Latest Approach to the diagnosis of a Breast Lump,focusing on triple assessment for the diagnosis

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