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Approach to the diagnosis of a breast lump
- 1. Approach to the diagnosis of a Breast Lump Lt. Dhirendra
- 2. Focus • Palpable mass in a woman’s breast-potentially serious lesion • All palpable lesions require evaluation • Triple assessment-effective strategy in the diagnosis of breast lumps • First step- confirm the presence of a discrete mass • Next step- distinguish simple cysts from solid lesions
- 3. Introduction • Risk of breast cancer increases with age • Median age of breast cancer diagnosis- 61 years • 95% of all breast cancer- women >40 years • Majority of breast cancers- sporadic (i.e., in patients without a family history of breast cancer) • First-degree relative with premenopausal breast cancer- high risk
- 4. Causes • Macrocyst (palpable cyst,25% of breast lesions) • Fibroadenoma, • Fat necrosis • Cancer
- 5. Triple assessment • Currently the gold standard • Components – Clinical assessment – Imaging – Tissue biopsy • Diagnostic accuracy- approaches 100%
- 6. Clinical assessment History • Age • A personal history of breast cancer • Past history of a breast biopsy • Family history of breast cancer • Recent trauma to the breast • Pregnancy • Lactation
- 7. Physical examination • Alone cannot definitively establish a mass as benign or malignant • Irregular fixed masses-suspicious for malignancy • Malignant lesions – skin thickening (e.g., peau d'orange) – nipple changes
- 8. • Complete bilateral breast examination – Variation in breast size – Fungating mass – Dimpling or retraction of skin – Nipple inversion or excoriation • Diagnostic accuracy of physical examination is 60 - 85%.
- 9. Patient positioning • Arms over her head • Hands on their hips and squeeze inwards- flexing the pectoral muscles- chest wall involvement • Lymph nodes axillary, cervical, supraclavicular, and infraclavicular fossae should be evaluated • Proper examination occurs with the patient both seated upright and lying supine – as masses can often be appreciated more in one position than another
- 10. Interpretation • Benign masses – no skin changes – smooth and mobile – soft to firm to palpation – well-defined margins • Malignant masses – generally hard and immobile – may be fixed to surrounding structures – poorly defined or irregular margins • Infections, such as mastitis- signs of inflammation
- 11. Imaging Mammography • Beneficial in finding occult malignancies • All women 30 years or older with a breast mass-mammography • Spot compression views and magnification views are recommended • Multi-focal or multi-centric disease should be noted
- 12. • Palpable breast mass-mammography – sensitivity 82% to 94% – specificity 55% to 84% for detecting breast cancer • Breast Imaging Reporting and Data System (BIRADS)
- 13. BIRADS • Score-1 to 3 followed with an ultrasound • Score-4 to 5 requires a tissue biopsy • Palpable mass-negative imaging study surgical follow-up • Score of 6 is given only after a biopsy- cancerous
- 14. Ultrasound of the breast • Considered the diagnostic test of choice in patients <30 years old,because – Density of breast tissue in younger women-limits sensitivity of mammography – False-negative rate 52% in patients <35 years old with a palpable malignant breast mass • Ultrasound may identify simple or complex cyst architecture
- 15. • Simple cysts are fluid-filled lesions-smooth, round, well-demarcated, and anechoic • If no internal septations or debris,may simply be followed
- 16. Breast aspiration and biopsy • Fine-needle aspiration cytology(FNAC) • Core-needle biopsy • Excisional biopsy
- 17. Fine-needle aspiration cytology(FNAC) • 22- to 26-gauge needle into the breast mass and extracting cells • Cells can be placed on a slide or made into a cell block • Advantages – fast and easy to perform and it can be done in the OPD – distinguish benign from malignant lesions – for evaluating axillary lymph nodes • Disadvantages – does not show histological architecture – Cannot differentiate ductal carcinoma in situ from invasive malignancy
- 18. Core needle biopsy • Using an 8- to 14-gauge needle • Provides a larger tissue sample than FNAC • Fast and easy to perform, and allows histological diagnosis • Performed by palpation, under stereotactic control, or by ultrasound guidance • Method of choice for histological diagnosis
- 19. Excisional biopsy • Removing the entire breast mass-accurate histological diagnosis • Invasive technique • Benign asymptomatic mass, may be unnecessary • Malignant mass, it may not obviate the need for a second procedure to treat
- 20. Management Cysts • Painful cysts may be aspirated under ultrasound guidance • Cysts that recur or not completely resolve with aspiration- biopsy to rule out malignancy • Biopsy- in complex cysts or those with solid elements
- 21. Solid mass • Management for 'probably benign' masses – Clinical and USG surveillance every 6 months for 2 years, to document stability – Core needle biopsy- definitive diagnosis while leaving the lesion in situ – Surgical removal of the mass, if the lesion is bothersome to the patient • USG of the axilla- to evaluate lymphadenopathy, and abnormal lymph nodes biopsied • Cancerous- staging investigations follow and managed by multidisciplinary team
- 22. In a nutshell • Palpable mass in a woman’s breast- potentially serious lesion • All palpable lesions require evaluation • The triple assessment- effective strategy in the management of breast lumps • The first step-confirm the presence of a discrete mass • Next objective- distinguish simple cysts from solid lesions • Simple cysts are aspirated to dryness and require no further treatment if do not recur • Pathological cysts require surgical excision. • A solid lesion requires a firm diagnosis, necessitating histological examination • Benign solid lesions may be managed expectantly- regular follow-up • Malignant solid lesions- referred to a multidisciplinary team for management
- 23. Discussion