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 described as a mass that develops in the breast tissue. The breast consists of many different types of tissue, like mammary glands, and mammary ducts, and tubes. Fibrous tissue, adipose tissue, nerves, blood vessels, and lymph nodes also form important components of the breast. 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 be used to diagnose suspicious lesions. Women of reproductive age are more prone to develop breast lumps or masses. Occasionally, breast masses can be associated with hormonal changes (ie, fibrocystic changes), which have a waxing and waning course. Breast masses, although uncommon, can occur in men. If the diagnosis of cancer 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, cases have been seen in men also. Often it presents as a mass or lump in the breast which can also have associated symptoms like discharge, discoloration, pain, itching, induration, and lymph engorgement. 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 have a modifying effect on the incidence of breast cancer.
  • Breast cancer can present as a lump or mass in the breast or area of the armpit, thickening or dimpling of the skin, redness of skin irritation around the nipple, any abnormal discharge, abnormality in the shape and size of the breast, or subjective symptoms like pain and traction.
  • The risk of breast cancer increases with increasing age; and most of the cases are often seen after the age of 50 years. Certain genetic mutations like BRCA1 and BRCA2, also predispose to the occurrence of breast cancer. Furthermore, early menarche and late menopause also increase the risk, due to prolonged exposure to hormones. Moreover, dense breast tissue, due to more connective tissue, has increased chances of breast cancer, also making it hard to diagnose. 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, also increase the chances of breast cancer. Any radiation treatment in the past, also makes breast cancer more common.

Common Causes

• Breast cysts
  • These are the fluid-filled, sacs in the breast tissue. They can be either round or oval-shaped and of varied sizes. In the majority of cases, they are palpable as a smooth, round, movable mass, which can present with symptoms like pain and tenderness. Mostly seen in women in their reproductive years, like in the 30s and 40s. The size of the cyst can vary intermittently based on hormonal influences, like menstruation and pregnancy. The cysts can be simple, which are just comprised of fluid, or complex, which have a combination of both fluid and solid components. The exact diagnosis can be confirmed by biopsy.
• Adenosis
  • Adenosis is basically a nonmalignant breast condition, which is categorized by enlargement and increase in the number of 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, which are predominantly seen in lactating women. The leading factor 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 fatty tissue of the breast. Moreover, 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 painless, occasionally it can be tender with symptoms like 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 the women in the age group of the 20s and 30s 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 mammillary ducts of the breast. 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 the diagnosis, which can be often confirmed by biopsy.
• Lipoma
  • A lipoma is a benign lesion or tumor which is 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. On palpation, they are freely mobile, soft, smooth, and pliable 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.

Management

Breast Mass

Greater than 30 years

Less than 30 years

Mammogram

Mass not present

Mass present

MALIGNANT

BENIGN

INDETERMINATE

ULTRASOUND

END WORK UP

MASS NOT PRESENT

MASS PRESENT

SIMPLE CYST

BIOPSY

SOLID CYST