Presentation on theme: "Breast Mass Linda M. Barney, MD Wright State University."— Presentation 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. 1 st 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 discharge No prior history of lumps or breast complaints No change with menstrual cycles, LMP 2 weeks prior Denies trauma
Pertinent PMH Healthy, exercises regularly No prior surgeries No chronic medical problems Menarche age 12, no pregnancies, regular cycles, OCPs x 2 years Denies smoking, alcohol or drugs Works 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 Diagnosis Based on History and Presentation
Differential Diagnosis Consider 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? 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.
Mammogram Comparison CC View Left Right
Observation May be reasonable in a young patient with low risk history and benign appearance on imaging May be reasonable in a young patient with low risk history and benign appearance on imaging Requires follow-up short and long term with intervention for clinical concern Requires follow-up short and long term with intervention for clinical concern
Discuss options for tissue diagnosis What are the advantages and disadvantages of each?
Management, Ms. Marcus Core Needle Biopsy Core Needle Biopsy US Directed Biopsy US Directed Biopsy Excisional Biopsy Excisional 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.
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
Summary Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging Distinct US features are often noted Distinct US features are often noted Tissue diagnosis is favored for observation Tissue diagnosis is favored for observation Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observed Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observed Indeterminate lesions warrant tissue diagnosis Indeterminate lesions warrant tissue diagnosis
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