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Management of the Palpable
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CHAPTER CONTENTS
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The Male Breast
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Management of the Palpable
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CHAPTER CONTENTS
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Radiologic Examination Mammography Ultrasound
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Management of the Palpable
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CHAPTER CONTENTS
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Magnetic Resonance Imaging
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Management of the Palpable
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CHAPTER CONTENTS
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Pathologic Examination Triple-Test Evaluation Fine-Needle Aspiration Core Needle Biopsy
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Management of the Palpable
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CHAPTER CONTENTS
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Incisional Biopsy Excisional Biopsy
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Management of the Palpable
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CHAPTER CONTENTS
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Specific Clinical Settings
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Management of the Palpable
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CHAPTER CONTENTS
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The Young Patient The Pregnant Patient
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Management of the Palpable
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CHAPTER CONTENTS
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Ductal Carcinoma In Situ
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Management of the Palpable
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CHAPTER CONTENTS
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The Patient with a Personal History of Cancer
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Management of the Palpable
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CHAPTER CONTENTS
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Other Mass-Forming Lesions
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Management of the Palpable
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CHAPTER CONTENTS
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Hematoma Seroma
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Management of the Palpable
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CHAPTER CONTENTS
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Fat Necrosis Hamartomas
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Management of the Palpable
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CHAPTER CONTENTS
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The breast mass is the most common symptom of women presenting to breast centers, accounting for more than half of the complaints. Although most are benign, the presence of a mass can cause considerable anxiety because of the concern for cancer. The most important task of the physi- cian evaluating a breast mass is to exclude the presence of malignancy, and provide an accurate diagnosis.
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Management of the Palpable
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CHAPTER CONTENTS
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The presence of a mass should never be dismissed because of young age, male gender, or a lack of risk fac- tors such as a family history of cancer. Diagnostic delays of breast cancer are a common cause for litigation, and such claims are most frequently seen for non-Hispanic white women in their 40s who are premenopausal, married, have a history of fibrocystic change, and who are enrolled in an HMO. Although delays in the diagnosis of a breast cancer may need to be 8 months or longer to be detrimental, no factor should override an expeditious and thorough evalua- tion, which must provide an explanation that is concordant with the patient’s history, physical examination, imaging, and pathologic findings.
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Management of the Palpable
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HISTORY
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A thorough history is the first step in the proper evaluation of any breast mass. Historical elements must, at bare mini- mum, include a proper breast history which includes cur- rent and prior symptoms, risk factors for cancer, and the patient’s gynecologic and menstrual history. The etiology of
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Management of the Palpable
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HISTORY
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previous masses should be detailed, and specifics about any current and prior breast problems must include the charac- ter, frequency, severity, and duration of the issue.
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Management of the Palpable
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HISTORY
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Breast evaluation nearly always includes diagnostic imaging. The complete history must therefore include details about mammograms, ultrasounds, and magnetic resonance imaging (MRI), including the dates, findings, and follow-up for abnormalities on these studies. Although annual mam- mographic screening is currently recommended for aver- age-risk women aged 40 years and older, many patients are either not aware of this recommendation or choose not to follow it. MRI is also recommended as a screening modality only in women whose lifetime risk is ≥20% to 25% (1), but MRIs are still being used outside this setting.
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Management of the Palpable
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HISTORY
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Other symptoms such as palpable lymph nodes, breast pain, skin changes, nipple inversion, and the character of any discharge (including color, bilaterality, number of ducts involved, and spontaneity) should also be assessed, as these complete the history and may narrow the differential diagno- sis. While a complete review of systems is often performed solely to satisfy reimbursement criteria, discussion of other organ systems may contribute substantially to understand- ing the current illness and to determine a patient’s candi- dacy for certain treatments, especially if a mass is found to be malignant (Table 4-1).
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Management of the Palpable
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HISTORY
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Past medical history may also shed light on current findings, either clarifying an ongoing process, or sug- gesting something that can recur over a woman’s life- time. Mass-forming lesions are listed in Table 4-2. Certain
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Management of the Palpable
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HISTORY
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29
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Management of the Palpable
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HISTORY
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benign entities may present as a recurring mass, such as pseudoangiomatous stromal hyperplasia, fibroadenomas, duct ectasia, mastitis, or abscess formation.
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Management of the Palpable
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HISTORY
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A discussion of past surgical history, including breast surgeries and needle biopsies, often reminds patients to
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Management of the Palpable
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HISTORY
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mention prior benign conditions such as fibrocystic change, simple cysts, fibroadenomata, and fat necrosis. Knowledge of a patient’s prior breast pathology is important for overall assessment and to help determine their risk of cancer. Often, patients are unfamiliar with specifics of their pathology and simply told that their prior biopsies are “benign,” but this lay description may encompass atypical hyperplasia (a lesion requiring further evaluation if recently diagnosed), lobular carcinoma in situ (LCIS, a high-risk marker), or other entities that confer elevated risk. Pathology reports and/ or slides may be of assistance to complete the evaluation if details are uncertain.
