Palpable breast mass

Published on 10/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 10/03/2015

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Chapter 6 PALPABLE BREAST MASS

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.