Breast Mass

Valerie L. Staradub, M.D.
Harvard Medical School

Monica Morrow, M.D., F.A.C.S.
Foxchase Cancer Center

Definition/Key Clinical Features
Differential Diagnosis
Best Tests
Best Therapy
Best References

Definition/Key Clinical Features

• Changes in breast nodularity are distinguished from normal nodular breast tissue by three criteria (i.e., borders, mobility, skin changes) and a texture different from that of the adjacent normal breast

• Well-circumscribed borders
• Firm and rubbery texture
• Mobile
• No skin changes
• No nipple changes

• Irregular borders
• Hard texture
• Fixed to surrounding tissue
• Evident dimpling and retraction
• Bloody discharge from or scaling of nipples

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• Breast nodularity
• Cystic masses
• Fibroadenomas
• Phyllodes tumors

• Cysts are frequent during perimenopause
• Well-circumscribed, firm masses with well-demarcated borders
• Associated with a history of menstrual-cycle variation
• Fibroadenomas are a frequent cause of breast mass
  • Occur most often in younger women
  • Typically firm, rubbery, well-circumscribed, nontender, and very mobile
• Phyllodes tumors are suggested by a rapid change in mass size

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• History
  • Initial and most important step in diagnosis is to characterize the mass by determining its duration, fluctuation with the menstrual cycle, associated tenderness, and any changes in size since it was first identified by the patient
  • An evaluation of the patient's risk for breast cancer is appropriate (although breast mass characteristics rather than patient risk for cancer should be the primary determinant of the workup)
• Physical examination
  • To confirm the presence of a mass, the examination should be conducted in an upright sitting and supine position, with arms both relaxed and raised over the head
  • In the supine position, breast palpation is performed with the ipsilateral arm placed behind the head to spread the breast tissue across the chest wall
  • Skin or nipple retraction, edema, and erythema should be noted, as should any size discrepancies
• Imaging evaluation
  • The appropriate imaging/diagnostic workup is specific to the outcome of the physical examination and should be used to differentiate a cystic from a solid mass
  • A directed ultrasound is often the only required study in women younger than 35 yr; mammography is only recommended if the mass is considered suspicious for malignancy
  • In women older than 40 yr, a diagnostic imaging workup should be performed, beginning with mammography; if no abnormality is seen, directed ultrasound should be used to exclude the presence of mammographically occult carcinoma
• Biopsy
  • Solid masses can be diagnosed with FNA cytology, core needle biopsy, or excisional biopsy

• A triple diagnosis test using physical examination, imaging studies, and FNA cytology is an alternative to surgical incision to establish that a mass is benign
  • If the mass is not visualized by mammography or if the FNA contains insufficient cells for diagnosis, the triple test cannot be confirmatory for a benign lesion
• An alternative approach is core-needle biopsy, which provides a histologic specimen that can be interpreted by a general pathologist and a specific histologic diagnosis rather than a simple “benign” classification
• If a breast mass has characteristics suggestive of carcinoma, a diagnostic mammogram that includes multiple views (not two standard views, as in screening mammography) is warranted, followed by needle biopsy (core or FNA) and surgical biopsy if diagnosis remains unknown

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• A benign breast mass should be followed for 2 yr, during which time it is monitored for growth via serial examination and imaging studies performed every 6 mo
• A suspicious dominant breast mass is best managed by a lumpectomy that includes excision of some adjacent normal breast tissue; if the margins are free of cancer, the diagnostic procedure serves as the definitive breast procedure

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Best References

Ariga R: Am J Surg 184:410, 2002 [PMID 12433603]

Dennis MA: Radiology 219:186, 2001 [PMID 11274555]

Kerlikowske K: Ann Intern Med 139:274, 2003 [PMID 12965983]

Morris KT: Arch Surg 133:930, 1998 [PMID 9749842]

February 2007