Breast lumps differential diagnosis

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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]

Overview

Breast lumps must be differentiated from other diseases such as malignancy, cysts, inflammation and non-inflammatory solid lumps. Breast symptoms such as nipple discharge and mastalgia require assessment as well.

Differentiating Breast lumps from other Diseases

Differential diagnosis of breast lumps include:

Diseases	Etiology	Benign	Malignant	Clinical manifestation									Paraclinical findings			Gold standard diagnosis	Associated findings
				Demography	History	Symptoms			Signs				Lab findings	Histopathology	Imaging
						Mass	Mastalgia	Nipple discharge	Breast exam	Skin changes	LAP	Others
Fibroadenoma	Unknown	+	Very slight increased risk of breast cancer in complex fibroadenoma	Most common benign tumor, women aged 20-30 years	Increased in size during pregnancy or with estrogen therapy, and regress after menopause	+	±	–	Solitary, well-defined mobile mass	–	–	NA	Nl	Proliferative breast lesion without atypia	Well-defined Solid mass	Mammography Ultrasound Biopsy	NA
Breast cyst	Hormonal fluctuation	+	No increased risk of malignancy for simple cyst <1% for complicated cyst <1% to 23% for complex cyst	Cmmon masses found in premenopausal, perimenopausal, and postmenopausal women Mostly seen among HRT users	May resolve after aspiration Further evaluation for not completely resolved masses	+	±	–	Solitary Cluster of small masses or an ill-defined mass Smooth, firm, and frequently tender	–	–	NA	Nl	Nonproliferative breast lesions	simple cyst: Well circumscribed, posterior acoustic enhancement without internal echoes Complicated cyst: Homogenous low-level internal echoes due to without solid components Complex cyst: thick walls greater than 0.5 mm with solid component	Ultrasound Fine needle aspiration (FNA)	NA
Fibrocystic change	Unknown Imbalance between estrogen and progesterone	+	No increased risk of malignancy Slightly increased risk of malignancy in presence of positive familial history of breast cancer	Unknown prevalence among adolescents >50% in women of reproductive age	Become present before menses and improve during mensturation	+	+	±	Painful breast tissue Tender, nodular swelling	–	–	NA	Nl	Nonproliferative breast lesions	Small cysts in mammary zone Fibroglandular tissue around the mass	Ultrasound Mammography (it is not recommended for adolescents)	NA
Galactocele	Milk duct obstruction	+	No increased risk of malignancy	Milk retention cysts with fluid collection among pregnant women and during breast-feeding	After ending lactation, the cysts resolve	+	±	±	Soft masses Cystic masses	–	–	NA	Nl	Retention cyst resulting from lactiferous duct occlusion	Mammography: Intermediate mass in absence of classic fat-fluid level Ultrasound: Complex mass	Ultrasound Mammography	NA
Cysts of montgomery	Obstruction of periareolar glands of montgomery	+	No increased risk of malignancy	Most common in age of 10-20 years old	More than 80% resolve spontaneously Drainage is essential in rare cases	+	±	±	Asymptomatic subareolar mass Drainage of clear to brownish fluid	±	–	NA	Nl	Acute inflammation due to obstruction of the Montgomery's gland	Single cystic lesion in retroareolar area	Ultrasound	NA
Hamartoma	Unknown	+	Coexisting malignancy can occur	Common in women older than 35 years old	Asymptomatic ones found incidentally or painless breast lump Usually excised	±	–	–	Soft breast lump Breast enlargement without palpable mass	±	–	NA	Nl	Benign proliferation of fibrous, glandular, and fatty tissue Thin capsule of connective tissue	Well-described Discrete, solid, and encapsulated lesion	Ultrasound Mammography	NA
