breast mass linda m. barney, md wright state university

Breast Mass

Linda M. Barney, MD

Wright State University

Ms. Marcus

Ms. Marcus is a 23-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

History

What other points of the history do you want to know?

History, Ms. Marcus Consider the following:

Characterization of Symptoms:

Temporal sequence

Alleviating / Exacerbating factors:

Associated signs/symptoms:

Pertinent PMH ROS MEDS Relevant Family Hx.

Characterize Symptoms

4 month history of left breast lump. 1st noticed in the shower ~ 1 week before menses Olive sized and nontender May have increased in size slightly No change with menstrual cycles

Associated Signs & Symptoms

Denies pain, skin change, nipple dischargeNo prior history of lumps or breast complaintsNo change with menstrual cycles, LMP 2 weeks

priorDenies trauma

Pertinent PMH

Healthy, exercises regularlyNo prior surgeriesNo chronic medical problemsMenarche age 12, no pregnancies, regular

cycles, OCP’s x 2 yearsDenies smoking, alcohol or drugsWorks as a systems analyst

Alleviating/ Exacerbating factors

No change with activity

Uses Ibuprofen for cramps with no change in the lump

Drinks decaffeinated tea and sodas only

Family History

Maternal grandmother with breast cancer at age 70

Mother and older sister with Fibrocystic Breast Condition

No Gyn or Colon CA in family

Differential DiagnosisBased on History and Presentation

Differential DiagnosisConsider the following

Fibrocystic Mass Cyst Fibroadenoma Breast Cancer Hematoma Abscess Fat necrosis Lactational Adenoma

Physical Examination

What would you look for?

Physical Examination, Ms. Marcus

Relevant Exam findings for a problem focused assessment

Breasts: Symmetrical, no skin changes, nipples everted/ no discharge. Right breast w/no dominant findings. Left breast with 2cm well circumscribed mobile mass 12’ position near areolar margin.

Nodes: No axillary or supraclavicular nodes

Remaining Examination findings non-contributory

Laboratory

What would you obtain?

Lab Discussion

No labs indicated Patient has no clinical signs of infection or

nipple discharge and no suggestion of any systemic disease

Studies

What further studies would you want at this time?

Studies, Ms. Marcus

Breast Ultrasound ? Screening Mammogram ?

PA/Lat Chest ? Diagnostic Mammogram ?

CT Scan of Chest ? Breast MRI ?

PET SCAN ? Other:

Ultrasound Left Breast

Studies – Results

Focused L breast US demonstrates a 2.2cm well-circumscribed, homogeneous, hypoechoic nodule, with no abnormal shadowing

Wider than tall orientation No additional abnormalities are noted

What is the differential diagnosis at this point?

Revised Differential Diagnosis

1 Fibroadenoma

2 Cyst

3 Fibrocytic Mass

4 Breast Cancer

What next?

Options

1. Additional Imaging?

2. Biopsy

3. OR?

4. Observation?

5. Other?

What next?

Discussion of suggested interventions

Limited value of additional imaging in a young female without high risk history. Dense breast tissue limits the utility of screening mammography, but should be ordered when clinically indicated. The lesion is well characterized by ultrasound.

A mammogram for Ms. Marcus is noted on the next slide.

MammogramComparison CC View

Left Right

ObservationObservation

May be reasonable in a young patient with low May be reasonable in a young patient with low risk history and benign appearance on imagingrisk history and benign appearance on imaging

Requires follow-up short and long term with Requires follow-up short and long term with intervention for clinical concernintervention for clinical concern

Discuss options for tissue diagnosis

What are the advantages and

disadvantages of each?

Biopsy Techniques

Needle Core Biopsy FNA Excisional Biopsy Image Guided Biopsy

• Ultrasound• Stereotactic

Management, Ms. Marcus

Core Needle BiopsyCore Needle Biopsy

US Directed BiopsyUS Directed Biopsy

Excisional BiopsyExcisional Biopsy

US Directed Biopsy

Management

Less advantage for image guided biopsy in a palpable mass but useful for deeper, hard to access lesions. Allows for targeting specific areas of a lesion. Enables marker clip placement for follow-up.

Excision is diagnostic and therapeutic. May disadvantage patients with suspected malignancy as it requires a second operation for definitive treatment. Best suited for the benign or indeterminate lesion where patient preference is removal rather than biopsy with observation.

Pathology

Fibroadenoma

Interventions at this point?

Discussion

Observation versus Excision Indications for excision

Rapid growth Inability to differentiate from aggressive pathology such as

Phyllodes Tumor or Breast Cancer Patient preference

Fibroadenoma Discussion

Features• Usually younger women• Usually solitary mass, occasionally multiple• May increase with pregnancy or involute post-menopause

Pathology• Benign tumor• Circumscribed rubbery mass• Overgrown fibrous stroma compressing epithelium• May have some increased risk of breast cancer long term

especially if associated with proliferative breast pathology*

Alternative Diagnosis

What if her mass was more tender and developed acutely since her last period?

Imaging studies follow

Ultrasound Left Breast

Mammogram Bilateral

MLO Views

Left Breast Right Breast

Would you like to revise your Differential Diagnosis?

Differential Diagnosis

Simple Cyst Complex Cyst Abscess Fibrocystic Mass Fibroadenoma Breast Cancer

Interventions at this point?

Management Options

FNA FNA w/ US guidance Core Biopsy Excision Observation

QUESTIONS ??????

Summary

Fibroadenomas are benign lesions presenting as a Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging palpable mass or well-defined lesions on imaging

Distinct US features are often notedDistinct US features are often noted

Tissue diagnosis is favored for observationTissue diagnosis is favored for observation

Simple cysts in low risk population can be aspirated Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observedfor symptoms & diagnosis or observed

Indeterminate lesions warrant tissue diagnosisIndeterminate lesions warrant tissue diagnosis

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