Breast Lump

Aka: Breast Lump, Breast Mass

1. See Also
   1. Nipple Discharge
   2. Mastalgia
2. History: Risk Factors Evaluation
   1. See Breast Cancer Risk Factors
3. 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
4. Causes: 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%
5. Types: Breast Mass
   1. BreastCyst
   2. Fibroadenoma
   3. Fibrocystic Breast
   4. Breast Cancer
6. Precautions
   1. Do not discount Breast Masses in younger patients
   2. Exercise high level of suspicion (High Risk) in postmenopausal asymmetrical palpable mass
7. Exam
   1. Consider reexamine during days 5-10 of Menstrual Cycle in premenopausal asymmetrical palpable mass
   2. Careful Clinical Breast Exam
      1. See Breast Exam
      2. Perform with patient seated with hands on hips, and then with patient supine
      3. Evaluation includes lesion locations (based on clock position on Breast and distance from areola edge)
      4. Evaluate characteristics, Nipple Discharge and skin changes
      5. Evaluate for axillary, supraclavicular and Cervical Lymphadenopathy
   3. Document patient identified Breast Mass location
      1. Patient points to the lump with one finger
   4. Dominant mass
      1. Three dimensional lesion that is distinct from surrounding tissue
      2. Asymmetric when compared with opposite side
   5. Document position of lesion on clock-face and distance from the nipple
      1. Correlate palpable mass on exam with patient reported location
8. Imaging
   1. Breast Ultrasound
      1. Most useful first-line study in age 30 years and younger
   2. Diagnostic Mammogram in mass evaluation
      1. Most useful first-line study in age 40 years old or older
      2. Also 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 MRI
      1. Not typically utilized in Breast Mass evaluation
         1. May be considerd in prior lumpectomy evaluation for recurrence versus scar
      2. Used for Breast Cancer Screening in high risk women (>25% lifetime risk)
         1. See Breast MRI for Breast Cancer Screening indications
         2. Not indicated for general Breast Cancer Screening due to high False Positive Rate and expense
9. Diagnostics
   1. Breast aspiration (fine needle aspirate)
      1. Indicated for simple cyst aspiration
   2. Core needle biopsy
      1. Preferred diagnostic biopsy for abnormal exam, Ultrasound or Mammogram
      2. Higher accuracy than fine needle biopsy
         1. Higher Test Sensitivity, Test Specificity and detection of malignant invasion
      3. Preferred over open biopsy in most cases
         1. Similar accuracy to open biopsy
         2. Lower risk of scarring and other complications, as well as faster healing and lower cost
   3. Punch Biopsy of skin
      1. Consider if abnormal Breast Skin Changes in the absence of a Breast Mass
   4. Excisional Breast biopsy (open Breast biopsy)
      1. Core needle biopsy is preferred
   5. Triple Test Score
10. Evaluation: Initial
    1. History and Exam as above
    2. Consider reexamine during days 5-10 of Menstrual Cycle in premenopausal asymmetrical palpable mass
    3. Consider suspicious findings (for urgency of evaluation, but does not obviate need for Breast imaging)
       1. Hard, irregular lesion (contrast with soft, smooth, regular benign lesions)
       2. Breast Mass immobile, fixed to surrounding tissue
       3. Poorly defined margins
       4. Overlying skin changes may be present
    4. Dominant Breast Mass identified
       1. See evaluation protocols below
          1. Start with diagnostic Mammogram in age over 30 years
          2. Start with breast Ultrasound in age <30 years old
       2. Consider early Breast surgeon rerferral if Breast Cancer Risk Factors or suspicious exam findings
    5. 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
11. Evaluation: Age 30 years or older (Mammogram first)
    1. Step 1: Diagnostic Mammogram
       1. BI-RADS 1 to 3: Go to Step 2
       2. BI-RADS 4 or 5: Obtain core needle biopsy of lesion and urgent surgery Consultation
    2. Step 2: Breast Ultrasound
       1. BI-RADS 1 (negative, no lesion identified) or BI-RADS 3 (probably benign lesion)
          1. High Clinical Suspicion: Obtain core needle biopsy of lesion
          2. Low Clinical Suspicion
             1. Clinical Breast Exam, Ultrasound, Mammogram every 6 months for 1-2 years
             2. Obtain core needle biopsy if significant increase in size or suspicion
             3. Resume routine screening if negative evaluation after 2 years of monitoring
       2. BI-RADS 2 (benign lesion)
          1. Resume routine screening
       3. BI-RADS 4 (suspicious) to BI-RADS 5 (highly suggestive of malignancy)
          1. Obtain core needle biopsy of lesion and urgent surgery Consultation
12. Evaluation: Age less than 30 years old (Ultrasound first)
    1. Based on Breast Ultrasound
    2. May also consider Breast Cyst Aspiration for presumed simple cysts at time of exam (see below)
    3. BI-RADS 1 (negative, no lesion identified) or BI-RADS 3 (probably benign lesion)
       1. High Clinical Suspicion: Obtain core needle biopsy of lesion and Mammogram
       2. Low Clinical Suspicion
          1. Clinical Breast Exam, breast Ultrasound every 6 months for 1-2 years
          2. Obtain core needle biopsy if significant increase in size or suspicion
          3. Resume routine screening if negative evaluation after 2 years of monitoring
    4. BI-RADS 2 (benign lesion)
       1. Resume routine screening
       2. Consider Breast Cyst Aspiration for simple cyst (see protocol below)
    5. BI-RADS 4 (suspicious) to BI-RADS 5 (highly suggestive of malignancy)
       1. Obtain core needle biopsy of lesion and urgent surgery Consultation
13. Evaluation: Breast Cyst Aspiration (FNA)
    1. See Breast Cyst Aspiration
    2. Indicated for presumed simple cystic Breast Masses (esp. age <30-40 years old)
    3. Repeat Clinical Breast Exam (and consider breast Ultrasound) in 4-6 weeks
       1. Follow imaging protocol as above if residual Breast Mass after aspiration
       2. Refer if bloody fluid on Breast Cyst Aspiration
    4. Exercise caution (esp. age >40 years old or other Breast Cancer Risk Factors)
       1. Fine Needle Aspiration (Breast Cyst Aspiration) is less accurate than core needle biopsy
       2. Only recommended for simple cysts
14. References
    1. Klein (2005) Am Fam Physician 71:1731-8 [PubMed]
    2. Moy (2017) J Am Coll Radiol 14(5S):S203-24 [PubMed]
    3. Salzman (2019) Am Fam Physician 99(8): 505-14 [PubMed]
    4. Salzman (2012) Am Fam Physician 86(4): 343-9 [PubMed]