Download Detection and Evaluation of a Palpable Breast Mass

Mayo Clin Proc, June 2001, Vol 76
Detection and Evaluation of a Palpable Breast Mass
641
Concise Review for Clinicians
Detection and Evaluation of a Palpable Breast Mass
SANDHYA PRUTHI, MD
The discovery of a breast mass, either self-detected or
identified by a clinician, is a common, often distressing
occurrence for many women. Although most detected
breast masses are benign, every woman presenting with a
breast mass should be evaluated to exclude or establish a
diagnosis of cancer. This article provides a succinct overview of normal breast anatomy and reviews common
causes of breast masses. The role of the clinical breast
examination is discussed, and an algorithm is provided for
optimal utilization of available tools in the diagnostic
evaluation of a breast mass. The evaluation should be
performed expeditiously and the results communicated
promptly to the patient. Regardless of the age of the
woman, a clinically suspicious mass must be evaluated
even if findings on a mammogram are normal.
Mayo Clin Proc. 2001;76:641-648
CBE = clinical breast examination; CNB = core needle biopsy;
FNA = fine-needle aspiration; FNAB = FNA biopsy
B
reast tissue components include subcutaneous fat,
stromal and parenchymal tissue supported by fibrous
bands known as Cooper suspensory ligaments, blood vessels, nerves, and lymphatics. The pigmented areolar tissue
contains hair follicles, apocrine sweat glands, and small
raised nodular structures called Morgagni tubercles, which
define the openings of the Montgomery (sebaceous) glands
that are capable of secreting milk. The nipple contains
sensory nerve endings and smooth muscle bundles, with 8
to 20 major ducts opening to the surface. These ducts
extend proximally to the lactiferous sinuses leading to terminal ducts that enter a lobe composed of 20 to 40 lobules.
Subcutaneous fat surrounds the lobes and is found predominantly in the superficial and peripheral regions of the
breast.1 The glandular nodularity of breast tissue is most
pronounced in the upper outer quadrant of the breast. During the estrogen-stimulated proliferative phase of the menstrual cycle, the nodularity and texture of the breasts can
wax and wane as the stromal tissue becomes edematous
with venous congestion.
tory of breast cancer or ovarian cancer, age at which the
first-degree relative (mother, sister, or daughter) was affected with breast cancer, parity, age at first live birth, age
at menarche, late cessation of menses, and use of hormone
replacement therapy. Also important is information on previous cyst aspirations and personal history of atypical hyperplasia (ductal or lobular), which can increase the risk of
breast cancer 3 to 5 times and double that in women with a
family history. The average lifetime risk of breast cancer is
12% or approximately 1 in 8 women.2 Although known risk
factors including age can increase the risk of breast cancer,
they do not influence the probability that a breast mass is
more likely to be malignant. The decision to evaluate a
palpable mass should not depend on the presence or absence of risk factors. Of paramount importance, more than
75% of women with newly diagnosed breast cancer have
no identifiable risk factors.
CLINICAL BREAST EXAMINATION
The clinical breast examination (CBE) can be used as a
screening tool to detect breast cancer in asymptomatic
women or as a diagnostic examination to evaluate breast
complaints. A thorough CBE includes inspecting the
breast, proper positioning of the patient, examining the
entire perimeter of the breast tissue, using a consistent
technique and pattern of search, and applying varying pressure with palpation. A retrospective review by van Dam et
al3 found that the CBE has a positive predictive value of
73% and a negative predictive value of 87%. The technique
of CBE, even when performed in large-scale studies, has
generally not been standardized, which may partly be due
to the highly subjective interpretation of CBE findings
among clinicians. A well-conducted CBE can detect up to
50% of cancers not detected by mammography alone.4
HISTORY
Key historical features in the evaluation of a breast lump
are the length of time the mass has been present, presence
of pain, change in size or texture over time, relationship to
menstrual cycle, and nipple discharge. Assessment of risk
factors for breast cancer includes identifying a family hisFrom the Division of General Internal Medicine, Mayo Clinic, Rochester, Minn.
A question-and-answer section appears at the end of this article.
Address reprint requests and correspondence to Sandhya Pruthi,
MD, Division of General Internal Medicine, Mayo Clinic, 200 First St
SW, Rochester, MN 55905.