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Management of the Palpable
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HISTORY
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In men, the history should include additional questions about hepatic dysfunction, sexual dysfunction, and current medications to rule out potential causes of gynecomastia which can present as a central breast mass. Clearance of tes- tosterone can be impaired by hepatic dysfunction, resulting in increased peripheral conversion of testosterone to estra- diol and estrone, resulting in stimulation and hypertrophy of the breast tissue. Sexual dysfunction may indicate abnormal testosterone levels. Several medications such as H2 blockers and phenytoin, and drugs such as marijuana have also been associated with gynecomastia. Acute hypertrophy may also be painful, and associated symptoms should therefore be elicited.
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Management of the Palpable
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PHYSICAL EXAMINATION
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A presenting symptom that is designated as a new breast “mass” can span everything from a barely perceptible thick- ened region of the breast to a large fungating cancer or severe adenopathy. Physical examination is important prior to any diagnostic imaging so that the study can be chosen and targeted appropriately, and so that the radiologist can best assist in evaluating what has been seen on examination. Normal breast tissue can demonstrate nodularity which is difficult to distinguish from an abnormal process, causing difficulty for patients as well as physicians. One study of 542 patients under 30 years of age referred for a breast mass found that among the 80% of masses detected by self-breast examination, only 53% were true masses, underscoring the difficulties seen in younger women (2). A second study by Morrow and colleagues evaluating 605 patients under 40 years of age also found that only 27% had an identifiable etiology other than fibrocystic change (3). Among masses felt to be true abnormalities on examination by the surgeon, 28% were false positives.
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Management of the Palpable
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PHYSICAL EXAMINATION
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In some cases, the physician will not detect any abnor- mality on the clinical breast examination even after focusing on the area of concern. In this situation, the patient should be reassured about the absence of worrisome findings and the physician should recheck to ensure that a screening mammogram has been performed within the past year for the average-risk patient who is 40 years of age and older.
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Management of the Palpable
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PHYSICAL EXAMINATION
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In other women, a subtle abnormality that remains ill-defined is detected. Such a lesion, sometimes referred to as a breast “thickening,” is one whose extent cannot be clearly defined in three dimensions. These poorly defined areas of promi- nence may represent a true parenchymal abnormality, or in many cases may reflect the prominence of an underlying rib that elevates the normally nodular breast tissue superficial to it. If there is uncertainty about whether a finding repre- sents a true mass, the clinician should compare it to the mirror-image location in the opposite breast, and if appli- cable, palpate that region of breast tissue again once it has been moved off the underlying bony prominence. If any level of concern remains, further imaging evaluation is required, and for those physicians whose experience evaluating breast
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Management of the Palpable
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PHYSICAL EXAMINATION
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FIGURE 4-1 General schema for initial evaluation of a mass on examination based on its palpable characteristics. On presentation with the complaint of a mass, four findings can occur: (i) No abnormality noted,
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Management of the Palpable
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PHYSICAL EXAMINATION
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(ii) a thickening that may be either uncertain or equivocal, (iii) a clini- cally benign mass, or (iv) a clinically suspicious mass. These characteristics determine the next appropriate step in evaluation. When the characteristics of a thickening are equivocal or uncer- tain, imaging is indicated.
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Management of the Palpable
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PHYSICAL EXAMINATION
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masses is limited, a follow-up examination in 2 to 3 months after the initial visit is appropriate.
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Management of the Palpable
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PHYSICAL EXAMINATION
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When the examination is complete, the patient can be characterized as having four possible findings: (i) no abnor- mality present, (ii) a thickening without the characteristics of a dominant mass, (iii) a dominant mass with benign char- acteristics on palpation, or (iv) a dominant mass with malig- nant characteristics (Fig. 4-1).
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Management of the Palpable
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PHYSICAL EXAMINATION
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Documentation
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The documentation of any findings present on physical examination should be performed consistently and include a description of the superficial appearance of the breasts, including the skin, nipples, and areolae, as well as whether a mass or retractions can be detected by observation alone, or with movement. Exanthems, nipple inversion, and the character of any discharge should be noted.
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Management of the Palpable
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PHYSICAL EXAMINATION
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Documentation
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When documenting the characteristics of a mass, detail is of the utmost importance as it assists in the formulation of a differential diagnosis. Many women have diffusely nodu- lar breasts and therefore the size of the mass and its loca- tion should be detailed. At minimum, the mass should be described by indicating the breast in question and the quad- rant of the mass, although it is helpful to specify more detail whenever possible by utilizing tangents emanating from the nipple as numbers on the clock when facing the patient. The mass is also described by its distance from the nipple along that tangent, such as “a 2-cm left breast mass at the 4:00 position, 6 cm from the nipple.” Other characteristics that should be specified include whether its borders are smooth or irregular, details about its consistency (such as being soft, firm, or scirrhous), and whether it is discrete or an indis- tinct thickening. Characteristics associated with malignancy should also be noted. These include fixation to the chest wall or skin, skin satellite nodules, or edema of the skin (includ- ing peau d’orange) and ulceration. These characteristics are indicative of cancer and assist in its evaluation and staging.
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Management of the Palpable
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PHYSICAL EXAMINATION
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The Axilla
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The location of some masses may be difficult to distinguish between being present in the tail of the breast or the low axilla. Although normal lymph nodes are usually not pal- pable, small nonsuspicious lymph nodes may be detectable especially in thin individuals, often described as “shotty”
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Management of the Palpable
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PHYSICAL EXAMINATION
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The Axilla
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nodes (the term originating from and referring to shot or pellets of lead and not “shoddy,” as in poor quality). Lymph nodes may vary in size from several millimeters to several centimeters when abnormally enlarged, and tend to be dis- crete oblong nodules that have greater freedom of move- ment than breast parenchymal masses unless the nodes are fixed to one another or to the chest wall. These should also be described in detail, paying particular attention to the number of palpable nodes, fixation, laterality, and size.
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Management of the Palpable
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PHYSICAL EXAMINATION
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The Male Breast
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In men, there is usually less breast tissue, except in those with gynecomastia. Most of the breast tissue is located behind and concentric to the nipple–areola complex, and gynecomastia is typically described as disc-like or plate- like. Eccentricity in relation to the nipple and areola should be noted as such lesions are more likely to be malignant. Despite the smaller amount of breast tissue, the examina- tion and documentation for the male breast remains similar to the female examination.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Mammography
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Mammogram remains the standard of care for the evalua- tion of breast abnormalities, and is necessary even when a mass very clearly seems malignant. When a palpable abnor- mality is found, a diagnostic mammogram is performed that consists of at least one view in addition to those taken in a screening study. A skin marker is placed over the palpable area of interest, and additional views are taken if deemed appropriate by the radiologist. Mammographic imaging may be sufficient if a suspicious mass is found, corresponding to the area in question. If nothing is seen on mammogram or if the mass appears to be benign, characterization by ultrasound is indicated, as mammograms typically miss approximately 10% to 25% of cancers detectable by physical examination regardless of tumor size (4), and they cannot differentiate solid from cystic abnormalities.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Mammography
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When possible, mammograms should be obtained prior to a biopsy of any mass because of the consequent mammographic changes that may occur. The two exceptions to this are in evaluating the pregnant and very young patient
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Mammography
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(covered below). Hann et al. reviewed mammographic results immediately after stereotactic biopsy, and demonstrated that among 113 cases, 76% demonstrated changes due to the core biopsy, with 58 (51%) having a core biopsy–induced hema- toma (5). There were 31 (27%) lesions where the visualized lesion size changed, and three cases (3%) where hematoma obscured the ability to see calcifications at the site.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Mammography
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Prior mammograms from outside facilities should be obtained for comparison prior to any intervention. Review of all imaging by all treating physicians is critical for correla- tion to the palpable abnormality. If a breast cancer is diag- nosed histologically without the use of bilateral imaging, the clinician should ensure that a bilateral mammogram has been obtained within the past 6 months to rule out evident multicentric or contralateral disease requiring simultaneous intervention, even if no other palpable findings are present on examination.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Mammography
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The inability to see a palpable mass on mammogram should prompt an ultrasound, but the inability to see the lesion on either set of imaging does not mean that the lesion should be disregarded. If the lesion is discrete, biopsy should be performed. MRI is sometimes performed as an additional step to evaluate a mass that is mammographically occult, although MRI adds little because it is a poor substitute for the required pathologic diagnosis due to its lack of specific- ity. A palpable mass not seen on mammogram or ultrasound should undergo needle biopsy as the next step.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Mammography
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Mammography in Men
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Although mammography in men may confirm that a mass is of low clinical suspicion or assist in cases where body habi- tus makes a patient’s physical examination more difficult, it generally adds little to the workup of the palpable breast mass. The physical examination in males is particularly important, largely because of the smaller amount of breast tissue that allows a prominence of male breast cancers on examination and the low prevalence of benign breast masses other than gynecomastia. In a Mayo Clinic study evaluating mammograms performed on men, 196 were performed for breast masses and other symptomatic complaints. Among these, 1 benign-appearing mammogram among 203 missed a cancer (0.5%), but all three cancers in this series presented with a discrete palpable mass, 2 associated with overlying retractions and 1 with interval enlargement and lymphade- nopathy (6). In a series of 104 male patients with cancer, Borgen et al. also reported that most patients presented with more than one symptom, including masses in 77, nipple retraction in 18, bloody discharge in 16, skin ulceration in 10, and others with Paget’s disease, clinical inflammatory carci- noma, and fixed tumors (7). These series suggest that male cancers usually present with at least one suspicious physical examination finding, and while bilateral mammography may be considered in men once a cancer is suspected or diag- nosed to rule out bilaterality, its role and benefit in the rou- tine evaluation of the male breast mass has yet to be defined.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
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Ultrasound enables directed characterization of an abnor- mality, but is not a screening study. Ultrasound is most com- monly used to determine whether a breast mass is cystic or solid, and to characterize its appearance. Solid masses may appear benign or malignant, and cystic masses are charac- terized as simple or complex.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Ultrasound
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Cyst Evaluation
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Cysts are most frequently seen between the ages of 40 and 49 years (8) but account for only 10% of masses in women
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Ultrasound
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Cyst Evaluation
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younger than 40, and 25% of masses in women overall (3). More than half of all women who have cysts develop more one than during their lifetime, which may present synchro- nously or metachronously. Ultrasound can characterize them as simple, containing a smooth, thin wall that is well circumscribed with few internal echoes, or complex, which is defined as any cyst that doesn’t meet these criteria, specif- ically having a significant solid component, internal echoes or a fluid-debris level, scalloped or irregular borders, and the presence of septations. Ultrasound is 98% to 100% accu- rate for characterization of benign cysts when strict criteria are utilized (9). Complex cysts have an overall rate of malig- nancy as low as 0.3%, but complex cystic lesions containing a significant solid component may be malignant in up to 23% of cases and so complex cysts are generally aspirated.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Cyst Evaluation
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Cysts that appear simple on ultrasound have a negligible risk of cancer, and do not require aspiration unless the patient is symptomatic. In such cases, aspiration is performed to relieve the distension and discomfort and not for fluid evalu- ation. Complex cysts require aspiration to rule out bloody fluid which is suggestive of malignancy. Benign cyst fluid is typically green, yellow, or brown, and should not be sent for cytology because dead epithelial cells present in that fluid may appear atypical despite the low likelihood of malig- nancy. One study evaluating 6,747 cysts in 4,105 women with nonbloody aspiration found no cancers (8).
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Cyst Evaluation
|
Ultrasound is often the only imaging study required for a clinically benign breast mass found in women younger than 35 years, because of the substantially lower risk of malignancy, and because breast density often precludes mammographic visualization in this age group. Despite this difficulty in younger women, bilateral mammograms remain standard and should still be obtained when breast cancer is diagnosed because of its potential to assess the presence of multicentric or bilateral disease. Digital mammography has demonstrated some benefit over analogue studies in younger women and those with dense breasts (10), but in those who are the most difficult to assess, MRI may be of assistance because it is not affected by breast density.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
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Cyst Evaluation
|
In the young woman, masses that are benign to palpa- tion may undergo an attempt at aspiration prior to ultrasono- graphic imaging. Those with nonbloody benign cyst aspirate in whom the aspiration resolves the palpable abnormality may undergo observation. When planning to perform an aspi- ration, one must be cognizant that a traumatic aspiration can cause a bloody aspirate or potentially a hematoma, leading to further unnecessary workup and making ultrasound assess- ment more difficult. It is therefore important to attempt blind aspiration only in cases where the lesion is easily accessible by minimal manipulation and few needle passes.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
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Ultrasound
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Cyst Evaluation
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For those in whom the cyst recurs, repeat aspiration is acceptable, although with multiple recurrences, a mammo- gram (because of the small increase in risk of malignancy) and ultrasound (to further evaluate the cyst) should be con- sidered, and excision is an option primarily reserved for a suspicious lesion or when repeat aspirations are no longer desired by the patient.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
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The physical examination is important in combination with imaging to assess solid lesions. One of the more common solid abnormalities seen in young women are fibroadeno- mas (11), but these have also been found in women in their 40s and 50s (12). These masses are typically round or multilobulated, firm or “rubbery,” nontender, and freely mobile within the breast parenchyma. The physical exami- nation for diagnosis of the fibroadenoma is helpful, but not definitive, as demonstrated by one study evaluating women
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
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under 35 years of age in whom a clinical diagnosis of a fibroadenoma was made. Although imaging and histologic evaluation in this subset was not specified, in the 77 women where the mass persisted, only 56 (72%) were confirmed his- tologically to be fibroadenomas by FNA (13).
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
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Combining imaging and physical examination for evalu- ation of the palpable mass improves cancer detection over imaging alone. van Dam and colleagues found that in their series of 201 patients, ultrasound and mammogram each had respective sensitivities for cancer detection of 78% and 94% and specificities of 94% and 55% (14). When combining ultra- sound, mammogram, and physical examination together, sensitivity increased to 97% for cancer detection, but with a decrease in specificity to only 49%. In the Sydney Breast Imaging Accuracy Study in which 240 women with, and 240 age-matched women without cancer were evaluated, ultra-
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
|
sound had a 76% sensitivity for cancer and an 88% specific- ity. Most notable was the significant sensitivity advantage that ultrasound had over mammography in women aged 45 and younger (85% vs. 72%), suggesting that ultrasound is a critical addition to mammography in the evaluation of breast lesions in young women (15).
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
|
Unfortunately, the common and benign fibroadenoma can be difficult to distinguish by imaging from the uncom- mon and malignant phyllodes tumors. Bode et al. reviewed ultrasonography and core biopsy with subsequent excision performed on 57 fibroadenomas and 12 phyllodes tumors, finding that 42% of the phyllodes tumors were initially felt to be benign on ultrasound, while 46% of the fibroadenomas were indeterminate or suspicious (16). This underscores the need for the triple test (see below), which is standard even when imaging suggests a benign solid mass (Fig. 4-2).
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Ultrasound
|
Solid Mass Evaluation
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FIGURE 4-2 Specific schema for evaluation of a discrete mass on examination. Evaluation workflow, including imaging and tissue diagnosis, based on the presence of a discrete mass on examination. If a mass is found to be clinically suspicious on examina- tion, imaging should still be performed, but in such as case a tissue diagnosis is indicated, regardless of the imaging findings.
