Breast Mass
Joyce A. Copeland
Approach
The goal of the evaluation of a breast mass is to differentiate masses that are cancerous from benign masses in a timely and cost-effective manner.
History
A. Current medical history and chief complaint
1. When and how was the mass discovered? Does the patient perform regular breast self-examinations? What, if any, changes have occurred since discovery of the mass?
2. Age and menstrual status. Cancer is more prominent in women aged more than 50 years, although it can be seen in 3% of women who are aged 20 to 29 years. In the postmenopausal age group, 85% of masses prove to be cancer (1). Postmenopausal women have a higher risk for breast cancer (BC). Pregnancy expands the list of possible causes of a mass to include mastitis, galactocele, or a breast abscess.
3. Is the mass painful? If so, is there any cyclic variation in the pain? Has there been any nipple discharge (Chapter 11.6)? Cyclic pain suggests a cystic origin. Persistent pain may represent BC or an inflammatory process.
B. Past medical history
1. What is the reproductive history and current menstrual status? Has the patient ever breastfed an infant? Is she on estrogen replacement therapy (ERT)? A woman who breastfeeds for 2 or more years may decrease her risk for BC. ERT has a controversial role in the cause or advancement of breast cancer.
2. Breast history. The patient should be questioned about any previous breast mass, breast biopsy, or surgery and the clinical outcome. Has she had a personal history of breast cancer or atypical hyperplasia on a previous biopsy? A prior history of BC or atypical hyperplasia on a biopsy increases the risk for malignancy.
C. Family history. Is there a family history of breast cancer? If yes, what is the relationship of the family member and at what age was the cancer diagnosed and what was the relative’s menstrual status? A mother or sister with premenopausal BC increases risk to the highest level.
Physical examination
A. Inspection. Inspect the breasts for symmetry, contour, skin retraction, rashes, peau d’orange, nipple discharge, erythema, or edema.
1. Symmetry and contour can be disrupted on any breast. Retraction suggests either chronic inflammation or BC caused by skin adherence to the mass.
2. Peau d’orange is a puckering or indentation of the skin over a mass. A rash can be related to Paget’s disease with a related ductal carcinoma.
B. Palpation and compression. Palpate both breasts, including the nipple and areolar region. Palpate the supraclavicular, infraclavicular, and axillary region for adenopathy. Evaluate the consistency, regularity, location, mobility, and tenderness of the mass. Hard, immobile, irregular masses raise the suspicion for BC. Smooth, cystic, or rubbery masses suggest a cyst or fibroadenoma. Fibrocystic changes are often nondiscrete and irregular, but are also mobile and relatively soft. Compressing the nipple may express a discharge (Chapter 11.6).
Testing
A. Imaging studies. The mammogram is used to characterize the nature of the mass and to provide an assessment of the remainder of the breast tissue and the contralateral breast. It is not a diagnostic procedure. Ultrasound is used to characterize a mass as solid or cystic or to identify masses that may not be identified by mammography. The ultrasound is helpful in evaluating a mass in a patient aged less than 30 years and it can be used as an adjunct in performing aspiration or a biopsy for the indeterminate lesion.
B. Fine needle aspiration (FNA) (2). The FNA can be used to obtain tissue or fluid in a palpable mass. Fluid aspiration plus resolution of the mass suggests a cystic origin. Grossly bloody fluid demands further evaluation of the mass. A cystic mass in a postmenopausal woman not on ERT requires a more thorough evaluation.
1. If the mass resolves, reexamine the breast in 4 to 6 weeks. If the fluid reaccumulates, reaspirate.
2. Residual mass or asymmetry after aspiration requires mammography and biopsy. If no aspirate is obtained, proceed with excisional biopsy.
C. FNA biopsy (FNAB) (4). The sensitivity of FNAB is 0.65 to 0.98 and the specificity is 0.34 to 1.0. The result of this procedure provides material for a cytologic examination. Correlation with imaging studies must be concordant in conclusion or excisional biopsy is indicated. Imaging guidance is indicated for a nonpalpable mass. Atypia of any degree warrants excisional biopsy.
D. Triple test for solid mass (3). The triple test includes physical examination, imaging findings, and cytology via FNAB. The technique demonstrates a sensitivity of 97% to 100%, with a specificity of 98% to 100% (3). Concordance for benign findings allows no further testing. Malignant cytopathology requires excisional biopsy. Inconclusive results without concordance requires open excisional biopsy.
E. Open excisional biopsy. A lesion that is highly suspicious on clinical examination or mammography is best evaluated with open biopsy and excision. Atypical cells on biopsy also require a more definitive tissue diagnosis.
Diagnostic assessment
The evaluation of a breast mass requires knowledge of BC risk factors and the characteristics of benign and malignant lesions. Characterizing the consistency and mobility of the mass combined with information about the patient’s age and menopausal status helps to provide an initial evaluation of the risk for BC. It is important to know what resources and skills are accessible in the community when selecting a diagnostic modality. Sensitivity to the patient’s fears, diligent follow-up, and communication are important in the care of the patient and to reduce medicolegal risk. If a patient remains fearful or uncomfortable with the evaluation, referral for a second opinion is a wise move.
References
1. White G, Griffith C, Nenstiel R, Dyess D. Breast cancer: reducing mortality through early detection. Clinician Rev 1996;6(9):77–79, 83–84, 100–106.
2. Osuch J, Bonham V, Morris L. Primary care guide to managing a breast mass: step-by-step workup. Medscape Women’s Health 1998;3:5.
3. The Uniform Approach to Breast Fine-Needle Aspiration Biopsy. [Editorial Opinion]. National Cancer Institute Conference. Am J Surg 1997;174(4):371–385.
4. Andolsek KM, Copeland J. Conditions of the breast. In: Taylor RB, ed. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag; 1998.
Book Source Details
- Book Title: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter
- Author(s): Robert B. Taylor (editor)
- Year of Publication: 2000
- Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2000 Lippincott Williams & Wilkins.
Other Book Chapters Related to Breast symptoms
Read excerpts from these other book chapters related to Breast symptoms:
Medical Books Excerpts
- Peau d'orange
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Breast ulcer
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Nipple Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Breast Mass
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
- Breast pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
- [ read ]
Copyright Details: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, Copyright © 2008 Williams & Wilkins.
More About Causes of Breast symptoms
» Next page: Breast Mass/Discharge (Field Guide to Bedside Diagnosis)
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