Benign Breast Mass

• Three females with ages 23, 35, and 55 years, respectively, went to see you for consult. All have a mass in one of their breasts.

A. What important general data from the patients do you think are important to be able to guide you in your

diagnosis?

1. Age– Risk increases with age

2. Gynecologic History:– Menarche– Menopause (age 55)– Parity

• Early full term pregnancy is protective• Multigravida is protective

– Breastfeeding practices• Breast Feeding protective

– Use of HRT, oral contraceptives

A. What important general data from the patients do you think are important to be able to guide you in your

diagnosis?3. Family History (Cancer)

Institute of Public Health UKRelative Risk of Ca

4. Other Risk Factors– History of radiation exposure– Obesity

Relative Risk of Cancer2nd degree relative 1.51st degree relative 2.1

Mother 2.0Sister 2.3

Mother and Sister 3.6

B. In the Physical Examination, differentiate a benign from a malignant lesion.

Benign Lesion• Freely movable• Regular edges• Rounded feeling• More likely to feel tender to

touch

Malignant Lesion• Firm• Indistinct borders• Attchments to the skin or

deep fascia with dimpling or nipple retraction

• Bloody discharge from nipple

• Skin changes on breast (redness, crusting, dimpling)

It is not possible to distinguish a benign from a malignant cyst by physical exam alone with certainty.

C. How will you approach a 23-year old, with a 2 X 2 X 2cm, firm, mobile, well-circumscribed non-tender

mass on her L breast?

1. Diagnosis? 2. Role of imaging modalities for this case.3. Options in the management?

A single breast lump is likely to be:

•FibroadenomaUnder 30•Fibroadenoma, fibrocystic changes,

atypical hyperplasia, or other benign problem

30s and 40s

•Cysts, non-invasive cancers50 and older

Fibroadenoma

• Benign • Common in young females (20-30 years old)• Usually small (2-3cm)• Related to estrogen• Not premalignant

Role of imaging modalities for this case

Breast Mass Ultrasound Bilateral Mammography

• Ultrasound– A small circumscribed discrete mass suggests the presence of a

simple cyst or fibroadenoma for women younger than 30 years old– Distinguish between cystic and solid masses– Not an effective screening test for cancer– Can confirm the diagnosis of a simple cyst or support a diagnosis of

fibroadenoma– Can diagnose a simple cyst if four criteria are fulfilled:

1. Round or oval shape2. Sharply defined margins3. Lack of internal echoes4. Posterior accoustic enhancement

Ultrasound of Fibroadenoma

• Well-circumscribed elliptic mass • Uniform echogenicity• Lesion is larger in the transverse than in the

anteroposterior direction• Well-demarcated margins

Management of Fibroadenoma

•ObservationBelow 25 y/o•Observation•Excision

25-35 y/o

•ExcisionAbove 35 y/o

D. 35-year old, with a 2 x 2 x 2cm, firm, mobile, well-circumscribed non-tender mass on her R breast

1. Role of imaging modality? Choice? 2. A mammogram was taken as seen in the

picture. Is this benign or malignant? 3. Differentiate radiologically a benign lesion

from a malignant one. 4. Should the patient have a mother who is a

breast cancer survivor, how would that information change your management?

Role of Imaging Modalities

• Diagnostic Mammography– To screen the normal surrounding breast tissue

and the opposite breast for non-palpable cancers– To make a diagnosis of the palpable mass

A mammogram was taken as seen in the picture. Is this benign or malignant?

BenignNormal

Differentiate radiologically a benign lesion from a malignant one.

Benign lesion• round or oval smooth-

edged masses with the outline clearly defined

Differentiate radiologically a benign lesion from a malignant one.

Malignant• Spiculated density with ill

defined margins• Suggestive features include:

– Clustered microcalcifications– Asymmetric density– Ductal assymetry– Distortion of skin, nipple and

normal breast architecture

There is a small spiculated tumour in the middle of the right breast. Note

the asymetry.

Examples of benign mass and a malignant spiculations

Should the patient have a mother who is a breast cancer survivor, how would that information change

your management?

• Close surveillance with SBE, mammography and possibly MRI– SBE at age 18– Semi-annual SBE at age 25– Annual mammography beginning age 25 or 10 yrs

prior earliest age of onset of a family member• Chemoprevention using Tamoxifen