breast mass management

1. MANAGEMENT OF PALPABLE
BREAST MASS
DR SANDHYA

2. • Most common symptom a women presents to
breast clinic.
• Anxiety due to concern for cancer
• Evaluate to r/o cancer and provide diagnosis
• Diagnostic delays common cause of litigation
• Never dismiss a lump in young female, male
gender, lack of family history of cancer

3. ETIOLOGY
• Abscess
• Adenopathy
• Amyloidosi
• Duct ectasia
• DCIS
• Epidermal inclusion cysts
• Fat necrosis

4. • Fibroadenoma
• Fibrocystic disease
• Focal fibrosis
• Galactocele
• Gynaecomastia
• Hamartoma
• Hematoma
• Idiopathic granulomatous mastitis
• Invasive carcinoma

5. • Lactating adenomas
• Lipoma
• Lymphadenopathy
• Mucocele
• Sarcoma(phylloids)
• Sarcoidosis
• Seroma
• Simple and complex cyst

6. HISTORY PART A: PRESENTING
SYMPTOM
• duration of the symptoms or mass,
• change in size,
• associated pain or skin changes,
• relationship to pregnancy or the menstrual cycle,
• previous trauma.
• Nipple discharge (color , spontaneous or not,
unilateral or bilateral, emanating from a single
duct or multiple duct).
• skin changes in the nipple or areola

7. PART B: HORMONAL HISTORY
• age of menarche,
• date of last menstrual period,
• regularity of menstrual cycle, number of
pregnancies,
• age at first-term pregnancy,
• lactational history, and
• age at menopause or surgical menopause

8. PART C: PREVIOUS BREAST HISTORY
• history of previous breast biopsies, breast cancer, or
cyst aspiration
• any known pathology results and treatment regimens.
• oral contraceptive use and hormonal replacement .
• dates of previous mammograms and location of the
films.
• detailed family history of breast and gynecologic
cancer should be recorded, including the age at
diagnosis and the location. This history should include
at least two generations as well as any associated
cancers, such as ovary, colon, or prostate (in men).

9. PART D: BREAST CANCER RISK
• HORMONAL: increase a patient's risk by 1.5- to 4.0-fold
• increased exposure to estrogen or progesterone due to early
menarche (before age 12 years) and late menopause (age >55
years),
• high body-mass index after menopause,
• exposure to ionizing radiation to thorax
• late age at first full-term pregnancy (Women with a first birth
after age 30 years were shown to have twice the risk of those
with a first birth before age 18 years)
• Breast-feeding may exert a protective effect
• Lifetime and 5-year breast cancer risk can be estimated using
the Gail model, which is based on age, onset of menses, onset
of menopause, age at first birth, and prior breast biopsies.

10. PATHOLOGY
• No increased risk is associated with adenosis, cysts, duct
ectasia, or apocrine metaplasia.
• There is a slightly increased risk with moderate or florid
hyperplasia, papillomatosis, and complex fibroadenomas.
• Atypical ductal or lobular hyperplasia carries a 4- to 5-fold
increased risk of developing cancer; the risk increases to
10-fold if there is a positive family history.
• Patients with increased risk should be counseled
appropriately.
• Those with atypia or lobular carcinoma in situ (LCIS) should
be followed with semiannual physical examinations and
yearly mammograms.

11. GENETICS
• Family history of breast cancer in a first-
degree relative is associated with an
approximate doubling of risk.
• If two first-degree relatives have a history of
breast cancer (e.g., a mother and a sister have
had breast cancer), the risk is even higher.
• These familial effects are enhanced if the
relative had either early-onset cancer or
bilateral disease.

12. • BRCA1 and BRCA2 are breast cancer susceptibility genes associated
with 80% of hereditary breast cancers, and they account for
approximately 5% to 10% of all breast cancers.
• Women with BRCA1 mutations have an estimated risk of 85% for
breast cancer by age 70 years, a 50% chance of developing a second
primary breast cancer, and a 20% chance of developing ovarian
cancer.
• BRCA2 mutations carry a lower risk for breast cancer and account for
4% to 6% of all male breast cancers.
• Surveillance should include a monthly BSE, semiannual clinical
examination, and annual mammography beginning at age 25 to 35
years.
• Screening for BRCA1 and BRCA2 gene mutations should be reserved
for women who have a strong family history and have undergone a
multidisciplinary evaluation, including genetic counseling.
• Prophylactic bilateral mastectomy provides a cancer risk reduction of
90% to 100% and is an option for some patients.