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Management of the Palpable
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RADIOLOGIC EXAMINATION
|
Magnetic Resonance Imaging
| null |
There are few indications for MRI in the workup of breast masses. MRI is best suited for settings where standard imag- ing techniques are insufficient, or where a patient’s elevated breast cancer risk outweighs the false-positives, costs, and disadvantages of the modality. The absence of a lesion noted on MRI does not negate the presence of a concerning mass on physical examination. MRI has an 85% negative predic- tive value for cancer in palpable masses containing calcifica- tions, which drops to less than 80% when no calcifications are present. MRI is highly sensitive, but also nonspecific. One study of 1,909 women with a significant familial risk of cancer demonstrated a threefold increase in the number of unnecessary biopsies because of the MRIs performed (17).
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Triple-Test Evaluation
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Masses that are found to be solid on imaging require triple- test evaluation which refers to physical examination, radio- logic examination, and needle biopsy performed by core or fine-needle aspiration (FNA). The triple test requires concor- dance between the three aspects of evaluation and is not confirmatory if a mammogram does not visualize the lesion or if an FNA contains insufficient cells for diagnosis. The lat- ter case mandates core needle biopsy for completion of the triple-test evaluation without surgery.
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Triple-Test Evaluation
| null |
The triple test is performed even in cases where masses are considered benign on imaging because some malignant lesions can have a benign appearance. In one series of 191 patients, Steinberg et al. found the sensitivity and specific- ity of triple test to be 95.5% and 100%, respectively (18). In a smaller series of 46 lesions in 43 patients, concordance between the three modalities provided a positive predic- tive value and specificity of 100%, while nonconcordance dropped the positive predictive value to 64% (19). The triple test also saved an average of $1,412 per case in comparison with open biopsy, demonstrating that it provides accurate diagnostic results and is cost-effective, despite the use of both imaging and pathologic evaluation. In one of the larg- est series evaluating the combination, benign triple tests in 2,184 patients demonstrated only 7 (0.32%) with carcinoma
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Triple-Test Evaluation
| null |
on follow-up (20).
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Triple-Test Evaluation
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Postbiopsy Follow-Up
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Although the accuracy of the triple test is high, benign concor- dant results do not obviate further surveillance of a palpable mass. Serial examinations and imaging at 6-month intervals for 1 to 2 years are often recommended to ensure stability, and growth should prompt surgical excision, especially in older women where benign masses are less frequently seen. Even fibroadenomas undergoing needle biopsy should be followed as those that are monoclonal have been reported on very rare occasions to transform into or recur as phyl- lodes tumors. There is no consensus regarding a threshold for excision when growth of a lesion occurs, although one series noted that 20% growth on ultrasound over 6 months was the 95th percentile in women under 50 and the 90th percentile in those 50 and older (21). They found that all masses excised with slower growth were benign, and rec- ommended that a 6-month growth rate of 20% become the threshold above which excision should be performed. This threshold has not been universally adopted, however, and smaller growth rates may prompt excision as there are no data relating outcome to growth rates of masses initially diagnosed as benign.
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Triple-Test Evaluation
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Postbiopsy Follow-Up
|
The triple test has been found to be the most accurate combination of modalities, but anxiety over a palpable mass remains an indication for surgical excision once the rele- vant literature and data have been disclosed to the patient. Prior to performing a core biopsy to complete the triple test there should be a discussion with the patient. The triple test implies observation if the biopsy is concordant and benign, and the consent process should clarify that the patient is comfortable with leaving the mass in situ.
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Fine-Needle Aspiration
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FNA involves the use of a handheld syringe and needle to percutaneously aspirate a tumor mass in order to obtain cytology for evaluation. This was first described in detail by Martin and Ellis in 1930, and is most commonly employed for palpable breast lesions that do not require imaging in order to target the lesion. FNA has been established as a variably accurate method of diagnosis and clinicians should consequently perform validation of their own results. In a large meta-analysis of 29 studies comprising 31,340 aspira- tions, the sensitivity of FNA varied from 65% to 98% and specificity ranged between 34% and 100% (22).
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Fine-Needle Aspiration
| null |
FNA has the advantages of being easily performed with readily available equipment, requiring only a syringe and an appropriately sized needle. Its biggest limitations are that insufficient material may make proper diagnosis difficult, and FNA usually cannot rule out the presence of an inva- sive component for the uncommon mass that is pure DCIS (ductal carcinoma in situ; see below). It also does not cap- ture histologic architecture making subtyping difficult and it is inaccurate for some masses such as hamartomas.