Mayo Clin Proc. 2001;76:641-648
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© 2001 Mayo Foundation for Medical Education and Research
642
Detection and Evaluation of a Palpable Breast Mass
Breast tissue is naturally diffusely lobulated, and irregularity to palpation is not necessarily abnormal. Interpreting
CBE findings in the premenopausal woman is difficult
because findings can change depending on hormonal fluctuations in the woman’s menstrual cycle. Optimally, the
premenopausal woman should be examined 1 week after
onset of the last menstruation when breast engorgement
and nodular texture of breast tissue are usually decreased.
The influence of hormone replacement therapy can convert
breast tissue in some postmenopausal women to that in
perimenopausal women.
Normal structures in the breast can sometimes be mistaken for a mass, and using an improper examination technique, such as pinching the tissue, can create the impression of a mass. Fibroglandular tissues are rubbery-type
plaques, often palpable in the upper outer quadrant, that
blend into the surrounding breast tissue, lack discreteness,
and are often symmetrical. With deep palpation, a prominent rib or costochondral junction can be palpated. The
inferior ridge of breast tissue (inframammary fold) can be
indurated in a crescent-shaped pattern as a result of fat
compression from the weight of the overlying breast and is
symmetrical. Other CBE findings that can create the impression of a mass include a firm margin at the edge of the
breast, edge of a defect due to a previous biopsy or scar
tissue, and lobulated circular terminus of firm breast tissue
at the border of the areola.5
A palpable breast mass is defined as a dominant mass if
it is 3-dimensional, distinct from surrounding tissues, and
asymmetrical relative to the other breast. A dominant mass
will persist throughout a menstrual cycle. Smooth, welldemarcated dominant masses that are mobile are often
benign. Features that suggest a mass is more likely to be
malignant include firmness with poorly defined margins,
irregular edges, immobility, or fixation to the surrounding
tissue. Skin changes such as dimpling, retraction of the
nipple, nipple scaling, or bloody nipple discharge are other
findings suggestive of malignancy. An indeterminate mass
is often described as an area of vague or indiscrete
nodularity or thickening that differs from the surrounding
tissue, and the finding is not matched in a mirror-image
location in the opposite breast. Although most malignant
lumps are not associated with tenderness, the presence or
absence of pain should not influence the decision to investigate a suspicious mass. These characteristics are not exclusive, and when the CBE confirms the presence of a
dominant mass or a change in the breast, ancillary imaging
studies are essential in distinguishing a benign from a
malignant mass.
Documentation is crucial with particular attention to the
approximate size, site, mobility, and texture of the mass as
well as associated skin retraction, erythema, or adenopathy.
Mayo Clin Proc, June 2001, Vol 76
Failure to be impressed by physical findings and subsequent failure to diagnose breast cancer were cited as the
most common reasons for a delayed diagnosis of breast
cancer and the most common reasons for litigation against
physicians.6
The initial CBE should be performed when a woman is
between 20 and 30 years of age as part of the routine
physical examination every 3 years and continued annually when the woman is 40 years old. Women at high risk
should initiate a CBE 5 to 10 years earlier based on the
age of their affected relatives. The CBE should be scheduled to occur before or close to the date of the annual
mammogram. It is also important to teach women about
breast self-examination, and they should be encouraged
but not pressured to perform this examination. Women
should be informed to notify their physician promptly
about any breast changes that occur between the annual
CBE and the mammogram.
MOST COMMON CAUSES OF A DOMINANT MASS
Cysts
Cysts tend to occur commonly and frequently around the
fourth decade of life and in the perimenopausal period, and
they often fluctuate with the menstrual cycle. In the fourth
decade of life, the incidence of breast cancer begins to
increase, and CBE findings become more difficult to interpret because of perimenopausal hormonal fluctuations.
Cysts are thought to arise from dilatation or obstruction
of collecting ducts. Cysts are round or oval, usually well
demarcated from the surrounding tissue, smooth, firm, and
mobile. If a cyst enlarges rapidly it can be tender. A cyst
can present as a hard mass when the fluid is under tension
and feel similar to a carcinoma. It is not possible from the
CBE to distinguish a solid from a cystic mass. In postmenopausal women who are not receiving hormone replacement therapy, the finding of cystic lesions is uncommon, and if such lesions are detected further evaluation is
necessary.
