Breast lumps medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Shadan Mehraban, M.D.[2]

Management of breast lumps:

• women aged>40 years with palpable mass
  • Diagnostic mammography is considered as the first step
  • If the last screening test is related to more than previous 6 months, both breast mammography is required to rule out occult malignancy
  • No further evaluation is needed in case of clearly benign mass in mammography
  • Ultrasound imaging is required for the rest of cases appeared in mammography
    • Stereotactic biopsy is recommended in negative ultrasound findings addition to suspicious mammographic results
• Women aged<40 years with palpable mass
  • Ultrasound or mammography is suggested for initial management of women aged between 30 to 39 years
  • Ultrasound is the first step for women< 30 years presenting with palpable mass

Approach to breast lumps in women aged >40 years based on mammographic results :

• If mammographic results become negative,the next step is targeted ultrasound
  • Negative ultrasound results considered as BI-RADS 1, then clinical follow-up is needed
  • Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is needed
  • Probably benign results considered as BI-RADS 3, then ultrasound short interval follow-up is needed
  • Suspicious ultrasound results considered as BI-RADS 4 or 5, then core-needle biopsy is needed
• If mammographic results show only fatty tissue
  • considered as BI-RADS 1, then clinical follow-up is needed
• If mammographic results show benign mass
  • considered as BI-RADS 2, then clinical follow-up
• If mammographic results are in favor of probably benign lumps, the next step is targeted ultrasound
  • Negative ultrasound results considered as BI-RADS 3,then mammographic short interval follow-up is required
  • Benign ultrasound results considered as BI-RADS 2, then clinical follow-up is required
  • Probably benign ultrasound results considered as BI-RADS 3, then ultrasound short interval follow-up
  • Suspicious ultrasound results is considered as BI-RADS 4 or 5,then core needle biopsy is required
• If mammographic result is in favor of suspicious lesion, the next step is ultrasound to determine biopsy plan
  • Considered as BI-RADS 4 or 5, then core needle biopsy is required

Approach to breast lumps in women aged <40 years based on targeted ultrasound findings:

• If ultrasound results become negative, there are two approaches:
  • Considered as BI-RADS 1, then clinical follow-up is required
  • Perform diagnostic mammography
    • Negative results are in favor of BI-RADS 1, then clinical follow-up is required
    • Benign results are considered as BI-RADS 2,then clinical follow-up is required
    • Probably benign results considered as BI-RADS 3, Mammographic short interval follow-up is required
    • Suspicious results considered as BI-RADS 4 or 5, then core needle biopsy is required
• If ultrasound results show benign findings
  • Considered as BI-RADS 2, then clinical follow-up is required
• If ultrasound results show probably benign findings
  • Considered as BI-RADS 3, then short interval follow-up is required
• If ultrasound results become suspicious
  • Considered as BI-RADS 4 or 5, then core needle biopsy is required

Management of breast lumps determined by core needle biopsy:

• Atypical ductal hyperplasia
  • Excision of lump by surgical consultation and follow-up with clinical breast examination for every 6-12 months accompanied with mammography annually
• Atypical lobular hyperplasia, lobular neoplasia, lobular carcinoma in situ
  • Surgical consultation and follow-up with clinical breast examination for 6-12 months accompanied with mammography annually
• Flat epithelial atypia
  • Surgical consultation and follow-up with clinical breast examination for 6-12 months accompanied with mammography annually
• Papillomas
  • Multiple, peripheral papillomas,lesions with atypia, and size >10 mm require surgical consultation and Follow-up with clinical breast examination every 12 months and mammography annually
• Complex sclerosing lesion, radical scar
  • If the size<10mm and adequately sampled, observation would be enough
  • If the size>10mm; surgical consultation is require
  • If papillomas excised; follow-up with annual clinical breast examination and mammography is required
• Fibroadenoma
  • If accompanied with atypia and enlarging size, surgical consultation is required
  • Follow-up with annual clinical breast examination and mammography
• Complex fibroadenoma
  • Observation and follow-up with clinical breast examination and mammography annually
• Sclerosing adenosis
  • Observation and follow-up with clinical breast examination and mammography annually
• Fat necrosis
  • Observation and follow-up with clinical breast examination and mammography annually
• Columnar cell hyperplasia
  • Observation and follow-up with clinical breast examination and mammography annually
• Phyllodes tumor
  • Surgical consultation is required with follow-up with clinical breast examination and mammography annually
• Desmoid tumor and mammary fibromatosis
  • Surgical consultation is required with follow-up with clinical breast examination and mammography annually
• Pseudoangiomatous stromal hyperplasia
  • In symptomatic and large lesions, surgical consultation is required with annual clinical breast examination and mammography follow-up
• Apocrine metaplasia
  • In discordant and atypic lesions, surgical consultation is required and in case of excision,follow-up with clinical breast examination and mammography annually

References

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