Breast Mass Resident Survival Guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Aisha Adigun, B.Sc., M.D.[2]

Overview

A breast mass is a mass that develops in the breast tissue. The breast consists of many different tissue types, i.e., mammary glands, mammary ducts, and tubes. Fibrous tissue, adipose tissue, nerves, blood vessels, and lymph nodes also form essential breast components. As a result, breast masses differ widely in sizes, textures, and symptoms (i.e., pain, tenderness, discharge). Breast masses can be benign or malignant and is often an incidental finding. A breast ultrasound or mammogram can diagnose suspicious lesions. Women of reproductive age are more prone to develop breast lumps or masses. Occasionally, breast masses may be associated with hormonal changes (i.e., fibrocystic changes), which have a waxing and waning course. Breast masses, although uncommon, can occur in men. If a cancer diagnosis is confirmed, modalities like lumpectomy, mastectomy, chemotherapy, or radiation therapy are treatment options.

Causes

Life Threatening Causes

• Breast cancer
• Breast cancer is a type of cancer that originates in the breast tissue and occurs when the breast tissue starts growing at an uncontrollable rate. Although it is predominantly present in females, It also occurs in men. Breast cancer can be either ductal when it involves the mammary ducts or lobular when it starts in the glands. It is the most prevalent cancer in females and the second most common cause of death. Several factors, like increasing age, high hormone levels, economic status, and ethnic groups, affect breast cancer incidence.
• Breast cancer can present as a mass or lump in the breast and can have associated symptoms like discharge, discoloration, pain, itching, induration, and lymph engorgement. Dimpling the skin, abnormality in the shape and size of the breast, or subjective symptoms like pain and traction may also be present.
• The risk of breast cancer increases with increasing age, as most cases are diagnosed after 50 years. Mutations, like BRCA1 and BRCA2, also significantly increase the risk of breast cancer. Furthermore, early menarche and late menopause also increase the risk due to prolonged exposure to hormones. Women with a history of breast cancer have an increased risk of future recurrences of the same. Also, a history of breast cancer in mother, sister, or any first-degree relative or breast or ovarian cancer in other relatives increases breast cancer chances. Any radiation treatment in the past is also a breast cancer risk.

Common Causes

• Breast cysts
  • These are the fluid-filled sacs in the breast tissue. They can be either round or oval-shaped and vary in size. In most cases, they are palpable, smooth, round, movable masses, and present with symptoms like pain and tenderness. They are mostly seen in women of reproductive age i.e 30s and 40s but can also be found in men. The size of the cyst can vary intermittently based on hormonal influences, like menstruation and pregnancy. The cysts can be simple, consisting of fluid, or complex, with both fluid and solid components. The exact diagnosis is confirmed by biopsy.
• Adenosis
  • Adenosis is a nonmalignant breast condition categorized by enlargement and an increase in the milk-producing glands. These are more predominant in women with underlying fibrosis and cysts. A biopsy is needed for definitive diagnosis.
• Galactocele
  • Galactoceles are benign breast lesions, predominantly seen in lactating women. The leading cause of galactocele is the cessation of breastfeeding, which leads to retention of milk in the ducts and stagnation, which causes pouches to form known as galactoceles. Usually, it presents as a painless mass or lump in the breast. On palpation, they feel like simple cysts, but instead of fluid, they contain milk. Although they are symptomatic, they are not dangerous.
• Fat Necrosis
  • Fat necrosis is a benign non-cancerous condition affecting the breast, which occurs after damage or injury to the breast's fatty tissue, mostly due to trauma. It can be a side effect of breast surgery or any radiation therapy. It usually causes a firm mass or lump in the breast. Although it is mostly asymptomatic, occasionally it can present with tenderness, or discoloration.
• Fibroadenoma
  • Fibroadenomas are known as benign, non-malignant breast masses, which are made up of a combination of both glandular and stromal connective tissue. These lesions are more common in women between the ages of 20 and 30, and often show a regressing pattern after menopause. A biopsy is needed for a definitive diagnosis.
• Intraductal papilloma
  • Intra-ductal papillomas are non-cancerous tumors that grow inside the breast's mammillary ducts. They comprise glandular tissue, fibrous tissue, and various blood vessels. These can be either solitary or multiple papillomas. The solitary papillomas are single tumors growing in the larger mammillary ducts close to the nipple. They present with a nipple discharge, which can be clear or bloody. The multiple papillomas are present in breast tissue, which is farther away from the nipple. Ductograms, ultrasound, and mammograms are used for diagnosis, which can be often confirmed by biopsy.
• Lipoma
  • A lipoma is a benign lesion or tumor composed of adipose tissue, enclosed within a thin fibrous capsule. Although they can occur at any age, they are more common after the age of 40. They are freely mobile, soft, smooth, and pliable on palpation and generally do not cause any other symptoms like pain.
• Mastitis
  • Mastitis is defined as the inflammation or swelling in the breast tissue, preceded by an infection. The infection is caused by either an obstructed or clogged milk duct, which does not drain the milk completely, leading to stagnation and bacterial colonization. Sometimes, cracks or breaks in the skin surrounding the nipple can also lead to bacterial infection. Mostly it affects breastfeeding women, and the involvement is unilateral. The affected part is swollen, engorged, painful, and warm to the touch. Also, constitutional symptoms like fever, headache, and fatigue can be seen. Treatment involves mainly milk expression to avoid stagnation of milk in the ducts and glands and antibiotics.

Diagnosis

Palpable breast mass

Ultrasound(age<30) / Mammogram(age>30)

Fine-needle aspiration

Not visualized

Simple cyst

Complex cyst or solid mass

Mammography and fine-needle aspiration or core-needle biopsy

Aspirate, then repeat clinical breast exam in 4-6 weeeks

Mammography and fine-needle aspiration or core-needle biopsy

Cyst

Solid mass

Residual mass or bloody fluid

No residual mass

Malignant

Atypical/Suspicious

Benign

Non-diagnostic

Patient ≥ 40 years of age?

Repeat clinical breast exam in 4-6 weeeks

Definitive treatment

Core-needle biopsy or excisional biopsy and/or refer

Mammography

Patient ≥ 40 years of age?

Yes

No

Positive

Negative

Yes

No

Mammography or core-needle biopsy

Ultrasonography or core-needle biopsy

Ultrasonography or core-needle biopsy

Repeat clinical breast exam in 4-6 weeeks

Mammography or core-needle biopsy

Ultrasonography or core-needle biopsy

Treatment

• Treatment of a breast mass is dependent on the outcome of the diagnostic workup.

Do's

• Perform a complete clinical history and review of risk factors for every patient presenting with a breast mass.
• Perform diagnostic evaluation with radiographic imaging (ultrasound/mammography), and in some cases, breast biopsy.
• If a biopsy is benign, clinical evaluation with imaging should be revisited every 6 months for a period of two years.

Dont's

• Do not dismiss a breast mass without a diagnostic workup regardless of size.