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[1]
    • 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[2] [3]
    • 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[1] :

  • 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[1]:

  • 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

  1. 1.0 1.1 1.2 Harvey JA, Mahoney MC, Newell MS, Bailey L, Barke LD, D'Orsi C; et al. (2016). "ACR Appropriateness Criteria Palpable Breast Masses". J Am Coll Radiol. 13 (11S): e31–e42. doi:10.1016/j.jacr.2016.09.022. PMID 27814822.
  2. Lehman CD, Lee AY, Lee CI (2014). "Imaging management of palpable breast abnormalities". AJR Am J Roentgenol. 203 (5): 1142–53. doi:10.2214/AJR.14.12725. PMID 25341156.
  3. Loving VA, DeMartini WB, Eby PR, Gutierrez RL, Peacock S, Lehman CD (2010). "Targeted ultrasound in women younger than 30 years with focal breast signs or symptoms: outcomes analyses and management implications". AJR Am J Roentgenol. 195 (6): 1472–7. doi:10.2214/AJR.10.4396. PMID 21098212.


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