Palpable breast mass

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Chapter 6 PALPABLE BREAST MASS

Teri Kim, Theodore O’Connell

Approximately 190,000 new cases of breast cancer are diagnosed annually in the United States; however, most breast masses are benign. In order to diagnose these cancers, well over 1 million breast biopsies are performed each year. Fibroadenoma is the most common benign breast mass, whereas invasive ductal carcinoma is the most common malignancy.

After the patient history is obtained, a clinical breast examination is performed. Benign masses generally are smooth, soft to firm, and mobile, with well-defined margins and no skin changes. Malignant masses generally are hard, immobile, and fixed to surrounding skin and soft tissue, with poorly defined or irregular margins. With infections such as cellulitis and mastitis, the masses usually are erythematous, tender, and warm to the touch. However, similar symptoms may occur in patients with inflammatory breast cancer.

After the clinical breast examination, the initial step in the evaluation of a palpable dominant breast mass is to determine whether it is cystic or solid. This distinction may be made by targeted ultrasonography and diagnostic mammography or by fine-needle aspiration (FNA).

The next step in evaluating a patient with a palpable breast mass is determined by the patient’s age and the physician’s experience with performing office-based FNA. FNA of a palpable lesion is often a better choice than image-guided biopsy because it is easier on the patient, and aspiration directed to the palpable lesion will confirm the presence of the tumor at the site and obviate the need for image guidance at the time of surgical excision. FNA is preferable to core biopsy for small lesions because it is easier and more accurate for guiding a small-gauge needle into the lesion. Large masses can be diagnosed through either FNA or core biopsy.

FNA is used to aspirate cystic fluid or sample solid lesions for cytologic study. If FNA reveals fluid that is clear yellow, straw-colored, green, or brown (typical features of benign cystic fluid), the fluid can be discarded. The dominant mass should disappear, and a clinical breast examination should be repeated in 4 to 6 weeks. If there is residual mass after cyst aspiration or if the fluid is bloody, the evaluation proceeds with mammography, targeted ultrasonography, or core-needle biopsy. If FNA reveals a solid lesion, the evaluation proceeds with diagnostic mammography. Ultrasonography may be considered in women younger than 40 years.

If FNA is not possible during the initial presentation, ultrasonography should be considered to rule out cystic disease and delineate lesion margins.

The goal of biopsy is to direct a therapeutic course. Minimally invasive techniques are preferable to open surgical biopsy because they avoid both scarring and additional procedures that may not be necessary. If the lesion is cancerous, the goal is to establish a diagnosis as quickly and nontraumatically as possible in order to facilitate a discussion about treatment options.

Women presenting with a breast mass must undergo bilateral diagnostic mammography. Diagnostic mammography can be performed in women at any age; however, in women younger than 40 years, ultrasonography directed at the area of concern is the preferred study because the density of glandular breast tissue lowers the sensitivity of mammography.

The triple test is the combination of clinical breast examination, imaging, and tissue sampling. When the three assessments are performed adequately and produce concordant results, the diagnostic accuracy of the triple test approaches 100%. Discordant results or results that cannot be evaluated may indicate the need for excisional biopsy. The triple test score (TTS) was developed to help physicians interpret discordant results. A 3-point scale is used to score each component of the triple test (1 = benign, 2 = suspicious, and 3 = malignant). A TTS of 3 or 4 is consistent with a benign lesion. A TTS of 6 or more indicates possible malignancy that may necessitate surgical intervention. In patients with a TTS of 5, excisional biopsy is recommended for obtaining a definitive diagnosis. If all three elements indicate benign disease, the patient may be monitored with another examination in 4 to 6 weeks.

Key Historical Features

✓ Exact location of mass

✓ Duration of mass

✓ Changes in size over time

✓ Change in relation to menstrual cycle

✓ Fever, swelling, or redness

✓ Nipple discharge

✓ Medical history, especially of the following:

• History of breast or ovarian cancer

• Previous breast masses and biopsies

• Recent breast trauma

• Radiation therapy or chemotherapy

• Any radiation exposure

✓ Surgical history

✓ Obstetric and gynecologic history

• Age at menarche

• Age at first childbearing

• Number of pregnancies and number of children

• Age at menopause

• Current lactation status

• History of breastfeeding

✓ Medications and history of hormone therapy

✓ Family history, especially history of breast disease or ovarian cancer, age at onset, and relationship to the patient

✓ Carcinogen exposure, especially tobacco use, radiation exposure, and chemical exposure

Key Physical Findings

The breasts should be inspected visually with the patient in an upright position. The physician should note any asymmetry; obvious masses; nipple discharge; and skin changes, including rashes, dimpling, and inflammation. The physician should also note unilateral nipple retraction or inversion.

