Breast Mass

Linda M. Barney, MD
Wright State University
 Ms. Marcus

Ms. Marcus is a 23-year-old woman who

was referred by her Gynecologist for
evaluation of a breast mass.
 History

What other points of the history do

you want to know?
 History, Ms. Marcus
Consider the following:

Characterization of Associated signs/symptoms:

Symptoms:
Pertinent PMH
Temporal sequence
ROS
MEDS
Alleviating / Relevant Family Hx.
Exacerbating factors:
 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
 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
 Pertinent PMH

Healthy, exercises regularly

No prior surgeries
No chronic medical problems
Menarche age 12, no pregnancies, regular
cycles, OCPs x 2 years
Denies smoking, alcohol or drugs
Works as a systems analyst
 Alleviating/ Exacerbating factors

No change with activity

Uses Ibuprofen for cramps with no change in

the lump

Drinks decaffeinated tea and sodas only

 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

Differential Diagnosis
Based on History and Presentation
 Differential Diagnosis
Consider the following

Fibrocystic Mass
Cyst
Fibroadenoma
Breast Cancer
Hematoma
Abscess
Fat necrosis
Lactational Adenoma
 Physical Examination

What would you look for?

 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

 Laboratory
What would you obtain?
 Lab Discussion

No labs indicated
Patient has no clinical signs of infection or
nipple discharge and no suggestion of any
systemic disease
 Studies

What further studies would

you want at this time?
 Studies, Ms. Marcus

Breast Ultrasound ? Screening Mammogram ?

PA/Lat Chest ? Diagnostic Mammogram ?
CT Scan of Chest ? Breast MRI ?
PET SCAN ? Other:
Ultrasound Left Breast
 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?

Revised Differential Diagnosis

1 Fibroadenoma
2 Cyst
3 Fibrocytic Mass
4 Breast Cancer
What next?
 Options

1. Additional Imaging?
2. Biopsy
3. OR?
4. Observation?
5. Other?
 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.

 Mammogram
Comparison CC View

Left Right
 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
Discuss options for tissue diagnosis

What are the advantages and

disadvantages of each?
 Biopsy Techniques

Needle Core Biopsy

FNA
Excisional Biopsy
Image Guided Biopsy
Ultrasound
Stereotactic
 Management, Ms. Marcus

Core Needle Biopsy

US Directed Biopsy
Excisional Biopsy
US Directed Biopsy
 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.
 Pathology

Fibroadenoma
Interventions at this point?
 Discussion

Observation versus Excision

Indications for excision
Rapid growth
Inability to differentiate from aggressive pathology such as
Phyllodes Tumor or Breast Cancer
Patient preference
 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*
 Alternative Diagnosis

What if her mass was more tender and

developed acutely since her last period?

Imaging studies follow

Ultrasound Left Breast
 Mammogram Bilateral
MLO Views

Left Breast Right Breast

Would you like to revise your
Differential Diagnosis?
 Differential Diagnosis

Simple Cyst
Complex Cyst
Abscess
Fibrocystic Mass
Fibroadenoma
Breast Cancer
Interventions at this point?
 Management Options

FNA
FNA w/ US guidance
Core Biopsy
Excision
Observation
QUESTIONS ??????
 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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