Breast lumps


 * 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

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

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

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

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: