Approach to the diagnosis of a Breast Lump

Lt. Dhirendra

Focus

• Palpable mass in a woman’s breast-potentially serious lesion

• All palpable lesions require evaluation

• Triple assessment-effective strategy in the diagnosis of breast lumps

• First step- confirm the presence of a discrete mass

• Next step- distinguish simple cysts from solid lesions

Introduction

• Risk of breast cancer increases with age

• Median age of breast cancer diagnosis- 61 years

• 95% of all breast cancer- women >40 years

• Majority of breast cancers- sporadic (i.e., in patients without a family history of breast cancer)

• First-degree relative with premenopausal breast cancer- high risk

Causes

• Macrocyst (palpable cyst,25% of breast lesions)

• Fibroadenoma,

• Fat necrosis

• Cancer

Triple assessment

• Currently the gold standard

• Components

– Clinical assessment

– Imaging

– Tissue biopsy

• Diagnostic accuracy- approaches 100%

Clinical assessment

History

• Age

• A personal history of breast cancer

• Past history of a breast biopsy

• Family history of breast cancer

• Recent trauma to the breast

• Pregnancy

• Lactation

Physical examination

• Alone cannot definitively establish a mass as benign or malignant

• Irregular fixed masses-suspicious for malignancy

• Malignant lesions

– skin thickening

(e.g., peau d'orange)

– nipple changes

• Complete bilateral breast examination

– Variation in breast size

– Fungating mass

– Dimpling or retraction of skin

– Nipple inversion or excoriation

• Diagnostic accuracy of physical examination is 60 - 85%.

Patient positioning

• Arms over her head

• Hands on their hips and squeeze inwards- flexing the pectoral muscles- chest wall involvement

• Lymph nodes axillary, cervical, supraclavicular, and infraclavicular fossae should be evaluated

• Proper examination occurs with the patient both seated upright and lying supine

– as masses can often be appreciated more in one position than another

Interpretation

• Benign masses– no skin changes

– smooth and mobile

– soft to firm to palpation

– well-defined margins

• Malignant masses– generally hard and immobile

– may be fixed to surrounding structures

– poorly defined or irregular margins

• Infections, such as mastitis- signs of inflammation

Imaging

Mammography• Beneficial in finding occult malignancies

• All women 30 years or older with a breast mass-mammography

• Spot compression views and magnification views are recommended

• Multi-focal or multi-centric disease should be noted

• Palpable breast mass-mammography

– sensitivity 82% to 94%

– specificity 55% to 84% for detecting breast cancer

• Breast Imaging Reporting and Data System (BIRADS)

BIRADS

• Score-1 to 3 followed with an ultrasound

• Score-4 to 5 requires a tissue biopsy

• Palpable mass-negative imaging study surgical follow-up

• Score of 6 is given only after a biopsy-cancerous

Ultrasound of the breast

• Considered the diagnostic test of choice in patients <30 years old,because

– Density of breast tissue in younger women-limits sensitivity of mammography

– False-negative rate 52% in patients <35 years old with a palpable malignant breast mass

• Ultrasound may identify simple or complex cyst architecture

• Simple cysts are fluid-filled lesions-smooth, round, well-demarcated, and anechoic

• If no internal septations or debris,may simply be followed

Breast aspiration and biopsy • Fine-needle aspiration cytology(FNAC)

• Core-needle biopsy

• Excisional biopsy

Fine-needle aspiration cytology(FNAC)

• 22- to 26-gauge needle into the breast mass and extracting cells • Cells can be placed on a slide or made into a cell block • Advantages

– fast and easy to perform and it can be done in the OPD– distinguish benign from malignant lesions– for evaluating axillary lymph nodes

• Disadvantages– does not show histological

architecture – Cannot differentiate ductal

carcinoma in situ from invasive malignancy

Core needle biopsy

• Using an 8- to 14-gauge

needle

• Provides a larger tissue

sample than FNAC

• Fast and easy to perform,

and allows histological diagnosis

• Performed by palpation, under stereotactic control, or by ultrasound guidance

• Method of choice for histological diagnosis

Excisional biopsy

• Removing the entire breast mass-accurate histological diagnosis

• Invasive technique

• Benign asymptomatic mass, may be unnecessary

• Malignant mass, it may not obviate the need for a second procedure to treat

Management

Cysts

• Painful cysts may be aspirated under ultrasound guidance

• Cysts that recur or not completely resolve with aspiration- biopsy to rule out malignancy

• Biopsy- in complex cysts or those with solid elements

Solid mass

• Management for 'probably benign' masses

– Clinical and USG surveillance every 6 months for 2 years, to document stability

– Core needle biopsy- definitive diagnosis while leaving the lesion in situ

– Surgical removal of the mass, if the lesion is bothersome to the patient

• USG of the axilla- to evaluate lymphadenopathy, and abnormal lymph nodes biopsied

• Cancerous- staging investigations follow and managed by multidisciplinary team

In a nutshell

• Palpable mass in a woman’s breast- potentially serious lesion• All palpable lesions require evaluation• The triple assessment- effective strategy in the management of

breast lumps• The first step-confirm the presence of a discrete mass• Next objective- distinguish simple cysts from solid lesions• Simple cysts are aspirated to dryness and require no further

treatment if do not recur• Pathological cysts require surgical excision.• A solid lesion requires a firm diagnosis, necessitating histological

examination• Benign solid lesions may be managed expectantly- regular follow-up• Malignant solid lesions- referred to a multidisciplinary team for

management

Discussion