Breast lumps

Breast lumps
File:Breast lump.jpg
A small, palpable, hard lump in breast carcinoma. Image courtesy of Professor Peter Anderson DVM PhD and published with permission © PEIR, University of Alabama at Birmingham, Department of Pathology

Breast lumps Microchapters
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Patient Information
Overview
Historical Perspective
Classification
Pathophysiology
Causes
Differentiating Breast lumps from other Diseases
Epidemiology and Demographics
Risk Factors
Screening
Natural History, Complications and Prognosis
Diagnosis
Diagnostic Study of Choice
History and Symptoms
Physical Examination
Laboratory Findings
Electrocardiogram
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CT
MRI
Ultrasound
Other Imaging Findings
Other Diagnostic Studies
Treatment
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Epidemiology and Demographics

• 40% of breast complaints leading to an office visit
• 6% of all women ages 40-69 seek advice about breast lumps
• Cysts and fibroadenomas = most common underlying conditions
• 75-80% of breast biposies in the US are for benign lesions
• Breast cancer detected in

  • 4% of women with breast complaints
  • 8% of women with abnormal screening mammograms
  • 2% of women with abnormal findings on screening clinical breast exam

Breast Cancer Risk Factors

Breast Cancer Risk Factors

Age (> 70 vs. < 35)	RR 17.0
Positive Family History	RR 2.6
Early Menarche (< 12 years old)	RR 1.5
Late Menopause (> 55 years old)	RR 2.0
HRT Use (current)	RR 1.2-1.4
OCP Use (ever)	RR 1.07-1.2
Postmenopausal Body Mass Index (> 30.7)	RR 1.6

Pathophysiology & Etiology

• Cysts

  • Common in premenopausal women > 40 years old
  • Less frequent in younger women (10% of breast masses in women < 40 years old)
  • Uncommon in postmenopausal women not on hormone replacement therapy (HRT)
  • Often fluctuate with menstrual cycle
  • Especially common during periods of hormonal irregularity

• Fibroadenomas
• Prominent Fibrocystic Change (without a dominant mass)
• Fat Necrosis
• Malignancy

Diagnosis

• Triple Diagnosis

  • Use of physical examination, mammogram and fine needle aspiration biopsy (FNAB) for diagnosis of palpable lumps

    • If all 3 are benign: < 1% incidence of breast cancer

      • Follow patient with complete breast exam (CBE) every 3-6 months x 1 year to ensure stability

    • If all 3 are positive: 99.4% incidence breast cancer
    • If any 1 is positive: excisional biopsy recommended

Differential Diagnosis of a Breast Lump

• Breast Abscess
• Breast Cancer
• Carcinoma
• Cyst
• Cystic mastitis
• Cystosarcoma Phylloides
• Fat necrosis
• Fibroadenoma
• Fibrocystic changes
• Galactocele
• Gynecomastia
• Hematoma
• Intraductal papilloma
• Lipoma
• Lymphoma
• Mammary adenosis
• Mammary duct ectasia
• Phylloides tumor
• Prolactinoma
• Sebaceous cyst
• Trauma
• Tuberculosis abscess

History and Symptoms

• Characteristics of lump:

  • Location and duration of its presence, changes in size
  • Associated nipple discharge
  • Changes with menstrual cycle

    • Cysts tend to be more prominent

  • Premenstrually and may regress during follicular phase
  • Tenderness

    • Rapidly developing cysts may be tender

• Prior history of breast cancer or breast biopsy (atypical hyperplasia on prior biopsy most worrisome)

Physical Examination

• Suspicious findings

  • Single lesion
  • Hard
  • Immobile
  • Irregular borders
  • Size > 2 cm

• Exam not reliable for distinguishing benign vs. malignant (PPV 73%, NPV 87% at referral center)
• Cancers may be tender on exam (~ 15% of cases)
• Exam should include evaluation for supraclavicular and axillary LAN

Echocardiography or Ultrasound

• Ultrasonography:

  • In women < 35
  • May be helpful in conjunction with mammogram for women 35 and over
  • Also for evaluation of nonpalpable mass detected on screening mammogram
  • Simple cyst on ultrasound has extremely low risk cancer

Other Imaging Findings

Mammography

• Any woman age 35 or over with a breast mass
• Suspicious findings

  • Increased density
  • Irregular margins
  • Spiculation
  • Clustered

• Microcalcifications
• Can miss 10-20% of clinically palpable breast cancers
• Not cost-effective or clinically helpful in patients < 35 unless high suspicion cancer

Other Diagnostic Studies

Fine Needle Aspiration/Biopsy

• Fine Needle Aspiration

  • Office procedure for evaluation of palpable cyst (22-24 gauge needle)
  • Bloody fluid

    • Send for cytology and refer for surgical biopsy

  • Non-bloody fluid

    • Cytology extremely low yield (do not send)
    • If mass disappears, reexamine pt in 4-6 weeks
    • If no recurrence, resume routine follow-up
    • If recurrence, can repeat aspiration
    • Consider biopsy if further recurrence

  • Non-bloody fluid but residual mass after aspiration: surgical biopsy
  • Solid mass (no fluid)

    • Surgical biopsy or fine needle aspiration biopsy

• Fine Needle Aspiration Biopsy (FNAB)

  • Aspiration of cells from a solid mass
  • 21 gauge needle, operator-dependent
  • Wide variation in sens (65-98%), spec (34-100%)

• Core Needle Biopsy

  • 14-18 gauge needle allows for better histologic sample
  • Used mostly for evaluation of non-palpable masses (mammogram or ultrasound guidance)
  • Compares favorably with surgical biopsy at lower cost

• Excisional Biopsy

  • Recommended if solid mass suspicious for cancer by exam or mammo
  • Also recommended for palpable mass not seen on mammogram or for abnormal biopsy

Treatment

Recommendations

• Women < age 35

  • If no distinct lump found or primary care physician (PCP) unsure: refer to breast specialist for 2nd opinion
  • If non-suspicious lump on exam

    • Reassess 3-10 days after onset of next menses
    • If lump regresses, no further evaluation needed

  • If lump remains palpable and feels cystic

    • Fine needle aspiration (FNA)
    • Management of bloody vs. non-bloody fluid as above

  • If lump does not feel cystic

    • Ultrasound
    • If solid mass: FNAB, core biopsy or excisional biopsy
    • If cyst, FNA as above
    • If non-suspicious solid mass < 1 cm: likely fibroadenoma
    • Can follow by physical examination every 3-6 months

  • Mammography generally not helpful in this age group

• Women age 35 and over

  • Mammography and ultrasonography (note: mammography has 10-20% false-negative rate)
  • Cystic mass

    • FNA with mgmt of bloody vs. non-bloody fluid as above

  • Solid mass

    • Core biopsy, FNAB or excisional biopsy if no suspicious features
    • Excisional biopsy recommended if mass is suspicious by exam or mammogram

  • No specific findings on mammogram and ultrasound: refer to surgeon for likely excision

Acknowledgements

The content on this page was first contributed by: Rebecca Cunningham, M.D.

List of contributors:

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