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==[[Breast lumps overview|Overview]]==


==Epidemiology and Demographics==
==[[Breast lumps historical perspective|Historical Perspective]]==
* 40% of breast complaints leading to an office visit
* 6% of all women ages 40-69 seek advice about breast lumps
* Cysts and [[fibroadenoma]]s = 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 lumps classification|Classification]]==
=== Breast Cancer Risk Factors ===
{|
|-style="background:silver; color:black"
| '''Age (> 70 vs. < 35)''' ||  '''RR 17.0'''
|-style="background:silver; color:black"
| '''Positive Family History''' || '''RR 2.6'''
|- style="background:silver; color:black"
| '''Early Menarche (< 12 years old)''' || '''RR 1.5'''
|-style="background:silver; color:black"
| '''Late Menopause (> 55 years old) ''' || '''RR 2.0'''
|-style="background:silver; color:black"
| '''HRT Use (current)''' || '''RR 1.2-1.4'''
|-style="background:silver; color:black"
| '''OCP Use (ever)''' || '''RR 1.07-1.2'''
|-style="background:silver; color:black"
| '''Postmenopausal Body Mass Index  (> 30.7)''' || '''RR 1.6'''   
|}


== Pathophysiology & Etiology==
==[[Breast lumps pathophysiology|Pathophysiology]]==
* '''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 ==
==[[Breast lumps causes|Causes]]==
* '''''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 lumps differential diagnosis|Differentiating Breast lumps from other Diseases]]==
* [[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 ==
==[[Breast lumps epidemiology and demographics|Epidemiology and Demographics]]==
* 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 ==  
==[[Breast lumps risk factors|Risk Factors]]==
* 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:
==[[Breast lumps screening|Screening]]==
----
== Suggested Reading and Key General References ==


== Suggested Links and Web Resources ==
==[[Breast lumps natural history, complications and prognosis|Natural History, Complications and Prognosis]]==


== For Patients ==
==Diagnosis==
[[Breast lumps history and symptoms|History and Symptoms]] | [[Breast lumps physical examination|Physical Examination]] | [[Breast lumps laboratory findings|Laboratory Findings]] | [[Breast lumps CT|CT]] | [[Breast lumps MRI|MRI]] | [[Breast lumps ultrasound|Ultrasound]] | [[Breast lumps other imaging findings|Other Imaging Findings]] | [[Breast lumps other diagnostic studies|Other Diagnostic Studies]]


==Treatment==
[[Breast lumps medical therapy|Medical Therapy]] | [[Breast lumps surgery|Surgery]] | [[Breast lumps primary prevention|Primary Prevention]] | [[Breast lumps secondary prevention|Secondary Prevention]] | [[Breast lumps cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[Breast lumps future or investigational therapies|Future or Investigational Therapies]]
== Case Studies ==
[[Breast lumps case study one|Case #1]]


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Revision as of 14:33, 22 April 2013

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]

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Breast lumps from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms | Physical Examination | Laboratory Findings | CT | MRI | Ultrasound | Other Imaging Findings | Other Diagnostic Studies

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Medical Therapy | Surgery | Primary Prevention | Secondary Prevention | Cost-Effectiveness of Therapy | Future or Investigational Therapies

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