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Core Needle Biopsy
| null |
Core needle biopsy is associated with slightly greater dis- comfort and higher cost, but provides more tissue than FNA and provides histologic architecture to better classify pathologic subtype. It is less morbid than excisional biopsy, and even in early series comparing core needle to excisional biopsy, the results were identical in 90% of lesions. In the case of malignancy, the presence of invasion can be more easily assessed with core biopsy than FNA. Westenend and colleagues (23) performed both FNA and core needle biopsy in 286 breast lesions, of which 232 were palpable masses. FNA and core biopsy demonstrated no statistical differences in either sensitivity (92% and 88%, respectively), overall pos- itive predictive value (100% and 99%, respectively), or the number of inadequate specimens (7% for both). The diag- nostic differences were present in their specificity, which was higher at 90% for core biopsy (as vs. 82% for FNA), and for the positive predictive value of suspicious lesions (100% vs. 78%), and atypia (80% vs. 18%). In a multi-institutional study by Parker et al., among 1,363 lesions undergoing core and excisional biopsy under image guidance, only 15 (1.1%) false-negative core biopsies occurred, of which 12 were per- formed using stereotaxis, and 3 using ultrasound guidance
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Core Needle Biopsy
| null |
(24). Although this study was performed for lesions detected by imaging, it underscores the value of utilizing imaging with core biopsy for those areas of thickening that are equivocal on examination. Core biopsy remains the current standard of care for evaluation of masses of the breast.
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Management of the Palpable
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PATHOLOGIC EXAMINATION
|
Incisional Biopsy
| null |
Incisional biopsy is very rarely performed. This method of tissue sampling refers to the intentional surgical exci- sion of only a portion of a mass. Palpable lesions requir- ing biopsy are typically removed by excising the entire lesion (see below). When a mass cannot be excised in toto
|
Management of the Palpable
|
PATHOLOGIC EXAMINATION
|
Incisional Biopsy
| null |
(such as a large fungating cancer), a core biopsy or FNA is nearly always the preferred method of diagnosis, thereby avoiding the associated morbidities, including operative and anesthesia risks. Markers such as estrogen and proges- terone receptors as well as HER2/neu overexpression can be obtained from core biopsy, also eliminating any need for incisional or excisional biopsy.
|
Management of the Palpable
|
PATHOLOGIC EXAMINATION
|
Excisional Biopsy
| null |
The surgical excision of a lesion in the breast with the intent to remove it entirely is referred to as an excisional biopsy. In 2013, excisional biopsy is no longer the standard of care for the initial diagnosis of palpable breast masses, except where needle biopsy is not feasible for technical reasons, is nonconcordant with imaging or exam, is nondiagnostic, or demonstrates a high-risk lesion such as atypia.
|
Management of the Palpable
|
PATHOLOGIC EXAMINATION
|
Excisional Biopsy
| null |
Unfortunately, excisional biopsies are all too often per- formed without specimen orientation for the pathologist. For those excisional biopsies that demonstrate a malig- nancy, lack of orientation may necessitate complete reexci- sion of the entire cavity for even a single positive margin. This results in needless resection of tissue, especially as orientation of excisional biopsy specimens is simple to per- form. It is also inadvisable to perform intraoperative frozen section of an excisional biopsy because of the concerns about the accuracy of the analysis (25). Intraoperative assessment of an excised mass has few advantages other than to satisfy immediate physician and patient curiosity, and no change in definitive surgery (such as conversion from breast conservation to mastectomy) should ever be performed based on an initial result and without an in-depth discussion about treatment options. The specific schema for imaging and treatment of a discrete mass is shown in Figure 4-2.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
Assessment of the young female patient with a breast mass poses a challenge because of the difficulties in imaging dense breast tissue, because of the greater nodularity seen in those 30 and under whose breasts contain a lower pro- portion of fat, and because cosmetic and sexuality concerns about treatment tend to be greater in women of younger age. Malignancy is rare in women under 30, but complete evalu- ation of all masses is still required, including a tissue diag- nosis for those masses found to be solid. In a large series of 542 women under 30 who presented with the complaint of a breast mass (2), only 2% of cases were demonstrated to be malignant on biopsy, and among the benign lesions, the most common diagnosis was fibroadenoma, accounting for 72% of cases, with fibrocystic change next in frequency at 8%.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
The evaluation and treatment of young women should proceed similarly to older women, although with their increased breast density ultrasound is the primary modal- ity used to characterize a mass. If ultrasound demonstrates that the lesion is solid, core biopsy or FNA is indicated, and if malignancy is found, bilateral mammographic evalu- ation should then be performed. Likewise, if a lesion that is discrete is not seen on ultrasound, mammographic evalu- ation may characterize the lesion, but needle biopsy (or excision if not possible) should be performed as with any other age group. In the younger woman in whom a nonsus- picious lesion is less well defined, reexamination within
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
2 to 3 months at a different point during the menstrual
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
cycle may demonstrate resolution of the lesion, implying fibrocystic change. If any question remains, needle biopsy should be performed, but if the results are felt to be non concordant, excision may be considered.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
Care must be taken when excising lesions in younger adolescents. In addition to considering the cosmetic out- come of the scar that will be lifelong for the patient, the cen- tral subareolar breast bud can be mistaken for a new breast mass. This subareolar tissue should be spared because this is the origin of the ducts and deposition of fat that becomes the mature breast in the adult. Surgical damage of the breast bud has been reported to cause breast hypoplasia and significant disfigurement.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Young Patient
