breast mass linda m. barney, md wright state university
TRANSCRIPT
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 Symptoms:
Temporal sequence
Alleviating / Exacerbating factors:
Associated signs/symptoms:
Pertinent PMH ROS MEDS Relevant Family Hx.
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 dischargeNo prior history of lumps or breast complaintsNo change with menstrual cycles, LMP 2 weeks
priorDenies trauma
Pertinent PMH
Healthy, exercises regularlyNo prior surgeriesNo chronic medical problemsMenarche age 12, no pregnancies, regular
cycles, OCP’s x 2 yearsDenies smoking, alcohol or drugsWorks 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 DiagnosisBased on History and Presentation
Differential DiagnosisConsider 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.
MammogramComparison CC View
Left Right
ObservationObservation
May be reasonable in a young patient with low May be reasonable in a young patient with low risk history and benign appearance on imagingrisk history and benign appearance on imaging
Requires follow-up short and long term with Requires follow-up short and long term with intervention for clinical concernintervention 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 BiopsyCore Needle Biopsy
US Directed BiopsyUS Directed Biopsy
Excisional BiopsyExcisional 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 Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging palpable mass or well-defined lesions on imaging
Distinct US features are often notedDistinct US features are often noted
Tissue diagnosis is favored for observationTissue diagnosis is favored for observation
Simple cysts in low risk population can be aspirated Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observedfor symptoms & diagnosis or observed
Indeterminate lesions warrant tissue diagnosisIndeterminate lesions warrant tissue diagnosis
Acknowledgment The preceding educational materials were made available through the
ASSOCIATION FOR SURGICAL EDUCATIONASSOCIATION FOR SURGICAL EDUCATION
In order to improve our educational materials wewelcome your comments/ suggestions at: