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breast lump/mass

Etiology: 1) benign neoplasms a) fibrocystic disease (majority) - upper outer quadrant of breast - 40-50 years until menopause - premenstrual mastalgia, multiple lumps (nodules) vary in size with menstruation b) fibroadenoma - upper outer quadrant of breast - 20-30 years, oral contraception, family history of breast cancer c) cyst d) lipoma e) papilloma f) hamartoma g) phyloides tumor (benign) h) adenoma i) duct ectasia j) granular cell tumor k) neurofibroma l) hemangioma [4] 2) malignant neoplasms a) carcinoma of the breast (10-20%) b) cystosarcoma phyloides c) squamous cell carcinoma d) angiosarcoma e) leukemia/lymphoma [4] 3) inflammation/infection a) mastitis b) breast abscess c) tuberculosis 4) trauma a) fat necrosis b) hemangioma 5) granulomatous disease a) Wegener's granulomatosis b) sarcoidosis c) idiopathic granulomatous mastitis 6) other a) diabetic mastopathy b) gynecomastia (men) Physical examination: - although ~90% of breast lumps are benign, neither history nor physical examination can rule out breast cancer [4] - skin changes suggest mastitis or breast abscess vs inflammatory breast cancer - erythema, tenderness & a palpable fluctuant mass suggests breast abscess Laboratory: - pregnancy test if bilateral milky nipple discharge Special laboratory: - biopsy vs fine needle aspiration as indicated from imaging studies [4] a) even after a normal mammogram, but apparently not if ultrasound suggests benign cystic lesion (simple cyst) [4] b) core biopsy or excisional biopsy any solid mass c) fine needle aspiration with cytology for complex cystic masses [4,5] Radiology: 1) age 15-35: ultrasound (age 15-30 [4]) 2) pregnant* or lactating women: ultrasound 3) age > 35: (age > 30 [4]) a) mammography b) ultrasound as recommended by mammographer 4) mammography a) 10% of breast carcinoma is negative on mammography b) sensitivity of mammography may be much less in high-risk women [1] c) mammography + ultrasounography [4] d) fine-needle biopsy, core needle biopsy (1st line) if mammography is negative, but lump or mass is present - excisional biopsy as indicated by pathology from core needle biopsy e) an irregular mass with calcifications or spiculation suggests malignancy [4] 5) MRI in high-risk women [2] a) sensitivity 88%, specificity 67% [3] b) positive predictive value 72% c) negative predictive value 85% d) inadequate to preclude need for breast biopsy [4] * deferring investigation until postpartum is not appropriate [7] Management: 1) if lump persists during follicular phase of the menstrual cycle*, obtain mammogram or ultrasound 2) mammograms generally less useful in patients < 35 years of age 3) fine needle aspiration vs core needle biopsy (1st line) a) if lesion is bloody, excisional biopsy b) if residual mass remains after aspiration, excisional biopsy c) if fluid reaccumulates, repeat aspiration 4) excisional biopgy for atypical hyperplasia is seen on core needle biopsy, or when pathology & imaging findings are discordant 5) NOT all solid breast masses are visualized by ultrasound 6) a negative mammogram in the presence of a persistent breast mass does NOT exclude malignancy: breast biopsy indicated [4] * cyclic breast pain often occurs in the premunstrual phase, tends to be bilateral, & resolves with onset of menstruation [4]

Related

breast cancer breast; mammary gland fibroadenoma fibrocystic disease of the breast mammography mastitis

General

abnormal morphologic structure (malformation) breast disease; mammary gland disease

References

  1. Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 363-64
  2. Journal Watch 24(21):164, 2004 Warner E, Plewes DB, Hill KA, Causer PA, Zubovits JT, Jong RA, Cutrara MR, DeBoer G, Yaffe MJ, Messner SJ, Meschino WS, Piron CA, Narod SA. Surveillance of BRCA1 and BRCA2 mutation carriers with magnetic resonance imaging, ultrasound, mammography, and clinical breast examination. JAMA. 2004 Sep 15;292(11):1317-25. PMID: 15367553
  3. Journal Watch 25(3):25, 2005 Bluemke DA, Gatsonis CA, Chen MH, DeAngelis GA, DeBruhl N, Harms S, Heywang-Kobrunner SH, Hylton N, Kuhl CK, Lehman C, Pisano ED, Causer P, Schnitt SJ, Smazal SF, Stelling CB, Weatherall PT, Schnall MD. Magnetic resonance imaging of the breast prior to biopsy. JAMA. 2004 Dec 8;292(22):2735-42. PMID: 15585733
  4. Medical Knowledge Self Assessment Program (MKSAP) 14, 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2006, 2009, 2012, 2015, 2018, 2022. - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  5. Rungruang B, Kelley JL 3rd. Benign breast diseases: epidemiology, evaluation, and management. Clin Obstet Gynecol. 2011 Mar;54(1):110-24. PMID: 21278510
  6. Harvey JA, Mahoney MC, Newell MS et al ACR appropriateness criteria palpable breast masses. J Am Coll Radiol. 2013 Oct;10(10):742-9.e1-3. PMID: 24091044 - Moy L, Heller SL, Bailey L, et al; Expert Panel on Breast Imaging. ACR Appropriateness Criteria palpable breast masses. J Am Coll Radiol. 2017;14:S203-24. PMID: 28473077
  7. NEJM Knowledge+ - Swain M, Jeudy M. Breast Masses in Biological Females. JAMA. 2022 Jul 19;328(3):294-295. PMID: 35771591 No abstract available. https://jamanetwork.com/journals/jama/fullarticle/2794023 - Stein L, Chellman-Jeffers M. The radiologic workup of a palpable breast mass. Cleve Clin J Med. 2009 Mar;76(3):175-80. PMID: 19258464 Free article. Review. https://www.ccjm.org/content/76/3/175.long - Klein S. Evaluation of palpable breast masses. Am Fam Physician. 2005 May 1;71(9):1731-8. PMID: 15887452 Free article. Review. https://www.aafp.org/pubs/afp/issues/2005/0501/p1731.html