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:
Associated signs/symptoms:
Pertinent PMH
ROS
MEDS
Relevant Family Hx.
Characterization of Symptoms:
Temporal sequence
Alleviating / Exacerbating factors:

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 Diagnosis Based on History and Presentation

11. Differential Diagnosis Consider 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
Remaining Examination findings non-contributory

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 Breast Ultrasound ? Screening Mammogram ?
PA/Lat Chest ?
Diagnostic Mammogram ?
CT Scan of Chest ?
Breast MRI ?
PET SCAN ?
Other:

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. Mammogram Comparison CC View
Left Right

25. Observation
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

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 Core Needle Biopsy US Directed Biopsy
Excisional Biopsy

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 ; followed for development of invasive carcinoma over next 25 years
Risk carcinoma: 2.2x higher in FA patients vs. controls
Risk x 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

36. Ultrasound Left Breast

37. Mammogram Bilateral
MLO Views
Left Breast
Right Breast

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
Fibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imaging
Distinct US features are often noted
Tissue diagnosis is favored for observation
Simple cysts in low risk population can be aspirated for symptoms & diagnosis or observed
Indeterminate lesions warrant tissue diagnosis

44. Acknowledgment
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