Breast abscess	Complication of breast mastitis	+	No increased risk of malignancy	Complication of lactational mastitis in 14% of cases Common among African American women, heavy smokers , and obese patients	Resolve after drainage/ anti-biotic therapy	+	+	–	Localized inflammation of breast Tenderness	+	–	Fever Malaise	Blood culture is required in severe infection	Inflammatory mass Purulent material drainage either spontaneously or on incision	Fluid collection	Ultrasound	NA
Mastitis	Inflammation Infection	+	No increased risk of malignancy	Common among lactating women (first three months of breast-feeding) Periductal mastitis among smokers and associated with squamous metaplasia	Resolve after anti-biotic therapy/ drainage	±	+	±	Breast tenderness Swollen breast tissue	+	–	Fever Nipple retraction	Leukocytosis	Breast parenchyma inflammation: Acute mastitis: Staphylococcus infection Granulomatous mastitis: Tuberculosis or sarcoidosis infection	Ill-defined area with hyperechogenicity with inflamed fat lobules Skin thickening	Ultrasound	NA
Diseases	Etiology	Benign	Malignant	Demography	History	Mass	Pain	Nipple discharge	Breast exam	Skin changes	LAP	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Breast carcinoma	Generally unknown Genetic factors Hormonal exposure	–	+	Most common diagnosed cancer among women Leading cause of cancer death in women 40-49 years old	Positive family history	+	–	±	Hard Immobile Solitary Irregular margin	±	±	Breast size changes Nipple abnormality	Nl	Molecular alteration in epithelial cells Ductal Lobular Ductal/lobular Mucinous Tubular Medullary Papillary	Mammography: Spiculated soft tissue, mass microcalcification Ultrasound: Spiculated, hypoechoic lesion, shadowing, internal calcification	Ultrasound Mammography	HER2- positive or negative Estrogen receptor (ER) Progestrone receptor (PR)
Ductal carcinoma in situ (DCIS)	Unknown May be related to genes BRCA1, BRCA2	–	+	Contain 25% of all breast cancers Increase risk with aging	Positive family history nulliparity Obesity	±	–	±	May have normal physical exam	–	–	NA	Nl	Noninvasive breast cancer Heterogenous group of neoplastic lesions	Suspicious microcalcification	Mammography	NA
Microinvasive breast cancer	Unknown	–	+	Uncommon Commonly referred to DCIS with microinvasion Average age 50-60 years old	Nulliparity Positive family history	+	–	±	Solitary firm palpable mass	–	±	NA	Nl	Associated with high grade DCIS	A mass with or without calcification stromal reaction	Mammography	NA
Breast sarcoma	Primary: Unknown Secondary: Radiotherapy	–	+	Rare type, < 1% of all breast malignancies Average age of between 45-50 years	Positive history of breast cancer Rapid increase in size	+	–	–	Well-defined, firm mass	±	–	NA	Nl	Heterogeneous nonepithelial malignancies from connective tissue of breast	Noncalcified oval mass Indistinct margins	Mammography	NA
Phyllodes tumor	Unknown	±	±	Most common in premenopausal women (40-50 years)	Represent 1% of breast tumors Grow aggressively Classify in benign, borderline, and malignant groups	±	–	–	Smooth and multinodular Well-defined Firm mass Mobile	–	–	NA	Nl	Nonepithelial breast neoplasm with average size of 5 cm	Solid mass Hypoechoic Well-circumscribed	Ultrasound Mammography	NA
Lymphoma	Non-Hodgkin lymphoma	–	+	Extremely rare ( 0.04%-0.5%) Average age 55-60 years	Unilateral mass in older women In childbearing women, bilateral and similar to inflammatory breast cancer, possibly having Burkitt lymphoma	+	–	–	Well-defined, firm mass Multiple	–	±	NA	Nl	Diffuse B cell lymphomas	Nonspecific circumscribed masses Without calcification	Mammography Core biopsy	NA
