Breast Lumps / Masses are very common, particularly among women of reproductive age. Over 25% of women are affected by breast disease in their lifetime, and the vast majority of these cases will present initially as a new breast mass in the primary care setting. Breast masses have a wide range of causes, from physiological adenosis to highly aggressive malignancy.  Although the majority of breast masses present in adult women, children and men can also be affected. Indeed, male breast cancer is a well-documented condition and requires a considered index of suspicion for its timely diagnosis and intervention.

Breast cancer is the most common type of cancer in women worldwide, with an incidence of approximately 12%, and therefore although the vast majority of breast lumps are benign, a thorough and structured approach is required in all cases. In general, the approach should follow the triple-assessment pathway of clinical examination, radiological imaging, and pathology analysis. Such an approach will be described in this article, with examples throughout of the common breast pathologies encountered.

Anatomy

The breast, or mammary gland, is a modified sweat gland containing various proportions of fibrous tissue, glandular tissue, and adipose tissue. Each breast has 15 to 20 lobes, which are drained by lactiferous ducts that converge beneath the nipple in the subareolar region. The lobes are supported by fibrous stroma and fatty stroma. Lymphatic drainage is primarily through the axillary lymph nodes, but can also involve the pectoral, subscapular and internal mammary nodes.

Breast tissue is present in children and males but is more developed in females of reproductive age due to hormonal surges that arise at puberty. Breast tissues involute significantly following the menopause, the glandular tissue atrophies due to the reduction of circulating estrogen levels and is largely replaced by fatty tissue. Breast tissues, and indeed the majority of breast pathologies, are responsive to changes in hormone levels.

History

A thorough and accurate history is the cornerstone of approaching any new breast mass. Particular emphasis should be placed on the chronological development of the lump and symptoms associated with it.

Timing

It is not always possible to establish the duration for which the mass has been present. Patients who do not regularly carry out breast self-examination may take longer to notice a breast lump, and indeed a proportion of breast lumps are identified through routine screening, so this is not necessarily an accurate way of determining acuity of such a mass.[7] More important is to establish whether the mass had developed in association with trauma or other symptoms and how rapidly the mass appears to be growing or changing, if at all

Causes of Breast Lumps / Masses

  • Localized – An acutely tender breast lump is more likely to be an abscess or hematoma secondary to trauma. Cancerous breast masses rarely present with pain, although the presence of pain should not exclude neoplastic lesions from the differential. Nipple changes or discharge merits attention, as these can correlate with some less common breast tumors, as well as changes to the overlying skin, including ulceration, eczema, or tethering.
  • Systemic – As is the case with every new patient assessment, a careful systems review should take place to seek evidence of disseminated disease. History of weight loss, dyspnoea, and bone pain are important in highlighting potential sites of metastasis.
  • Family History – Family history would be one of the key risk factors for breast cancer, particularly if family members were young (>50) at the age of diagnosis. Establishing an accurate family history is crucial, and it should also include relatives diagnosed with non-breast cancers, especially if at a young age. Detailed family history can be highly useful in generating an accurate risk profile.

Symptoms of Breast Lumps / Masses 

  • Painless or painful
  • Firm or rubbery
  • Mobile
  • Solitary-round with distinct, smooth borders
  • Round with distinct, smooth borders
  • Easily moved
  • Firm or rubbery

People who have a simple fibroadenoma have a slightly increased risk of developing malignant (harmful) breast cancer. Complex fibroadenomas may increase the risk of breast cancer.[rx]

In the male breast, fibroepithelial tumors are very rare and are mostly phyllodes tumors. Exceptionally rare case reports exist of fibroadenomas in the male breast, however these cases may be associated with antiandrogen treatment.[rx]

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Diagnosis of Breast Lumps / Masses

History and Physical

  • Age is the most important factor in the incidence of breast lumps / Masses . Therefore, when obtaining a medical history, age is the most important factor which should be considered.
  • A family history of breast cancer is also significant. Female patients who have first-degree relatives with breast cancer should be monitored and observed more carefully for malignant features than patients without this family history.

