Z-axis resolution ≤1mm and temporal resolution ≤250ms. Strong recommendation

· The radiologist/radiographer should obtain Prospective ECG-triggering CCTA (the most commonly protocol) when the heart rate is regular and low (< 65 BPM). Strong recommendation;

· The radiologist/radiographer should obtain Retrospective ECG gating for coronary artery evaluation when the heart rate is high and in cases of arrhythmia. Strong recommendation

· The radiologist/radiographer may obtain Retrospective ECG gating for ventricular functional assessment when other modalities are not available. Conditional recommendation

· The radiologist is responsible for safety considerations of coronary CTA related to radiation exposure using the principle of As Low As Reasonably Achievable (ALARA). Strong recommendation

· The radiologist/radiographer should perform CCTA with the minimum accepted radiation dose (approximately 3 mSv), by applying the radiation protection measures as ECG-based tube current modulation , a high-pitch helical scan , reducing the tube potential from 120 to 100 kVp, noise reduction methods such as iterative reconstruction and suitable Z-axis coverage . Strong recommendation

· The radiologist/radiographer should perform CCTA after administration of intravenous iodinated water-soluble contrast media to ensure optimal vascular enhancement between 250 and 300HU in the ascending aorta. Strong recommendation

· The radiologist is responsible for safety considerations of coronary CTA related to allergic reactions to iodinated contrast agents, and contrast-induced nephropathy. Strong recommendation

· The radiologist should check the renal function tests before administration of the contrast media. If the eGFR value is greater than 30 the patient can receive IV iodinated contrast. If eGFR is less than or equal to 30 the case will need approval by the radiologist before IV contrast is used to minimize the risk of contrast-related AKI. Strong recommendation

· The radiologist should ensure the presence of patient safety equipment includings: advanced cardiovascular life support (ACLS) equipment in the patient preparation and scanner areas. Properly trained ACLS-certified nurses or similar qualified staff should supervise the premedication of patients as administration of beta blockers and nitrates. A rapid response team and/or an ACLS-certified physician should be readily available for prompt response to urgent or emergent complications. Strong recommendation

· The radiologist should perform CCTA after preparing the patient by Beta-blocker (metoprolol) to control the heart rate for maximum image quality during low and regular heart rates. Strong recommendation

· The radiologist should be familiar with the common contra-indications for beta-blockers such as heart block, hypotension, systolic dysfunction, poorly controlled asthma, severe aortic valve stenosis, severe bradycardia. Strong recommendation

· The radiologist may perform CCTA after preparing the patient by giving oral (sublingual) nitroglycerin Conditional recommendations

· The radiologist should be familiar with the common contraindications for nitroglycerin as erectile dysfunction medication (sildenafil, tadalafil, etc.) taken within the last 24-48 hr., increased intracranial pressure, right-sided myocardial infarction, severe anemia, known allergy or hypersensitivity . Conditional recommendations

· The radiologist should process the axial source image in a dedicated workstation and get more advanced post-processing techniques to assess cardiac anatomy such as multiplanar reformats, curved multiplanar reformats, volume-rendered three-dimensional images, and cinematic rendering. If functional information is obtained, then segmentation of the ventricular cavities can be used to quantify ventricular volumes and systolic function. Good Practice Statement

· The interpreting radiologist must be a physician adequately trained in cardiac CT as defined in recent training guidelines issued by the Society of Cardiovascular CT. The interpreting radiologist should be promptly available in place or by phone for consultation about patient preparation and scan protocol. Good Practice Statement

· The radiologist should report the radiological findings of CTA in one of the following formats: The Written Conventional Report or The Coronary Artery Disease-Reporting and Data System (CAD-RADS 2.0). The report should contain the relevant imaging findings, their interpretation, an overall summary/conclusion, and recommendations for further management. Good Practice Statement

NIPPLE DISCHARGE

“last update: 2 April 2026” Download Guideline

– Executive Summary

The scope of this guideline is concerned with imaging of female patients in the adult age group >18 years presenting with nipple discharge either physiologic or pathologic.

