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

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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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