Fibroadenomas
Fibroadenomas commonly present in young women in
the first half of the reproductive period, with the median
age at diagnosis being 30 years. Although the exact incidence of fibroadenomas in the general population is unknown, about 50% of all breast biopsies are performed
because of fibroadenomas. They occur when periductal
stromal connective tissue proliferates within the lobules of
the breast. Exogenous estrogen, progesterone, lactation,
and pregnancy can stimulate the growth of fibroadenomas.
The clinical diagnosis of a fibroadenoma is accurate in one
half to two thirds of cases. These masses are commonly
located in the upper outer quadrants of the breast and are
Mayo Clin Proc, June 2001, Vol 76
well circumscribed, firm, rubbery, mobile, nontender, and
difficult to distinguish from a cyst.
Most fibroadenomas have a characteristic ultrasonographic appearance that can be identified with a greater
degree of certainty with ultrasonography than by CBE
only. Ultrasonography also aids in monitoring the size of
the lesion over time. Routine practice has been to excise
fibroadenomas. However, there is increasing support for
observation in women younger than 40 years, provided the
lesion can be accurately diagnosed with nonsurgical procedures and the woman is comfortable with this option. In a
prospective study by Dixon et al7 of 202 women younger
than 40 years in whom a fibroadenoma was diagnosed by a
combination of CBE, ultrasonography, and fine-needle aspiration biopsy (FNAB), more than 90% opted for conservative management.
Fibrocystic Changes
Fibrocystic changes tend to occur most commonly in
women in their 20s and 30s. Histological study reveals
macrocysts, microcysts, proliferation of epithelial tissue,
duct hyperplasia, and connective tissue fibrosis. The CBE
discloses prominent rubbery, thickened symmetrical
plaques of glandular breast tissue that lack discreteness,
blend into the surrounding breast tissue, and are often
found in the upper outer quadrant. Pain is the most frequent
complaint and can be cyclical and fluctuate with the changing hormonal milieu associated with the menstrual cycle.
The pain is often bilateral, is poorly localized, and extends
to the shoulder, axilla, or arm. Symptoms may remain
stable or worsen until menopause. Up to 20% of women
may experience spontaneous resolution.8
Carcinomas
An estimated 182,800 new invasive cases of breast cancer occurred among women in the United States during
2000. In approximately 78% of women, breast cancer is
diagnosed when they are older than 50 years, and in about
22%, breast cancer is diagnosed before they are 50 years
old. An estimated 7% of invasive breast cancers are diagnosed in women younger than 40 years. Breast cancer
mortality was estimated at 48,800 in the year 2000.9 Breast
cancer mortality has decreased, with the largest decrease
in women younger than 50 years. The decrease in mortality has been attributed to a combination of increased
awareness of the importance of screening for breast cancer, earlier detection, mammography screening, and improved treatment. Breast self-examinations are encouraged, and the growing acceptance of this examination,
particularly among younger women, is an important factor in the earlier presentation of women with palpable
breast lumps.
Detection and Evaluation of a Palpable Breast Mass
643
ROLE OF MAMMOGRAPHY
The 2 categories of mammograms are screening and diagnostic. Screening mammography consists of 2 standard
views of each breast that are complementary—the craniocaudal and mediolateral oblique—and is specifically
designed for asymptomatic women. The mediolateral
oblique view includes breast tissue high in the axilla
down to the inframammary fold and ideally the free margin of the pectoralis major muscle. The craniocaudal
view should reveal the deep, medial, and lateral breast
tissue.
Women presenting with a breast mass must undergo
bilateral diagnostic mammography. Diagnostic mammography can be performed in women at any age; however, in
women younger than 40 years, the dense glandular breast
tissue lowers the sensitivity, and therefore ultrasound directed at the area of concern is the preferred study. With
diagnostic mammography, a radiologist must be present to
analyze the films and correlate the patient’s symptoms and
clinical findings with the mammographic findings. Diagnostic imaging includes ancillary procedures such as ultrasonography, spot-compression views to evaluate asymmetrical densities or better define areas of clinical concern,
and magnification views to delineate the morphology of
calcifications or improve visibility of masses. Diagnostic
mammography can often clarify the nature of a palpable
mass and aid in the detection of a clinically occult lesion in
either breast. Irregular or clustered calcifications in the area
of a mass may increase the suspicion of carcinoma. Documentation of the extent of the lesion may influence the
suitability of the patient for breast-conserving surgery if
cancer is suspected. Appropriate imaging studies before
surgical referral can facilitate and expedite the work-up of
palpable masses.
