Breast Mass

1. Breast Mass Linda M. Barney, MD Wright State University

2. Ms. Marcus Ms. Marcus is a 23-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.

3. History What other points of the history do you want to know?

4. History, Ms. Marcus Consider the following: Characterization of Symptoms: Temporal sequence Alleviating / Exacerbating factors: Associated signs/symptoms: Pertinent PMH ROS MEDS Relevant Family Hx.

5. 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

6. Associated Signs & Symptoms Denies pain, skin change, nipple discharge No prior history of lumps or breast complaints No change with menstrual cycles, LMP 2 weeks prior Denies trauma

7. Pertinent PMH Healthy, exercises regularly No prior surgeries No chronic medical problems Menarche age 12, no pregnancies, regular cycles, OCP�s x 2 years Denies smoking, alcohol or drugs Works as a systems analyst

8. Alleviating/ Exacerbating factors No change with activity Uses Ibuprofen for cramps with no change in the lump Drinks decaffeinated tea and sodas only

9. 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

10. Differential DiagnosisBased on History and Presentation

11. Differential DiagnosisConsider the following Fibrocystic Mass Cyst Fibroadenoma Breast Cancer Hematoma Abscess Fat necrosis Lactational Adenoma

12. Physical Examination What would you look for?

13. 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

14. Laboratory What would you obtain?

15. Lab Discussion No labs indicated Patient has no clinical signs of infection or nipple discharge and no suggestion of any systemic disease

16. Studies What further studies would  you want at this time?

17. Studies, Ms. Marcus

18. Ultrasound Left Breast

19. 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?

20. Revised Differential Diagnosis 1 Fibroadenoma 2 Cyst 3 Fibrocytic Mass 4 Breast Cancer

21. What next?

22. Options Additional Imaging? Biopsy OR? Observation? Other?

23. 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.

24. MammogramComparison CC View

26. Discuss options for tissue diagnosis What are the advantages and disadvantages of each?

27. Biopsy Techniques Needle Core Biopsy FNA Excisional Biopsy Image Guided Biopsy Ultrasound Stereotactic

28. Management, Ms. Marcus

29. US Directed Biopsy

30. 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.

31. Pathology Fibroadenoma

32. Interventions at this point?

33. Discussion Observation versus Excision Indications for excision Rapid growth Inability to differentiate from aggressive pathology such as Phyllodes Tumor or Breast Cancer Patient preference

34. 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* Most common benign breast tumor in adults; peak incidence 20-40, decreases post-menopause Clinical presentation: palpable mass or non-palpable well-demarcated density on a mammogram Pathogenesis: hyperplasia of intralobular stroma (probably not a true neoplasm, but still often classified as �benign neoplasm� because it is a �new growth� forming a mass lesion) Definition: benign circumscribed tumor of admixed fibrous and glandular epithelial elements Dupont, Page et.al.: Long-Term Risk of Breast Cancer in Women with Fibroadenoma. NEJM 331:10-15, 1994. 1835 patients diagnosed with fibroadenoma (FA) between 1950-1968; followed for development of invasive carcinoma over next 25 years Risk carcinoma: 2.2x higher in FA patients vs. controls Risk 3.7-3.9x higher if epithelial proliferative disease identified in adjacent breast or if family history of carcinoma Most common benign breast tumor in adults; peak incidence 20-40, decreases post-menopause Clinical presentation: palpable mass or non-palpable well-demarcated density on a mammogram Pathogenesis: hyperplasia of intralobular stroma (probably not a true neoplasm, but still often classified as �benign neoplasm� because it is a �new growth� forming a mass lesion) Definition: benign circumscribed tumor of admixed fibrous and glandular epithelial elements Dupont, Page et.al.: Long-Term Risk of Breast Cancer in Women with Fibroadenoma. NEJM 331:10-15, 1994. 1835 patients diagnosed with fibroadenoma (FA) between 1950-1968; followed for development of invasive carcinoma over next 25 years Risk carcinoma: 2.2x higher in FA patients vs. controls Risk 3.7-3.9x higher if epithelial proliferative disease identified in adjacent breast or if family history of carcinoma

35. Alternative Diagnosis What if her mass was more tender and developed acutely since her last period? Imaging studies follow

38. Would you like to revise your Differential Diagnosis?

39. Differential Diagnosis Simple Cyst Complex Cyst Abscess Fibrocystic Mass Fibroadenoma Breast Cancer

40. Interventions at this point?

41. Management Options FNA FNA w/ US guidance Core Biopsy Excision Observation

42. QUESTIONS ??????

43. Summary

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