| null |
Young male patients referred for breast masses will pre- dominantly be adolescents found to have gynecomastia. Welch et al. reviewed all male breast patients at a large ter- tiary pediatric hospital that were referred for ultrasound. The patients were between 1 month and 18 years, and 72% of the 25 patients, between 7 and 18 years of age, were found to have gynecomastia, 13 of which were unilateral and three bilateral but asymmetric (26). In most cases, adolescent male gynecomastia can be observed as it will resolve in adulthood.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
The pregnant patient poses a dilemma when presenting with a breast mass. During pregnancy, the proliferative effect of circulating hormones causes the breasts to become increas- ingly nodular and engorged, making the physical examina- tion extremely difficult. A nodule found prior to pregnancy or early in its course should be evaluated promptly and not observed. This is because the increasing prolifera- tion of glandular elements and consequent nodularity dur- ing pregnancy and lactation can obscure an initial finding. Ultrasound is the imaging modality of choice, as this will determine whether a mass represents a simple cyst, a galac- tocele, an abscess, or a benign lymph node. The sensitivity of mammography and ultrasound for pregnancy associated breast cancer are 78% and 100%, respectively.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
Even with shielding, mammography is incorrectly thought by many to be contraindicated during pregnancy, even by physicians, despite its delivery of only 0.5 mGy to the fetus in comparison to the 1.0 mGy of normal back- ground radiation that the fetus receives over the 9 months of pregnancy. Although MRI is safe, the gadolinium used as the contrast agent is contraindicated, leaving MRI without contrast as an option that is less optimal than ultrasound.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
If the mass is solid, needle biopsy should be attempted prior to mammogram since mammography will not provide a definitive diagnosis of a solid mass. Core biopsy in the pregnant patient prior to mammography will also reduce unnecessary fetal irradiation, even though the consequent risk is low. If malignancy is diagnosed, bilateral mammogra- phy with fetal shielding is then appropriate.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
Core biopsy is the best option for tissue sampling in the pregnant patient. Fine-needle aspiration is more dif- ficult to perform and is associated with a higher risk of false-positives during pregnancy due to the prolifera- tive changes that occur within the breast. Although core biopsy during pregnancy has the added risk of milk fis- tula, this should not deter or raise the threshold for its use in the evaluation of a palpable mass. In theory, core biopsy should have a lower risk of milk fistula than excisional biopsy, but this has not been proven. Excisional biopsy is not appropriate during pregnancy when core biopsy is an option because of its unnecessary morbidity and cost.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
Ductal Carcinoma In Situ
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
As with any malignancy, ductal carcinoma in situ (DCIS) can be found in association with a mass, although it most commonly now presents as calcifications on mammogram without abnormal examination findings. Comedo DCIS is generally high grade and more likely to contain invasion which is why it is the only subtype likely to present with a mass, and why it accounted for the majority of DCIS cases detected before mammography was routinely used.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Pregnant Patient
| null |
Core needle biopsy is the current standard of care for the diagnosis of breast masses; however, 10% to 20% of lesions diagnosed as DCIS by core needle biopsy are found to be understaged on final excision, demonstrating invasion. Meijnen et al. evaluated 172 DCIS lesions diagnosed by core biopsy, and found that a mass on examination or a mass on imaging were the two most significant independent risk factors for the presence of invasion (27). It remains unclear whether DCIS that presents as a mass in men also has a higher risk of invasion because the series have been too small and too few to make generalizations.
|
Management of the Palpable
|
SPECIFIC CLINICAL SETTINGS
|
The Patient with a Personal History of Cancer
| null |
The patient who has a history of breast cancer has under- gone either breast-conserving therapy or mastectomy. In those women who have had BCT, surgical scarring and radiation-induced changes may make evaluation more dif- ficult. Mammography after BCT is less sensitive overall and specifically in the quadrant of the prior surgery, which may explain why 45% of recurrences after BCT can be detected only by palpation. In the patient who has had a mastectomy without reconstruction, abnormal nodularity on examina- tion is most commonly found in the scar or skin and should immediately undergo biopsy, as imaging is likely to add little to the evaluation. In those having had a mastectomy and reconstruction, ultrasound or MRI may assist in characteriz- ing recurrences. Imaging may be of benefit in this setting so that adequate surgical planning can help minimize any risk to the reconstruction.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hematoma
| null |
Hematomas of the breast are most commonly reported as a result of iatrogenic intervention, either in evaluation of a breast lesion or subsequent to its treatment, although spontaneous hematomas have been reported. They have also been rarely reported to identically mimic carcinoma on presentation. Physicians most likely encounter breast hematomas on examination after core biopsy, where it may be difficult to determine whether a lesion is truly pal- pable or whether a thickening in that location is due to a small amount of bleeding. Core needle biopsy can result in hematoma, and although significant bleeding is uncommon, a malignancy may be obscured in extreme examples (5). Postbiopsy hematoma rates range widely from less than 1%
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hematoma
| null |
(24) to 51% (5). When any question about a lesion’s palpabil- ity exists, needle localization should be planned in case the thickened area is solely due to hematoma and resolves by the date of surgery, leaving a nonconcordant mass.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hematoma