Of importance, although a suspicious finding on a mammogram may increase the probability of malignancy, normal findings on mammography or ultrasonography do not
rule out cancer in the presence of a palpable abnormality.
ROLE OF ULTRASONOGRAPHY AND OTHER
IMAGING MODALITIES
Breast ultrasonography complements diagnostic mammography in the evaluation of a palpable breast mass. It delineates the shape, borders, and acoustic properties of the
mass. The primary use of ultrasonography is to distinguish
cystic lesions from solid masses. Ultrasonography has
other uses: assessment of the underlying cause of an abnormal finding on CBE, evaluation of a palpable breast mass
in a young woman with dense breast tissue or a woman
with breast implants, differentiation of poorly delineated
masses as cystic or solid, and assessment of peripheral
masses located outside the field of view of a mammo-
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Detection and Evaluation of a Palpable Breast Mass
gram.10 Ultrasonography can guide interventional procedures because the needle can be visualized continuously
within the mass, ensuring an adequate sample. Whole
breast ultrasonography has not been shown to be effective
for routine screening because of the high false-positive rate
and inability to detect microcalcifications consistently. The
role of screening or evaluating women with magnetic resonance imaging and radionuclide scanning (sestamibi and
positron emission tomography) has yet to be defined, even
in high-risk women. The exception is the use of breast
magnetic resonance imaging in evaluating silicone implant
rupture that cannot be ruled out using mammography or
ultrasonography.
RECOMMENDATIONS FOR
SCREENING MAMMOGRAMS
The American Cancer Society and American College of
Radiology recommend annual screening mammograms for
women beginning at age 40 years. For women younger
than 40 years with a family history of breast cancer, annual
screening mammograms should be first obtained 5 to 10
years before the age of the youngest affected relative. For
women older than 75 years who are expected to live for 5 to
10 more years, CBE and screening mammography should
be performed annually.
DIAGNOSTIC WORK-UP OF A PALPABLE MASS
Advances in imaging techniques have revolutionized the
nonsurgical diagnostic work-up of breast masses. Further
technical refinements using image-guided biopsies have
led to a more accurate and expeditious pathologic evaluation of breast masses. However, this does not diminish the
complementary role of fine-needle aspiration (FNA) and
FNAB. For clarification, the terms FNAB and FNA cytology are used interchangeably in the literature. In this article, FNA refers to the procedure for removal of fluid and
FNAB refers to obtaining tissue from a solid lesion for
cytological evaluation.11
Cystic or Solid Mass?
The initial step in the evaluation of a palpable dominant
mass is to determine whether it is cystic or solid. The
preferred method for this distinction is targeted ultrasonography and diagnostic mammography. However, because
not all medical centers have these modalities or ready
access to such modalities, FNA in an office setting is
another option (Figure 1). An “office” FNA is a safe,
simple, and inexpensive technique with minimal patient
discomfort. If a clinician does not routinely perform FNA,
referral to a surgeon or radiologist should be considered.
Fluid that is clear yellow, straw colored, green, or brown
(typical features of benign cystic fluid) can be discarded.
Mayo Clin Proc, June 2001, Vol 76
The dominant mass should disappear, and a CBE should be
repeated in 4 to 6 weeks.
Recurrence of the mass should prompt evaluation with
diagnostic mammography and ultrasonography to exclude an associated malignancy. Although cysts are common and recur frequently, any change in size, appearance,
or consistency requires immediate follow-up. If there is no
recurrence, CBE and mammography are scheduled at an
appropriate interval.
Although a blood-tinged aspirate can be the result of a
traumatic aspiration, this type of fluid requires cytological
evaluation. If there are no malignant cells, diagnostic mammography and targeted ultrasonography should be performed to assess for cyst resolution and to exclude any
other worrisome features (eg, suspicious calcifications
etc). A solid or suspicious mass detected by imaging can
be further evaluated with an image-guided biopsy for a
tissue diagnosis, followed by surgical excision to exclude
malignancy.
If the mass persists after an office FNA or if the FNA is
unsuccessful, diagnostic mammography and ultrasonography should be performed, with additional work-up as outlined subsequently and in Figure 1.
When performed by an experienced operator, targeted
ultrasonography can reliably detect a cyst and is an adjunct to diagnostic mammography, which alone cannot
definitively identify a simple cyst. Ultrasonographic criteria of a simple cyst are round or oval mass, sharply defined
margins, lack of internal echoes, and posterior acoustic
enhancement.
A therapeutic FNA can be considered for a simple cyst
that is causing pain or anxiety. For asymptomatic patients,
follow-up CBE and mammography should be performed at
an appropriate interval.
A complex cyst with internal echoes should be evaluated as described in Figure 1. A breast mass that does not
meet the ultrasonographic criteria of a simple cyst and has
solid features, is suspicious, or is indeterminate requires a
biopsy.
Evaluation of a Solid Mass
Failure to aspirate or remove cystic fluid by FNA
suggests that the palpable mass is solid. Similarly, a lesion detected ultrasonographically that does not meet the
criteria of a simple cyst or is solid, indeterminate, or
suspicious requires biopsy for pathologic diagnosis. The
diagnostic gold standard is excisional biopsy of a persistent solid mass. Approximately 80% of breast biopsy
specimens in the United States are benign. Diagnostic
mammography should be performed before the biopsy
because a well-circumscribed mammographic lesion may
appear less distinct because of hematoma formation
Mayo Clin Proc, June 2001, Vol 76
Detection and Evaluation of a Palpable Breast Mass
645
Dominant,* indeterminate,† or suspicious‡ breast mass
or
Diagnostic mammogram§ and ultrasound
(DMUS)
Complex cyst
with internal
echoes
Suspicious,
solid, or indeterminate mass
Simple
cyst
Asymptomatic
US-guided
FNA
Symptomatic
Recommendation per
radiologist
or obtain
surgical
consult
Therapeutic
FNA
Excisional
biopsy
Normal
findings
2-3 mo FU
or surgical
consult based
on CBE
US-guided
FNAB or
CNB
Office fine-needle aspiration with
no initial mammogram or ultrasound
Typical benign
cystic fluid
Bloody fluid
No fluid or
mass persists
Dominant mass
disappears
Send for
cytology
Perform
DMUS
FU
CBE
4-6 wk
Perform
DMUS
FU CBE and
mammogram at
appropriate interval
No malignant
cells
Yes
No
Excisional
biopsy
Malignant cells
or nondiagnostic
Perform DMUS
Recurrence
of cyst
Yes
Perform
DMUS
No
FU CBE and
mammogram at
appropriate interval
Figure 1. Algorithm to evaluate a palpable breast mass. CBE = clinical breast examination; CNB = core needle biopsy; consult =
consultation; FNA = fine-needle aspiration; FNAB = FNA biopsy; FU = follow-up; US = ultrasonography.
*Three-dimensional mass that is distinct from surrounding tissue.
†Vague nodularity or thickening that differs from surrounding tissue.
‡Mass that is firm, irregular, immobile, and fixed to surrounding tissue or with associated skin changes such as dimpling.
§Perform diagnostic mammography if not done in the past 6 months. For women younger than 40 years with a dominant mass,
ultrasonography is initially performed, and obtaining a diagnostic mammogram is the radiologist’s decision.
within the aspirated breast due to a traumatic procedure.
Various nonoperative biopsy techniques exist that have
advantages and disadvantages, including FNAB of a solid
lesion, which yields a cytological diagnosis, and core
needle biopsy (CNB), which yields a histologic diagnosis, both of which can be performed with or without
ultrasound guidance. Image-guided biopsies are preferred
because of improved accuracy and reduced sampling
error.
Fine-needle aspiration biopsy is a common nonoperative technique for obtaining tissue provided a representative sample is obtained. Grant et al12 showed that FNAB
646
Detection and Evaluation of a Palpable Breast Mass
has a false-negative rate of 6%, no false-positive results,
and an accuracy of 94%. The accuracy of FNAB is institution dependent, and each institution must critically examine its own results and understand the limitations before
incorporating this procedure. The false-negative rate reported in the literature is 1% to 35%.13 Optimal results are
achieved with a careful technique (operator dependent),
adequate sampling with sufficient material, and evaluation
by experienced cytopathologists.
