Approach to the diagnosis

of a Breast Lump

Lt. Dhirendra
 Focus
Palpable mass in a womans breast-potentially
serious lesion
All palpable lesions require evaluation
Triple assessment-effective strategy in the
diagnosis of breast lumps
First step- confirm the presence of a discrete
mass
Next step- distinguish simple cysts from solid
lesions
 Introduction
Risk of breast cancer increases with age
Median age of breast cancer diagnosis- 61
years
95% of all breast cancer- women >40 years
Majority of breast cancers- sporadic (i.e., in
patients without a family history of breast
cancer)
First-degree relative with premenopausal
breast cancer- high risk
 Causes
Macrocyst (palpable cyst,25% of breast
lesions)
Fibroadenoma,
Fat necrosis
Cancer
 Triple assessment
Currently the gold standard
Components
Clinical assessment
Imaging
Tissue biopsy
Diagnostic accuracy- approaches 100%
 Clinical assessment
History
Age
A personal history of breast cancer
Past history of a breast biopsy
Family history of breast cancer
Recent trauma to the breast
Pregnancy
Lactation
 Physical examination
Alone cannot definitively establish a mass as
benign or malignant
Irregular fixed masses-suspicious for
malignancy
Malignant lesions
skin thickening
(e.g., peau d'orange)
nipple changes
 Complete bilateral breast examination
Variation in breast size
Fungating mass
Dimpling or retraction of skin
Nipple inversion or excoriation
Diagnostic accuracy of physical examination is
60 - 85%.
 Patient positioning
Arms over her head
Hands on their hips and squeeze inwards- flexing
the pectoral muscles- chest wall involvement
Lymph nodes axillary, cervical, supraclavicular,
and infraclavicular fossae should be evaluated
Proper examination occurs with the patient both
seated upright and lying supine
as masses can often be appreciated more in one
position than another
 Interpretation
Benign masses
no skin changes
smooth and mobile
soft to firm to palpation
well-defined margins
Malignant masses
generally hard and immobile
may be fixed to surrounding structures
poorly defined or irregular margins
Infections, such as mastitis- signs of
inflammation
 Imaging
Mammography
Beneficial in finding occult malignancies
All women 30 years or older with a breast
mass-mammography
Spot compression views and magnification
views are recommended
Multi-focal or multi-centric disease should be
noted
 Palpable breast mass-mammography
sensitivity 82% to 94%
specificity 55% to 84% for detecting breast cancer
Breast Imaging Reporting and Data System (BIRADS)
 BIRADS
Score-1 to 3 followed with an ultrasound
Score-4 to 5 requires a tissue biopsy
Palpable mass-negative imaging study surgical
follow-up
Score of 6 is given only after a biopsy-
cancerous
 Ultrasound of the breast
Considered the diagnostic test of choice in
patients <30 years old,because
Density of breast tissue in younger women-limits
sensitivity of mammography
False-negative rate 52% in patients <35 years old
with a palpable malignant breast mass
Ultrasound may identify simple or complex
cyst architecture
 Simple cysts are fluid-filled lesions-smooth,
round, well-demarcated, and anechoic
If no internal septations or debris,may simply
be followed
 Breast aspiration and biopsy
Fine-needle aspiration cytology(FNAC)
Core-needle biopsy
Excisional biopsy
Fine-needle aspiration cytology(FNAC)
22- to 26-gauge needle into the breast mass and extracting cells
Cells can be placed on a slide or made into a cell block
Advantages
fast and easy to perform and it can be done in the OPD
distinguish benign from malignant lesions
for evaluating axillary lymph nodes

Disadvantages
does not show histological
architecture
Cannot differentiate ductal
carcinoma in situ from invasive
malignancy
 Core needle biopsy
Using an 8- to 14-gauge
needle
Provides a larger tissue
sample than FNAC
Fast and easy to perform,
and allows histological diagnosis
Performed by palpation, under stereotactic
control, or by ultrasound guidance
Method of choice for histological diagnosis
 Excisional biopsy
Removing the entire breast mass-accurate
histological diagnosis
Invasive technique
Benign asymptomatic mass, may be
unnecessary
Malignant mass, it may not obviate the need
for a second procedure to treat
 Management
Cysts
Painful cysts may be aspirated under
ultrasound guidance
Cysts that recur or not completely resolve
with aspiration- biopsy to rule out malignancy
Biopsy- in complex cysts or those with solid
elements
 Solid mass
Management for 'probably benign' masses
Clinical and USG surveillance every 6 months for 2
years, to document stability
Core needle biopsy- definitive diagnosis while leaving
the lesion in situ
Surgical removal of the mass, if the lesion is
bothersome to the patient
USG of the axilla- to evaluate lymphadenopathy,
and abnormal lymph nodes biopsied
Cancerous- staging investigations follow and
managed by multidisciplinary team
 In a nutshell
Palpable mass in a womans breast- potentially serious lesion
All palpable lesions require evaluation
The triple assessment- effective strategy in the management of
breast lumps
The first step-confirm the presence of a discrete mass
Next objective- distinguish simple cysts from solid lesions
Simple cysts are aspirated to dryness and require no further
treatment if do not recur
Pathological cysts require surgical excision.
A solid lesion requires a firm diagnosis, necessitating histological
examination
Benign solid lesions may be managed expectantly- regular follow-up
Malignant solid lesions- referred to a multidisciplinary team for
management
Discussion