Breast lumps
| Breast lumps | |
| 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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Breast lumps Microchapters |
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Breast lumps On the Web |
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American Roentgen Ray Society Images of Breast lumps |
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
- If all 3 are benign: < 1% incidence of breast cancer
- Use of physical examination, mammogram and fine needle aspiration biopsy (FNAB) for diagnosis of palpable lumps
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: