Breast Lump

Aka: Breast Lump, Breast Mass

1. History: Risk Factors Evaluation
   1. See Breast Cancer Risk Factors
2. History: Characteristics of Breast Mass
   1. Mass Location ("Point with one finger to its location")
   2. Changes in size, pain, swelling
   3. Nipple Discharge
   4. Method of discovery
   5. Duration mass has been present
   6. Change with Menstrual Cycle (Hormonal influences)
   7. Tenderness at Breast Mass site
3. Etiologies of Discrete Breast Lumps
   1. Age under 20 years
      1. Fibroadenoma: 50%
      2. Benign Breast Mass: 50%
   2. Age 20 to 29 years
      1. Fibroadenoma: 35%
      2. Benign Breast Mass: 52%
      3. BreastCyst: 10%
      4. Breast Cancer: 3%
   3. Age 30 to 39 years
      1. Fibroadenoma: 18%
      2. Benign Breast Mass: 62%
      3. BreastCyst: 10%
      4. Breast Cancer: 10%
   4. Age 40 to 55 years
      1. Fibroadenoma: 9%
      2. Benign Breast Mass: 31%
      3. BreastCyst: 25%
      4. Breast Cancer: 35%
   5. Age over 55 years
      1. Benign Breast Mass: 13%
      2. BreastCyst: 2%
      3. Breast Cancer: 85%
4. Types
   1. BreastCyst
   2. Fibroadenoma
   3. Fibrocystic Breast
   4. Breast Cancer
5. Exam
   1. See Breast Exam
   2. Document patient identified Breast Mass location
      1. Patient points to the lump with one finger
   3. Dominant mass
      1. Three dimensional lesion that is distinct from surrounding tissue
      2. Asymmetric when compared with opposite side
   4. Document position of lesion on clock-face and distance from the nipple
      1. Correlate palpable mass on exam with patient reported location
6. Diagnostics
   1. Breast Ultrasound
   2. Mammogram in mass evaluation
      1. Not used to evaluate palpable mass
      2. Used to evaluate for other concurrent lesions
      3. Delay Mammogram 2 weeks after aspiration
         1. Aspiration may cause hematoma
         2. Wait time avoids false positives
   3. Breast aspiration, fine needle aspirate or core biopsy
   4. Excisional Breast biopsy
   5. Triple Test Score
7. Evaluation: Initial
   1. History and Exam as above
   2. Consider suspicious findings (for urgency of evaluation, but does not obviate need for Breast imaging)
      1. Hard, immobile lesion
      2. Breast Mass immobile, fixed to surrounding tissue
      3. Poorly defined margins
      4. Overlying skin changes may be present
   3. Dominant Breast Mass identified
      1. See evaluation protocols below based on either Ultrasound or FNA
      2. Diagnostic Mammogram in age over 30 years (or all ages with Breast Cancer Risk Factors)
      3. Consider early Breast surgeon rerferral if Breast Cancer Risk Factors or suspicious exam findings
   4. No Dominant Breast Mass identified
      1. Mammogram in age 40 years or older if not performed in last 12 months
      2. Repeat examination in 1-2 months,
      3. Consider early Breast surgeon rerferral if Breast Cancer Risk Factors or suspicious exam findings
8. Evaluation: Protocol 1 based on starting with Ultrasound
   1. Start with breast Ultrasound
   2. Ultrasound shows simple cyst
      1. Aspirate and
         1. See Breast Cyst Aspiration
      2. Repeat Clinical Breast Exam in 4-6 weeks
   3. Ultrasound shows complex cyst or solid lesion
      1. Mammogram and
      2. Fine needle aspirate or core-needle biopsy
         1. See Breast Cyst Aspiration
   4. Ultrasound does not reveal lesion
      1. Mammogram and
      2. Fine needle aspirate or core-needle biopsy
         1. See Breast Cyst Aspiration
9. Evaluation: Protocol 2 based on starting with FNA
   1. Start with fine-needle aspirate of Breast Mass
      1. See Breast Cyst Aspiration
   2. Breat mass is cystic
      1. No residual cyst after aspiration
         1. Age over 40: Mammogram or core needle biopsy
         2. Age under 40: Ultrasound or core needle biopsy
      2. Residual cyst or bloody fluid aspirated
         1. Repeat Clinical Breast Exam in 6 weeks
   3. Breast Mass is solid
      1. FNA malignant: Treat
      2. FNA Suspicious: Core-needle or Excisional Biopsy
      3. FNA non-diagnostic
         1. Age over 40: Mammogram or core needle biopsy
         2. Age under 40: Ultrasound or core needle biopsy
      4. FNA benign
         1. Obtain Mammogram
         2. If Mammogram positive
            1. Ultrasound or
            2. Core-needle biopsy
         3. If Mammogram negative
            1. Repeat Clinical Breast Exam in 6 weeks
10. Evaluation: Protocol 3 Basic Approach based on age
    1. Precautions
       1. Do not discount Breast Masses in younger patients
    2. Premenopausal asymmetrical palpable mass
       1. Reexamine during days 5-10 of Menstrual Cycle
       2. Mammogram if age over 30 years
       3. Breast Ultrasound if difficult localization
       4. Attempt aspiration of Breast lesion
          1. See Breast Cyst Aspiration
    3. Postmenopausal asymmetrical palpable mass
       1. Exercise high level of suspicion (High Risk)
       2. Mammogram
       3. Attempt aspiration of Breast lesion
          1. See Breast Cyst Aspiration
11. References
    1. Klein (2005) Am Fam Physician 71:1731-8 [PubMed]
    2. Salzman (2012) Am Fam Physician 86(4): 343-9 [PubMed]