A CNB yields a core of tissue that provides cellular
material for a more definitive histologic diagnosis. This
technique is associated with risks to underlying thoracic
structures, and sampling errors are relatively lower with
ultrasound guidance. Overall, CNB misses at least 2% of
cancers.14
The decision to use CNB, FNAB, or excisional biopsy
should be considered in the context of the clinical presentation, taking into account the ability and experience of the
operator. More importantly, the biopsy results should be
concordant with the mammographic and ultrasonographic
interpretation and clinical impression. If the findings are
discordant, a repeated biopsy or excisional biopsy is prudent. A tissue diagnosis obtained by CNB or FNAB of a
suspicious lesion can change a 2-stage to a 1-stage surgical
procedure. This is advantageous in the era of the sentinel
node procedure for regional node staging. If a palpable
mass is clinically suggestive of malignancy, an excisional
biopsy is necessary regardless of findings on the initial
needle biopsy. Stereotaxic needle biopsy is used primarily
in the evaluation of mammographically detected nonpalpable breast lesions and is an accurate, well-tolerated, and
cost-effective procedure.
If findings on CBE are normal, a mammogram should
be obtained at an appropriate time. However, if an indeterminate area of vague nodularity is detected on the CBE
but not a dominant mass, it is prudent to perform mammography and ultrasonography. If no abnormality is detected
on imaging, a follow-up CBE in 1 month or referral to a
breast specialist is appropriate. A change in the finding on
CBE or a persistent indeterminate mass necessitates a surgical referral.
Evaluation of a Palpable Breast Mass in Women
Younger Than 40 Years
Women younger than 40 years frequently present with
new breast lumps. However, benign breast disease is more
common in premenopausal women than in postmenopausal
women. For women younger than 40 years, a recent study
showed that a targeted ultrasound study is appropriate to
evaluate a questionable or indeterminate CBE finding. If
findings are normal, a short-term interval follow-up is necessary (2-4 months).
Mayo Clin Proc, June 2001, Vol 76
If findings on the CBE reveal a dominant mass with
features suggestive of malignancy, diagnostic mammography and ultrasonography are performed before proceeding with a biopsy, followed by surgical excision. If the
CBE reveals a dominant mass with clinically benign features, the woman has the option of elective surgical excision with no other imaging. However, if she desires the
option of observation, then further work-up includes ultrasonography of the dominant mass, FNAB or CNB to
confirm the presence of a benign lesion (often referred to
as the “triple test”—CBE, ultrasonography and/or mammography, and FNAB), and a short-term interval followup.15
If the CBE findings are consistent with normal fibroglandular breast tissue, a follow-up CBE in 2 to 4 months to
assess for change or stability is appropriate.
Mammography is less sensitive in younger women because of the increased breast density, resulting in a falsenegative rate of up to 25%. In women 35 to 40 years of age,
a diagnostic mammogram may be obtained if they have
normal or equivocal findings on an ultrasound study. For
younger women presenting with a dominant mass, an ultrasound study is initially performed, and a diagnostic mammogram is the radiologist’s decision.
Evaluation of a Palpable Breast Mass in
Pregnant or Lactating Women
About 1 in 3000 pregnant women will develop invasive
breast cancer. At the initial obstetric visit, a thorough CBE
is important. As the pregnancy continues and the hormonal
milieu intensifies each week, breast tissue becomes increasingly firm, nodular, and hypertrophied. Mammography is not performed routinely because of the increased
water content of breasts and loss of contrasting fatty tissue
that helps define discrete mammographic abnormalities.
Breast ultrasonography is accurate, is safe, and may be
helpful in determining whether the mass is cystic or solid.
Fine-needle aspiration biopsy does not have the same diagnostic accuracy in pregnancy as it does in the nonpregnant
state because of the increased cellularity of the breast tissue, and it can result in a false-positive diagnosis of malignancy. A thickness or a possible mass may feel similar to
normal hypertrophic thickness throughout the pregnancy,
and a follow-up CBE and ultrasonography are useful in
determining the importance of an abnormality. If a mass or
thickening persists, surgical evaluation is necessary to exclude malignancy. A breast biopsy in the pregnant woman
is technically difficult because of the increased vascularity
and likelihood of a postoperative hematoma. Because of
complications, such as an increased risk of infection or
milk fistulas, the woman should cease lactating before the
biopsy is performed.16
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Detection and Evaluation of a Palpable Breast Mass
647
VAGUE AREA OF THICKENING OR NODULARITY
An area of thickening or indiscrete changes in breast
texture can sometimes be the presenting breast complaint.
