approach to the diagnosis of a breast lump
TRANSCRIPT
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Approach to the diagnosis of a Breast Lump
Lt. Dhirendra
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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
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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
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Causes
• Macrocyst (palpable cyst,25% of breast lesions)
• Fibroadenoma,
• Fat necrosis
• Cancer
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Triple assessment
• Currently the gold standard
• Components
– Clinical assessment
– Imaging
– Tissue biopsy
• Diagnostic accuracy- approaches 100%
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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
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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
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• 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%.
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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
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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
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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
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• Palpable breast mass-mammography
– sensitivity 82% to 94%
– specificity 55% to 84% for detecting breast cancer
• Breast Imaging Reporting and Data System (BIRADS)
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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
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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
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• Simple cysts are fluid-filled lesions-smooth, round, well-demarcated, and anechoic
• If no internal septations or debris,may simply be followed
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Breast aspiration and biopsy • Fine-needle aspiration cytology(FNAC)
• Core-needle biopsy
• Excisional biopsy
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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
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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
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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
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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
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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
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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
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Discussion