Presentation on theme: "Breast Mass Linda M. Barney, MD Wright State University."— Presentation transcript:
1Breast MassLinda M. Barney, MDWright State University
2Ms. MarcusMs. Marcus is a 23-year-old woman who was referred by her Gynecologist for evaluation of a breast mass.
3HistoryWhat other points of the history do you want to know?
4History, Ms. Marcus Consider the following: Associated signs/symptoms:Pertinent PMHROSMEDSRelevant Family Hx.Characterization of Symptoms:Temporal sequenceAlleviating / Exacerbating factors:
5Characterize Symptoms 4 month history of left breast lump.1st noticed in the shower ~ 1 week before mensesOlive sized and nontenderMay have increased in size slightlyNo change with menstrual cycles
6Associated Signs & Symptoms Denies pain, skin change, nipple dischargeNo prior history of lumps or breast complaintsNo change with menstrual cycles, LMP 2 weeks priorDenies trauma
7Pertinent PMH Healthy, exercises regularly No prior surgeries No chronic medical problemsMenarche age 12, no pregnancies, regular cycles, OCP’s x 2 yearsDenies smoking, alcohol or drugsWorks as a systems analyst
8Alleviating/ Exacerbating factors No change with activityUses Ibuprofen for cramps with no change in the lumpDrinks decaffeinated tea and sodas only
9Family History Maternal grandmother with breast cancer at age 70 Mother and older sister with Fibrocystic Breast ConditionNo Gyn or Colon CA in family
10Differential Diagnosis Based on History and Presentation
11Differential Diagnosis Consider the following Fibrocystic MassCystFibroadenomaBreast CancerHematomaAbscessFat necrosisLactational Adenoma
13Physical Examination, Ms. Marcus Relevant Exam findings for a problem focused assessmentBreasts: 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 nodesRemaining Examination findings non-contributory
19Studies – ResultsFocused L breast US demonstrates a 2.2cm well-circumscribed, homogeneous, hypoechoic nodule, with no abnormal shadowingWider than tall orientationNo additional abnormalities are notedWhat is the differential diagnosis at this point?
20Revised Differential Diagnosis 1 Fibroadenoma2 Cyst3 Fibrocytic Mass4 Breast Cancer
23What 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.
30ManagementLess 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.
33Discussion Observation versus Excision Indications for excision Rapid growthInability to differentiate from aggressive pathology such as Phyllodes Tumor or Breast CancerPatient preference
34Fibroadenoma Discussion FeaturesUsually younger womenUsually solitary mass, occasionally multipleMay increase with pregnancy or involute post-menopausePathologyBenign tumorCircumscribed rubbery massOvergrown fibrous stroma compressing epitheliumMay 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-menopauseClinical presentation: palpable mass or non-palpable well-demarcated density on a mammogramPathogenesis: 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 elementsDupont, 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 yearsRisk carcinoma: 2.2x higher in FA patients vs. controlsRisk x higher if epithelial proliferative disease identified in adjacent breast or if family history of carcinoma
35Alternative Diagnosis What if her mass was more tender and developed acutely since her last period?Imaging studies follow
43SummaryFibroadenomas are benign lesions presenting as a palpable mass or well-defined lesions on imagingDistinct US features are often notedTissue diagnosis is favored for observationSimple cysts in low risk population can be aspirated for symptoms & diagnosis or observedIndeterminate lesions warrant tissue diagnosis
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