The recommendations according to the type of nipple discharge as well as the age group of the patient are as follows:

ADULT FEMALE, PHYSIOLOGIC NIPPLE DISCHARGE:

1. Digital Mammography:

If clinical findings are consistent with physiologic nipple discharge, routine screening mammography for patients 40 years of age or older is recommended. No further radiologic investigation is required and diagnostic breast imaging is unnecessary (3).

Strong recommendation

2. Image-guided Core Biopsy/ Fine Needle Aspiration:

We recommend against the use of image guided core biopsy or fine needle aspiration in these cases.

Strong recommendation

ADULT FEMALE, 40 YEARS OF AGE OR OLDER, PATHOLOGIC NIPPLE DISCHARGE:

1. Digital Mammography:

Mammography is the initial imaging modality in this age group. Both breasts should be imaged in two views; craniocaudal and mediolateral oblique views enabling the entire breast to be completely screened for any additional lesions. Additional mammographic views with spot compression and magnification are required for better evaluation of the retroareolar region when necessary (6).

Strong recommendation

2. Digital Breast Tomosynthesis:

It is recommended as an initial diagnostic tool if available. Many studies have proposed the use of DBT in assessing nipple discharge (7). It has also been proven that the sensitivity of DBT is higher than that of mammography with better detection rate and diagnosis of breast cancer.

Strong recommendation

3. Breast ultrasound:

Breast US is recommended as a complementary tool for mammography in initial evaluation and assessing extent of involvement.

US is also an important tool to guide for biopsy and localization for surgical excision.

Strong recommendation

4. MRI Breast:

MRI is not recommended as initial imaging for patients with pathologic nipple discharge. in patients with pathologic nipple discharge and negative mammography/ ultrasound, MRI is recommended to detect lesions of concern preoperatively. Imaging follow-up can be safely recommended for patients with normal MRI findings, thus avoiding unnecessary surgical duct excision (8).

Strong recommendation

5. Contrast enhanced mammography:

With CEM, lesions could be identified according to their density, morphologic as well as enhancement characteristics (9). It is currently being used for diagnostic purposes especially in dense breasts, preoperative evaluation, assessment of extent of disease and MRI contraindication. Ongoing studies also propose future directions in breast cancer screening (10). It may be considered in patients with pathologic nipple discharge and negative mammography/ ultrasound according to its availability.

Conditional recommendation

6. Image-Guided Core Biopsy:

Image-guided core needle biopsy is not recommended for initial evaluation of patients with pathologic nipple discharge.

Biopsy procedures can be guided by stereotactic mammography, contrast enhanced mammography, or US, depending on the imaging modality which best depicts the abnormality detected.

Vacuum-assisted core biopsy (VAB) is useful in complete sampling/ removing of small intraductal papillary lesions which may be therapeutic and can lead to cessation of nipple discharge in 90-97.2% of cases (11). Surgical major duct excision remains the gold standard for exclusion of malignancy in patients with unremarkable imaging.

Strong recommendation

7. Image-Guided Fine Needle Aspiration:

It is not recommended as the initial examination for evaluation of pathologic nipple discharge. Studies have shown that core needle biopsy is superior to fine needle aspiration (FNA) regarding accuracy and precise histological grading of breast cancer (12).

Conditional recommendation

ADULT FEMALE, 30 to 39 YEARS OF AGE, PATHOLOGIC NIPPLE DISCHARGE:

Same guidelines as adult female 40 years or older with the following consideration;

US is recommended as the initial imaging modality in this age group with the addition of mammography when necessary.

Strong recommendation

ADULT FEMALE, YOUNGER THAN 30 YEARS OF AGE, PATHOLOGIC NIPPLE DISCHARGE:

1. Breast ultrasound:

US is the initial imaging modality of choice in this age group.

Strong recommendation

2. Digital Mammography or Digital Breast Tomosynthesis:

Diagnostic mammography or DBT is beneficial if US shows a suspicious finding.

Strong recommendation

3. Contrast studies (contrast enhanced mammography/MRI):

Not recommended as initial imaging for patients with pathologic nipple discharge.

In women with dense breasts, CEM or contrast MRI should be recommended for proper staging and to exclude multicentricity/bilaterality.

Conditional recommendation

4. Image-guided Core Biopsy

If an imaging abnormality is seen, US can be used to guide biopsy.

Good practice statement