Each breast should be palpated, with the patient supine and one arm at a time raised above the patient’s head.

Other physical features as follows should be evaluated:

Suggested Work-Up

See the algorithm in Figure 6-1 for the management of a palpable breast mass. The triple test is discussed in the introduction to this chapter.

Figure 6-1. Diagnostic algorithm for patients with palpable breast masses.

(From Klein S: Evaluation of palpable breast masses. Am Fam Physician 2005;71:1731-1738.)

In a young woman who presents with a breast lump and with a history and physical examination results that are not suggestive of malignancy, it is reasonable to recheck the lump about a week after the onset of menstruation. If it does not regress, she needs further work-up.

Clinical breast examination	Best performed by a clinician 1 week after menses
Imaging
Mammography	Recommended for routine screening of all asymptomatic women 40 years and older
	Used for all women over age 40 with a solid mass, residual mass after cyst aspiration, or bloody fluid on cyst aspiration
Ultrasonography	Useful to differentiate between solid and cystic breast masses when a palpable breast mass is not well seen on a mammogram
	Especially helpful in young women with dense breast tissue when a palpable mass is not visualized on a mammogram
Biopsy
FNA	A 20- to 25-gauge needle is used to aspirate cystic fluid or sample solid lesions for cytologic study; if there is bloody fluid, or no fluid, the fluid or cells should be sent for cytologic analysis
	Often the first step in evaluating patients with palpable breast masses
Core-needle biopsy	A 14- to 18-gauge needle is used to sample a breast mass that is small or difficult to palpate
	Produces a larger tissue sample than does FNA and may be used in conjunction with ultrasonography or stereotactic imaging for lesions that are small or difficult to palpate
	May be used when FNA result is nondiagnostic, when FNA result is benign but mammography yields positive results, or when FNA result is atypical or suspect; also may be used when FNA reveals cystic fluid that is bloody or if there is residual mass after cyst aspiration
	Useful in distinguishing atypical hyperplasia and ductal carcinoma in situ from invasive disease
Excisional biopsy	The “gold standard” for evaluating breast masses
	Indicated in patients with clinically suspicious lesions and lesions in which results of imaging or tissue studies are equivocal

Additional Work-Up

For women at very high risk for breast cancer, genetic testing may be offered. Women with BRCA1 or BRCA2 mutations have a lifetime risk of developing breast cancer as high as 85%. Patients with these gene mutations also have an elevated risk for ovarian, colon, prostate, and pancreatic cancers. Of all women with breast cancer, approximately 5% to 10% may have BRCA1 or BRCA2 mutations. Genetic testing may be considered for members of high-risk families. Genetic counseling before and after testing is recommended.

FURTHER READING

Apantaku LM. Breast cancer diagnosis and screening. Am Fam Physician. 2000;62:596-602.

Esserman LJ. New approaches to the imaging, diagnosis, and biopsy of breast lesions. Cancer J. 2002;8(Supp 1):S1-S14.

Klein S. Evaluation of palpable breast masses. Am Fam Physician. 2005;71:1731-1738.

Morris KT, Pommier RF, Morris A, et al. Usefulness of the triple test score for palpable breast masses. Arch Surg. 2001;136:1008-1012.

Morris KT, Vetto JT, Petty JK, et al. A new score for the evaluation of palpable breast masses in women under age 40. Am J Surg. 2002;184:346-347.

Poggi MM, Harney KF. The breast. In: DeCherney AH, Nathan L, Goodwin TM, editors. Current Obstetrics & Gynecologic Diagnosis & Treatment. 10th. New York: McGraw-Hill; 2007:621-630.

Pruthi S. Detection and evaluation of a palpable breast mass. Mayo Clin Proc. 2001;76:641-648.

Steinberg JL, Trudeau ME, Ryder DE, et al. Combined fine-needle aspiration, physical examination and mammography in the diagnosis of palpable breast masses: their relation to outcome for women with primary breast cancer. Can J Surg. 1996;39:302-311. [Erratum in Can J Surg 1997;40:9.]

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