13. RISK FACTORS FOR CA BREAST- SUMMARY
• Female Gender
• Increasing age
• Genetic risk factors :BRCA1 or 2, Ataxia-telangiectasia ,Li-
Fraumeni, Cowden syndrome
• Family history of breast cancer
• Personal history of breast cancer
• Previous breast biopsy
• Proliferative breast disease without atypia, Atypical
hyperplasia Lobular carcinoma in situ
• Previous thoracic radiation
• Endocrine risk factors: Early menarche, Late menopause, Late
parity, Nulliparity ,Long-term hormone replacement with
estrogen and progesterone
• Lifestyle factors: Alcohol, Obesity

14. PHYSICAL EXAMINATION
• The physical examination should be performed with respect
for patient privacy and comfort without compromising the
complete evaluation.
• Inspect the breasts with the patient in the upright position,
initially with the arms and pectoral muscles relaxed.
• Look for symmetry; deformity; skin changes, such as
erythema or edema; and prior biopsy scars.
• The nipples are inspected for retraction, discoloration,
inversion, ulceration, and eczematous changes.
• The patient is then asked to lift her arms for a more careful
inspection of the lower half of the breasts. This maneuver
also highlights any subtle retraction/ dimpling that is not
readily visible with the arms relaxed.

15. AXILLARY EXAMINATION
• The regional nodes should be palpated with
the patient in the upright position, pectoral
muscles relaxed.
• Axillary and supraclavicular nodal regions are
evaluated.
• Size, number, and fixation of nodes should be
noted.

16. • The flat surface of the examiner's fingers should be
used to palpate the entire breast systematically.
• The examination should extend to the clavicle,
sternum, lower rib cage, and midaxillary line.
• If a dominant mass (defined as being three-
dimensional, distinct from surrounding tissues, and
asymmetric relative to the other breast) is palpated, its
size, shape, texture, tenderness, fixation to skin or
deep tissues, location, and relationship to the areola
should be noted.
• If uncertainty remains regarding the significance of an
area of nodularity in the absence of a dominant mass
in a premenopausal woman, a repeat examination at a
different point in the menstrual cycle may clarify the
issue.

17. • In patients who present with nipple discharge,
the nipple discharge is often elicited during
palpation of the breast.
• The character, color, and location of the
discharging duct or ducts should be
documented.

18. BREAST LUMP
HISTORY AND PHYSICAL EXAMINATION
NO
ABNORMALITY THICKENING CLINICALLY
BENIGN
CLINICALLY
SUSPICIOUS
IMAGING AND
BIOPSY
IMAGING
EVALUATION
REEVALUATE:
2-3 MONTHS
REASSURE

19. RADIOLOGIC EXAMINATION:
MAMMOGRAPHY
• Diagnostic Mammogram is ordered when a palpable
abnormality is found.
• It consists of atleast 1 additional view apart from those
taken during screening mammogram.
• A normal mammogram in the presence of a palpable
mass does not exclude malignancy, and either further
workup with a different imaging modality (ultrasound)
or a biopsy should be performed.
• Mammography is not generally performed in lactating
women or patients younger than age 30 years unless
the degree of clinical suspicion is high.

20. ULTRASONOGRAPHY
• Ultrasonography is used to further characterize a lesion
identified by either physical examination or mammography.
• Ultrasound can be used to determine whether a lesion is solid or
cystic or to better define its size, contour, or internal texture.
• Although not a useful screening modality by itself due to
significant false-positive and false-negative rates, when used as
an adjunct with mammography, ultrasonography may improve
diagnostic sensitivity of benign findings to >90%, especially
among younger patients, for whom mammographic sensitivity is
lower.
• Solid masses may have benign or malignant features.
• Malignant features of a solid mass on ultrasound are irregular
margins, hypoechoic to the surrounding tissue, with posterior
acoustical shadowing.
• Malignant-appearing masses usually have a vertical growth
appearance (taller than wider).
• Benign features include ellipsoid shape, hyperechogenicity or
hypoechogenicity, and smooth, wellcircumscribed margins.

