Breast Mass

1. Breast Mass Linda M. Barney, MD Wright State University

2. Ms. Marcus • Ms. Marcus is a 23-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

3. History What other points of the history do you want to know?

4. Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/symptoms: Pertinent PMH ROS MEDS Relevant Family Hx. History, Ms. MarcusConsider the following:

5. Characterize Symptoms • 4 month history of left breast lump. • 1st noticed in the shower ~ 1 week before menses • Olive sized and nontender • May have increased in size slightly • No change with menstrual cycles

6. Associated Signs & Symptoms • Denies pain, skin change, nipple discharge • No prior history of lumps or breast complaints • No change with menstrual cycles, LMP 2 weeks prior • Denies trauma

7. Pertinent PMH • Healthy, exercises regularly • No prior surgeries • No chronic medical problems • Menarche age 12, no pregnancies, regular cycles, OCP’s x 2 years • Denies smoking, alcohol or drugs • Works as a systems analyst

8. Alleviating/ Exacerbating factors • No change with activity • Uses Ibuprofen for cramps with no change in the lump • Drinks decaffeinated tea and sodas only

9. Family History • Maternal grandmother with breast cancer at age 70 • Mother and older sister with Fibrocystic Breast Condition • No Gyn or Colon CA in family

10. Differential DiagnosisBased on History and Presentation

11. Differential DiagnosisConsider the following • Fibrocystic Mass • Cyst • Fibroadenoma • Breast Cancer • Hematoma • Abscess • Fat necrosis • Lactational Adenoma

12. Physical Examination What would you look for?

13. Physical Examination, Ms. Marcus Relevant Exam findings for a problem focused assessment Breasts: Symmetrical, no skin changes, nipples everted/ no discharge. Right breast w/no dominant findings. Left breast with 2cm well circumscribed mobile mass 12’ position near areolar margin. Nodes: No axillary or supraclavicular nodes Remaining Examination findings non-contributory

14. Laboratory What would you obtain?

15. Lab Discussion • No labs indicated • Patient has no clinical signs of infection or nipple discharge and no suggestion of any systemic disease

16. Studies What further studies would you want at this time?

17. Studies, Ms. Marcus

18. Ultrasound Left Breast

19. Studies – Results • Focused L breast US demonstrates a 2.2cm well-circumscribed, homogeneous, hypoechoic nodule, with no abnormal shadowing • Wider than tall orientation • No additional abnormalities are noted What is the differential diagnosis at this point?

20. Revised Differential Diagnosis 1 Fibroadenoma 2 Cyst 3 Fibrocytic Mass 4 Breast Cancer

21. What next?

22. Options • Additional Imaging? • Biopsy • OR? • Observation? • Other?

23. What next? Discussion of suggested interventions Limited value of additional imaging in a young female without high risk history. Dense breast tissue limits the utility of screening mammography, but should be ordered when clinically indicated. The lesion is well characterized by ultrasound. A mammogram for Ms. Marcus is noted on the next slide.

24. MammogramComparison CC View Left Right

25. Observation • May be reasonable in a young patient with low risk history and benign appearance on imaging • Requires follow-up short and long term with intervention for clinical concern

26. Discuss options for tissue diagnosis What are the advantages and disadvantages of each?

27. Biopsy Techniques • Needle Core Biopsy • FNA • Excisional Biopsy • Image Guided Biopsy • Ultrasound • Stereotactic

28. Management, Ms. Marcus • Core Needle Biopsy • US Directed Biopsy • Excisional Biopsy

29. US Directed Biopsy

30. Management • Less advantage for image guided biopsy in a palpable mass but useful for deeper, hard to access lesions. Allows for targeting specific areas of a lesion. Enables marker clip placement for follow-up. • Excision is diagnostic and therapeutic. May disadvantage patients with suspected malignancy as it requires a second operation for definitive treatment. Best suited for the benign or indeterminate lesion where patient preference is removal rather than biopsy with observation.

31. Pathology • Fibroadenoma

32. Interventions at this point?

33. Discussion • Observation versus Excision • Indications for excision • Rapid growth • Inability to differentiate from aggressive pathology such as Phyllodes Tumor or Breast Cancer • Patient preference

34. Fibroadenoma Discussion • Features • Usually younger women • Usually solitary mass, occasionally multiple • May increase with pregnancy or involute post-menopause • Pathology • Benign tumor • Circumscribed rubbery mass • Overgrown fibrous stroma compressing epithelium • May have some increased risk of breast cancer long term especially if associated with proliferative breast pathology*

35. Alternative Diagnosis • What if her mass was more tender and developed acutely since her last period? • Imaging studies follow

36. Ultrasound Left Breast

37. Mammogram Bilateral MLO Views Left Breast Right Breast

38. Would you like to revise your Differential Diagnosis?

39. Differential Diagnosis • Simple Cyst • Complex Cyst • Abscess • Fibrocystic Mass • Fibroadenoma • Breast Cancer

40. Interventions at this point?

41. Management Options • FNA • FNA w/ US guidance • Core Biopsy • Excision • Observation

42. QUESTIONS ??????

43. Summary • Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging • Distinct US features are often noted • Tissue diagnosis is favored for observation • Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observed • Indeterminate lesions warrant tissue diagnosis

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