Duct ectasia	Unknown	+	–	Common among perimenopausal women	Usually resolve spontaneously	±	±	±	Usually asymptomatic	–	–	NA	Nl	Distention of subareolar ducts	Dilated milk ducts Fluid-filled ducts	Ultrasound	NA
Intraductal papilloma	Unknown	+	–	Common in women between 35-55 years old	Possibly benign ones Harbor areas of atypia or DCIS Surgical excision is recommended	+	±	±	Solitary or multiple lesion large lump near nipple	–	–	NA	Nl	Growth of papillary cell into a lumen	Well-defined Solid nodule	Core needle biopsy	NA
Lipoma	Unknown	+	–	Common between age of 40-60 years old	Benign tumors May experience recurrence	+	–	–	Solitary Mobile Soft mass	–	–	NA	Nl	Solitary tumor of mature fat cells	Well-Circumscribed Hypoechoic lesion	Core needle biopsy Excisional biopsy	NA
Sclerosing adenosis	Unknown	+	Small risk of malignancy	Result in repeating pain during mensturation	May present as a mass or incidental finding on mammogram No treatment is needed	±	+	–	Multiple lesion Firm Tender nodules	±	–	NA	Nl	Proliferative disease	Well-defined or irregular mass Microcalcification	Mammography	NA
Pseudoangiomatous stromal hyperplasia	Unknown	+	–	Common in reproductive age women	Benign stromal proliferation Stimulation of vascular lesion	+	–	–	Solitary firm mass Thickening	–	–	NA	Nl	Slit-like spaces between glandular units Confused with mammary angiosarcoma	Well-defined Solid mass Noncalcified	Ultrasound Mammography	NA
Mondor's disease	Complication of: Surgery Core biopsy Radiation therapy Trauma	+	–	Uncommon benign disease Occur on outer side of breast or under nipple	Benign and self-limiting disease Resolve after 4-6 weeks	+	+	–	Thick and tender cord on breast skin	+	–	NA	Nl	Thrombophlebitis of superficial veins of the breast	Tubular anechoic structure Multiple narrowing areas	Clinical examination Ultrasound Mammography	NA
Diseases	Etiology	Benign	Malignant	Demography	History	Mass	Pain	Nipple discharge	Breast exam	Skin changes	LAP	Others	Lab findings	Histopathology	Imaging	Gold standard diagnosis	Associated findings
Diabetic mastopathy	Unknown Autoimmune reaction	+	–	Lymphocytic mastitis or mastopathy Common among premenopausal women Longstanding diabetes mellitus type 1	Suspicious breast mass After diagnosis, excision is not required	+	–	–	Ill-defined mass Immobile	–	–	NA	Nl	Dense keloid-like fibrosis Periductal, lobular, and perivascular lymphocytic infiltration	Irregular mass Hypoechoic Dense lesion	Ultrasound Core needle biopsy	NA
Gynecomastia	Hormonal imbalance	+	–	Benign breast tissue swelling among men and boys around puberty	Benign proliferation of the male breast glandular tissue Usually underlying nipple mass At least 0.5 cm	+	±	±	Unilateral or bilateral firm mass Breast swelling Rubbery mass	–	–	NA	Nl	Glandular breast changes	Nodular pattern Dendritic pattern Diffuse glandular pattern	Ultrasound	NA
Sarcoidosis	Systemic involvement in sarcoidosis	+	–	Rare in patients with systemic involvement	Benign palpable mass May mimic malignancy feature	+	–	–	Firm mass Hard mass	–	–	NA	Nl	Idiopathic systemic granulomatous disorder	Irregular, Ill-defined, Spiculated solid mass	Biopsy	NA
Fat necrosis	Breast trauma Surgical intervention	+	–	Common among women May mimic malignancy features	Benign breast lumps develop after trauma/ surgery Suspicious lumps required biopsy No excision in established diagnosis	+	±	–	Hard or smooth mass Solitary mass Mobile	–	–	NA	Nl	Collections of liquefied fat	Collections of liquefied fat Oil cysts	Ultrasound	NA