21. USG CYST EVALUATION
• Age 40-49
• 25% of masses
• Simple: smooth, thin, well circumscribed wall with few
internal echoes
• Complex: any cyst which doesnot meet above criteria
or has solid cystic component, fluid-debris
level,septations, scalloped or irregular borders.
• 98-100% accurate in characterizing benign cysts.
• Complex cyst: chances of malignancy 0.3%
• Complex cyst containing solid component: 23%
• Simple cyst: no aspiration required, only done to
relieve distension and discomfort.
• Complex cyst: aspiration required to r/o bloody fluid:
s/o malignancy

22. USG SOLID MASS EVALUATION
• Commonest: Fibroadenoma
• Difficult to distinguish from malignant
phylloids tumor

23. DISCRETE PALPABLE BREAST MASS
MAMMOGRAM
NOT VISIBLE VISIBLE: SUSPICIOUS
VISIBLE: BENIGN
USG CORE BIOPSY

24. USG
COMPLEX CYST:
ASPIRATE
SOLID MASS: FNA
OR CORE BIOPSY
NOT VISIBLE VISIBLE
FNA OR CORE
BIOPSY
SIMPLE CYST:
OBSERVE
ADEQUATE SAMPLE
ATYPIA,
NONCONCORDANT,
INADEQUATE
TREAT APPROPRIATELY
EXCISIONAL BIOPSY, IF
FNA: CORE BIOPSY

25. MRI
• Excellent tool for the screening of young women with
increased risk for inherited breast cancer.
• In patients with indeterminate mammographic or
ultrasonographic findings, MRI may be used for clarifying
the imaging but should not replace biopsy for clinically
suspicious lesions.
• Disadvantages of MRI are cost, limited availability, and
decreased sensitivity for premalignant lesions.
• The images are evaluated for areas of enhancement and
the morphology of the enhancement curve is noted.
• Lesions suspicious for cancer will display postcontrast
enhancement with malignant morphologic features.
• MRI may be useful in patients who have axillary or other
adenopathy and no obvious primary tumor and in
evaluation of the integrity of the breast prosthesis.

26. Pathological examination: FNAC
• Reliable and accurate office technique with sensitivity greater
than 90%.
• A 22- to 25-gauge needle on a 10-mL syringe is advanced into
the mass, and suction is applied.
• Cells are collected in the hub of the needle. The suction is
released and the needle withdrawn. The contents of the
needle are expelled onto a glass slide. A second glass slide is
inverted over the first, and the two are pulled apart. One slide
is fixed immediately, and the second is allowed to air dry.
• Two to three passes are performed for a total of four to six
slides.
• False-negative findings are caused by inadequate sampling or
improper specimen processing.
• FNAB results should be concordant with clinical impression
and mammographic findings of the lesion (triple assessment)

27. • FNA has the advantages of being easily performed with
readily available equipment, requiring only a syringe
and an appropriately sized needle.
• Its biggest limitations are that insufficient material may
make proper diagnosis difficult, and FNA usually
cannot rule out the presence of an invasive component
for the uncommon mass that is pure DCIS
• It also does not capture histologic architecture making
subtyping difficult and
• It is inaccurate for some masses such as hamartomas.

28. CORE NEEDLE BIOPSY
• Tru-Cut device can be used to obtain more tissue.
• The skin is infiltrated with lidocaine and a nick
made in the skin.
• The needle is inserted into the mass and fired.
• Three to five cores are taken and placed in
formalin.
• Invasion, grade, and receptor status can be
determined.
• For indeterminate specimens, an open surgical
biopsy is necessary.

29. Excisional biopsy
• The surgical excision of a lesion in the breast with the intent
to remove it entirely is referred to as an excisional biopsy.
• excisional biopsy is no longer the standard of care for the
initial diagnosis of palpable breast masses, except where
needle biopsy is not feasible for technical reasons, is
nonconcordant with imaging or exam, is nondiagnostic, or
demonstrates a high-risk lesion such as atypia.
• Incisions should be oriented along Langer lines for optimal
cosmesis
• All incisions should be planned so that they can be
incorporated into a mastectomy incision.
• Masses should be excised as a single specimen, the
specimen should be oriented

30. THANK YOU