| null |
The appropriate management of a hematoma varies with its presentation. A palpable mass may be present with or without ecchymosis, which can sometimes extend laterally to the chest wall, below the inframammary fold and over to the opposite breast. In most cases, observation with use of
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hematoma
| null |
supportive garments and non-NSAID analgesics is sufficient, although hematomas in the postoperative period require a low threshold for reexploration. Expanding hematomas should be explored and evacuated with the intent to achieve hemostasis.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Seroma
| null |
Seromas are localized regions of serous fluid that usually occur after iatrogenic intervention. In some cases, ultra- sound may be required to differentiate a seroma from a solid nodule, depending on the degree of distension of the sur- rounding tissue. The breast contains an extensive lymphatic network, and any operative site may develop a seroma. While these are advantageous at local breast excision sites by maintaining breast contour, large seromas may create a palpable mass. When present after mastectomy, they may impede flap healing by interfering with skin adherence to the chest wall. Finally, a postreconstruction seroma can create a palpable mass that is most easily evaluated with ultrasound.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Seroma
| null |
There are few data on what predisposes women under- going BCT to develop significant breast seromas. Most investigations have focused on those that develop after axil- lary dissection, but factors that are known to contribute to seroma formation generally include the use of cautery, the extent of the dissection and amount of disease present, pri- mary tumor size, patient weight, the use of chemotherapy, and the type of surgery performed. Seromas are usually of little consequence and confer few symptoms, but when they become bothersome to the patient they may be ameliorated with a small number of repeated aspirations.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Fat Necrosis
| null |
Fat necrosis is a phenomenon that is occasionally seen in the breast due to its high fat content, and is significantly correlated with trauma or surgical intervention. Fat necro- sis results from lipase-induced aseptic saponification of adi- pose tissue that can create mass lesions that are tough to distinguish from carcinoma. Oil or lipid cysts are one mani- festation of fat necrosis that can be seen on imaging and are composed of a confined pool of neutral lipid surrounded by a membrane. This pathognomonic finding is not present in all cases, but when evident demonstrates a characteristic lucent center with a water-density rim that may calcify with time. Such a lesion does not require further evaluation, espe- cially with a history of trauma. Unfortunately, many cases of fat necrosis do not present in this fashion and may contain calcifications or fibrosis, which can appear as a spiculated mass and have a scirrhous feel on examination. Such a pre- sentation makes the diagnosis uncertain and necessitates core or excisional biopsy for diagnosis. On diagnosis, no treatment is required.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Hamartomas, previously known as fibroadenolipomas or lipofibroadenomas because of their components, are benign lesions that are often palpable as a mass and can grow to extremely large sizes, pushing the breast tissue outward as they grow rather than replacing it. Although they have been reported in men, they are most commonly seen in women, and traditionally appear mammographically as a fibrofatty mass, but may have a variable mammographic appearance. Ultrasound appearance is usually solid, but cystic regions may be present in 24% of cases. While most hamartomas have a benign radiographic appearance, biopsy is recom- mended as with other solid masses to confirm the diagnosis.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Neither FNA nor core biopsy can accurately make the diag- nosis of a hamartoma without correlation to imaging find- ings because of the variety of elements required to make a diagnosis. FNA results, at best, in a diagnosis of a non- specified benign lesion (28) because the cytologic features overlap with other benign disease. Core biopsy also often yields an insufficient variety of tissue types for a diagnosis, and surgical excision may be required when imaging corre- lation is not performed in order to reach a definitive diagno- sis. Hamartomas have on occasion been seen in association with atypia, as well as in situ and invasive malignancies, but correlation to these more concerning pathologic entities has not been found consistently enough to universally recom- mend surgical excision.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
If the diagnosis of hamartoma is entertained on evalua- tion of a breast mass, mammograms should be obtained and core biopsy attempted, while providing the pathologist with the imaging and clinical findings. Surgical excision may be required for definitive diagnosis, and clear margins should be sought because of the possibility of recurrence. As with any large solid mass, discomfort or anxiety regarding the lesion is an indication for excision, as is enlargement on sub- sequent follow-up.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
REFERENCES
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Saslow D, Boetes C, Burke W, et al. American cancer society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin 2007;57(2):75–89.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Vargas HI, Vargas MP, Eldrageely K, et al. Outcomes of surgical and sono- graphic assessment of breast masses in women younger than 30. Am Surg 2005;71(9):716–719.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Morrow M, Wong S, Venta L. The evaluation of breast masses in women younger than forty years of age. Surgery 1998;124(4):634–640; discussion 640–631.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Baker LH. Breast Cancer Detection Demonstration Project: five-year sum- mary report. CA Cancer J Clin 1982;32(4):194–225.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Hann LE, Liberman L, Dershaw DD, et al. Mammography immediately after stereotaxic breast biopsy: is it necessary? AJR Am J Roentgenol 1995;165(1):59–62.
|
Management of the Palpable
|
OTHER MASS-FORMING LESIONS
|
Hamartomas
| null |
Hines SL, Tan WW, Yasrebi M, et al. The role of mammography in male patients with breast symptoms. Mayo Clin Proc 2007;82(3):297–300.
|
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