If CBE findings are thought to be clinically normal by
the surgeon or breast specialist and findings on FNAB
and mammography or ultrasonography are normal, observation is appropriate with follow-up in 2 to 3 months. If
the mass persists, excision is indicated. Although findings
on CBE, mammography, and cytology are considered
accurate, results are highly dependent on the expertise
and communication among the surgeon, radiologist, and
cytopathologist.
The woman’s level of anxiety combined with a history of
breast cancer risk factors should be considered when a palpable mass is being evaluated. If the CBE reveals vague
nodularity consistent with normal breast tissue but the patient still perceives this as a breast mass, follow-up in 2 to 3
months or through 1 or 2 menstrual cycles is prudent. If after
follow-up, the mass is distinguishable from the surrounding
breast tissue, a surgical consultation is appropriate.17
For patients in the following situations, referral to a
breast specialist or surgeon for a second opinion is suggested: a woman presenting with a palpable mass but the
CBE is difficult to perform because of a history of a reduction or augmentation mammaplasty; a woman with extremely nodular breasts, a history of multiple biopsies with
scarring, localized persistent pain, bloody nipple discharge,
or skin breakdown on the nipple-areola complex; or a persistently worried woman with normal findings on work-up.
be reminded that normal results on a screening mammogram do not ensure that they are free of breast cancer, and
they should promptly notify their physician about any
change in their breasts.
CONCLUSION
Breast cancer is the second leading cause of cancer-related
death in women in the United States. Despite increasing
incidence rates, mortality rates are currently declining. The
decline may be due to the influence of screening, early
detection, and improved therapy. Detection of a breast
mass regardless of the woman’s age requires an evaluation
to confirm or exclude malignancy. The approach to the
work-up and management of palpable breast masses encompasses a thorough history, accurate CBE, diagnostic
mammography with the necessary ancillary imaging to
delineate the mass, and pathologic diagnosis. Ultrasonography has become an integral part of the diagnostic evaluation of a palpable mass. The choice of CNB, FNAB with or
without image guidance, or excisional biopsy depends on
the clinical scenario combined with the surgical and radiologic consultation.
Of importance, normal mammographic findings in a
woman at any age do not preclude the need for further
evaluation of a palpable breast mass. Similarly, normal
findings on CBE do not exclude the possibility of a
mammographically detectable malignancy. Women should
12.
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Questions About Detection and Evaluation of
a Palpable Breast Mass
1. Which one of the following can be associated with an
increased risk of breast cancer?
a. Breast-feeding
b. Late menarche
c. Early menopause
d. Multiparity
e. Age older than 35 years at first live birth
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Detection and Evaluation of a Palpable Breast Mass
2. Which one of the following is true regarding the CBE
performed by a health care provider?
a. It is a standardized and objective screening tool for
breast cancer
b. It can distinguish a cyst from a solid lesion
c. Interpretation of findings can be difficult in
premenopausal women
d. It can be replaced by mammography in the
evaluation of a breast mass
e. It is more sensitive than mammography in the
evaluation of a breast mass
3. Which one of the following is true regarding
diagnostic mammography?
a. It can detect a cystic lesion reliably
b. It includes only 2 standard views of each breast
c. Normal findings are reassuring in the presence of a
palpable mass
d. It is the appropriate imaging study for a pregnant
woman presenting with a breast lump
e. It should be performed when a woman presents
with an area of palpable concern
Mayo Clin Proc, June 2001, Vol 76
4. Which one of the following is true regarding the 4
most common causes of a dominant breast mass?
a. Cysts commonly present in the second and third
decade of life
b. About 50% of all breast biopsy specimens are
fibroadenomas
c. Distinguishing a cyst from a carcinoma is easy
d. Prominent fibrocystic changes are painless
e. Simple cysts are most common in postmenopausal
women
5. Which one of the following is not an indication for an
excisional biopsy?
a. FNA reveals blood-tinged fluid and the mass
persists
b. An irregular suspicious lesion is detected on CBE
c. Targeted ultrasonography reveals a solid suspicious
lesion
d. FNAB of a solid lesion reveals a nondiagnostic
specimen
e. FNA results in yellow fluid with resolution of the
mass
Correct answers:
1. e, 2. c, 3. e, 4. b, 5. e