Physical Examination

  • Clinical examination of a breast lump – is the first stage in the triple-assessment approach. Both breasts and axillae should be examined meticulously by the clinician, as well as carrying out a physical examination of other body systems as indicated by the history. Although it can be tempting to bypass the physical examination in favor of other, more targeted investigation modalities such as mammography or sonography, the findings of the physical examination are crucial for effective diagnosis and management of breast disease. Repeated studies have indicated that only by combining all three assessments can optimal sensitivity and specificity be achieved.
  • Clinical breast examination – is often conducted with a chaperone present to make the patient feel more comfortable. The entirely of the chest and abdomen should be exposed, Each breast and axilla should undergo a visual inspection, looking for skin changes, nipple discharge, visible masses or asymmetry, and tethering to underlying structure; this feature can be exaggerated by asking the patient to place their hands on their hips or lift the arms.The breasts can most easily be palpated by asking the patient to lie back at approximately 30 degrees and rest their hand palm-up underneath their head. Palpation of the breast must proceed in a structured manner; generally, clinicians will use a four-quadrant approach (upper outer, upper inner, lower outer, lower inner quadrants), followed by palpating the areola and then the axillary tail. Particular attention should focus on the inframammary fold and the axillary tail. The normal breast is examined first, and the tissue assessed for its overall consistency. Masses are most often detected in the upper outer quadrant, as the majority of breast tissue is located here.
  • Palpable breast masses – should be described in terms of location, size, shape, tenderness, fluctuance, mobility, texture, and pulsatility. If the patient describes nipple discharge that is not immediately visualized, it is appropriate to ask the patient to try to express the discharge themselves before the clinician attempting to do so.
  • Following palpation of the breast – the clinician must always palpate the axilla and supraclavicular region for lymphadenopathy. This area may present with enlarged, tender, or firm nodes, the number, and nature of which should be documented. During the examination of the axilla, the weight of the patient’s arm should be taken by the clinician to relax the pectoralis muscles.

Fibroadenoma most commonly occurs in the upper outer quadrant of the breast. On physical examination, it has the following features:

  • Non-tender or painless
  • Mobile
  • Solitary
  • Rapidly growing solid lump with rubbery consistency and regular borders.

After a thorough history and physical examination, the following imaging modalities are used for the diagnosis of fibroadenomas.

  • Mammography – The yield of mammography in young women is low, and its role in the diagnosis of fibroadenomas is limited. However, it may disclose features of infiltrative lesions in older women. In the mammographic image, fibroadenomas appear as soft, homogenous, and well-circumscribed nodules, and inner coarse calcifications are often observed.
  • A mammogram uses x-rays – to evaluate the suspicious masses in women above 35 years of age. Fibroadenoma on a mammogram appears as a distinct area from other breast tissue, with smooth round edges.
  • Mammographic features – of fibroadenomas are variable from a well-circumscribed discrete oval mass hypodense or isodense of breast glandular tissue to amass with macro lobulation or partially obscured margins. Involuting fibroadenomas in older, typically postmenopausal patients may contain calcification, often producing the classic, coarse popcorn calcification appearance.
  • Breast Ultrasound – Ultrasound (US) uses sound waves to detect the features of fibroadenomas in women younger than 35 years of age. US easily differentiates solid from cystic masses. On US, a fibroadenoma is typically seen as a well-circumscribed, round to ovoid, or macrolobulated mass with generally uniform hypoechogenicity.
  • Triple testing – a combination consisting of clinical examination, imaging, and excision biopsy – is essential for all women with a clinical finding such as a discrete palpable mass. Nodularity in young women less than 30 years of age may have management with clinical surveillance and short term follow up examination in 2 to 3 months. An investigation may be necessary if the lump has changed on review or if at the initial presentation, there is a new change in her breasts. Nodularity or thickening that is asymmetric in women over the age of 30 years, further investigation utilizing mammography and ultrasound, is warranted.
  • Short-term follow-up – is an important part of the management of nodularity so that the progression in size of a mass of nodularity or other associated findings (e.g., skin or nipple changes) is detected.
  • Mammography – with ultrasound examination is required for all discrete palpable lesions in women over the age of 35 to distinguish cysts from solid lesions. Complex cysts containing both fluid and solid matter require biopsy. For solid lesions, radiographically or ultrasonically directed core biopsy provides further information regarding the presence or absence of malignancy.
  • Core excision biopsy – involves a cutting needle with a spring-loaded, automated biopsy instrument which allows sufficient specimen/ tissue for histologic analysis. If necessary, a minimally invasive biopsy may be performed via a core needle biopsy
  • FNA allows a cytopathologist – to evaluate cellular material. However, the amount of material retrieved during FNA procedures being sufficient for diagnosis is non-successful in 35 to 47% of non-palpable lesions. A core biopsy is then the recommendation.
  • Cytology of nipple discharge – has limited specificity and sensitivity to detect malignancy (35 to 47%). If the results of both clinical and diagnostic evaluations are benign, a 6 to 12-month clinical breast examination, ultrasound, and mammography is the suggested follow-up to confirm a stable appearance.
  • MRI – can also be useful in the assessment of a new breast lump. It is not routinely used as it is more expensive with longer wait times but shows high sensitivity for detecting and delineating breast masses. It is the preferred modality for patients who have had previous breast augmentation surgery as the breast implants can distort the underlying parenchyma in mammography or ultrasound. It may also be a recommended approach for high-risk patients, such as those with known underlying BRCA mutations.
  • Baseline blood tests –  are usually recommended in a patient who is likely to undergo surgery, with particular emphasis on hemoglobin, bone profile, and liver function tests in case of suspected hepatic metastasis. Inflammatory markers and blood cultures should be considered where a breast abscess is suspected. Tumor markers such as Ca27.29 and Ca15-3 can be used for prognostication and monitoring for recurrence.
  • Nuclear medicine PET scanning, and bone isotope scanning – may help to assess the metastatic disease. Genome-mapping may be an option, for example, if a patient is suspected of carrying the BRCA1 or BRCA2 gene.
  • Core needle biopsy – A radiologist with guidance from an ultrasound usually performs this procedure. The doctor uses a needle to collect tissue samples from the lump, which go to a lab for analysis.
  • Fine-Needle Aspiration Cytology (FNAC) or core biopsy – Cytology allows an analysis of cells in isolation, while histological examination of a biopsy can provide more detail about the architecture of tissues. Both of these are invasive procedures involving risks to the patient and should, therefore, only take place when the index of suspicion is present. The decision whether to perform FNAC or core biopsy depends on several factors, including the expertise of the clinician, available diagnostic equipment, and site of the lesion. However, FNAC is generally preferred as first-line since it is less invasive.The need for pathological analysis has undergone review and, in certain cases, is thought to be unnecessary if the physical examination and radiological assessments are negative in a patient of low risk (i.e., young patients under the age of 25). The decision to proceed with FNAC or core biopsy is a clinical one, but in all cases should not be undertaken without due consideration of the risk-benefit analysis.
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Imaging reports are standardized using a tool called BIRADS – Breast Imaging Reporting and Data System (fifth edition). This standard allows breast imaging to be described according to a certain structure as follows: density of breast tissue, presence and location of a mass or masses, calcifications, asymmetry, and any associated features. This classification system divides patients into categories 0 to 6, depending on the likelihood of malignancy in the obtained images:

  • BIRADS 0 – insufficient or incomplete study
  • BIRADS 1 – normal study
  • BIRADS 2 – benign features
  • BIRADS 3 – probably benign (<2% risk of malignancy)
  • BIRADS 4 – suspicious features (divided into categories 4a, 4b and 4c depending on the likelihood of malignancy)
  • BIRADS 5 – probably malignant (>95% chance of malignancy)
  • BIRADS 6 – malignant (proven malignant on tissue biopsy)

The BIRADS system includes different classifications for masses depending on the imaging modality in question. In mammography, to be considered a mass, the lesion must be visible in two different projections, must have convex outer borders, and must be denser in the center than on the periphery. In ultrasound, a mass requires visualization in two different planes. Masses are defined according to their shape, margin, and density. In terms of shape, a mass can categorize as round, oval, or irregular. Circumscribed margins are more apt to be benign, whereas microlobulated, indistinct, or spiculated are more likely to be malignant. The margin may also appear obscured. Mass density is described in comparison to that of the surrounding normal tissues – higher, equal, or lower – or may reflect the presence of fat within the mass.

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Treatment of Breast Lumps / Masses

Treatment of a new breast lump depends on whether the lump is benign or malignant, and on the physical health and personal wishes of the patient

Any patient with a proven or suspected malignant mass should receive management with an interprofessional approach, with input from the oncology, radiology, pathology, surgical, specialist nursing, and anesthetic teams, as well as palliative care, social workers, and psychology teams where indicated. Breast cancers are typically treated through a combination of surgery, chemotherapy, radiation therapy, hormone therapy, and immunological therapy. The specific treatments of breast cancer are outside of the scope of this article.

Benign breast masses are treated according to etiology:

  • Breast cyst – A simple breast cysts usually involute without any intervention. If persistent or troublesome cyst aspiration may be an option, however, they tend to recur. Cyst aspirate may be sent for cytological analysis, but there is some controversy as to the benefit of this due to the risk of false-positives.
  • Fibroadenoma – These lesions are benign and usually involute without requiring any further treatment. However, surgical consultation should be considered if they are large, painful, or causing the patient distress, and these are often removed surgically. If there is diagnostic uncertainty, excision biopsy should take place for diagnostic purposes.
  • Fat necrosis, hematoma – This usually does not require any treatment other than analgesia and monitoring. However, the surgical consultant should merit consideration if the mass is causing the patient, significant pain, or cosmetic issues.
  • Breast abscess – In general, abscesses require surgical incision and drainage to identify and remove the source of infection. Smaller abscesses less than 3cm in size and lactational abscesses may resolve with oral antibiotics and needle aspiration, but there is a risk of recurrence. In the primary setting, lactational abscesses should have treatment with analgesia and oral antibiotics, and patients should be encouraged to continue breastfeeding if possible, with an onward referral for definitive management. Abscess in a non-lactating patient, or an unresolved, large or multiloculated abscess may require admission for intravenous antibiotics and surgical or radiological drainage, and early breast specialist opinion should be sought in these cases. Abscesses in a non-lactating female requires referral to a triple assessment clinic to rule out underlying inflammatory breast cancer.
  • Gynaecomastia – In males presenting with gynecomastia, the investigation should focus on the likely cause, and if none can be found, further referral to endocrinology is recommended.

References

 

 

 

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