gynecology and obstetrics
Breast Masses (Breast Lumps)
Evaluation of Breast Masses
History of present illnessshould include how long the mass has been present, whether the size is constant or varies, and whether the mass is painful. Previous occurrence of a mass and the outcome of its evaluation should be queried. Review of systemsshould determine whether nipple discharge is present and, if present, whether it is unilateral, spontaneous or only in response to breast manipulation and whether it is clear, milky, or bloody. Symptoms of advanced cancer (eg, weight loss, malaise, bone pain) should be sought. should include Risk Factors , including previous diagnosis of breast cancer, history of radiation therapy to the chest area before age 30 (eg, for Hodgkin lymphoma). Family history should note breast cancer in a 1st-degree relative (mother, sister, daughter) and, if family history is positive, whether the relative carried one of the inherited gene mutations that predispose to breast cancer (eg, Examination focuses on the breast and adjacent tissue. The breast is inspected for skin changes over the area of the mass, nipple inversion (retraction), and Nipple Discharge . Skin changes may include erythema, eczematous appearance, edema, or dimpling (sometimes termed peau d’orange [orange peel]). The mass is palpated for size, tenderness, consistency (ie, hard or soft, smooth or irregular), borders (well-defined or nondiscrete), and mobility (whether it feels freely mobile or fixed to the skin or chest wall). The axillary, supraclavicular, and infraclavicular areas are palpated for masses and adenopathy. Certain findings are of particular concern: Mass fixed to the skin or chest wall Stony hard, irregular mass Skin dimpling Thickened, erythematous skin Bloody or spontaneous nipple discharge Matted or fixed axillary lymph nodes Painful, tender, rubbery masses in women who have a history of similar findings and who are of reproductive age suggest fibrocystic changes. Red flag findings suggest cancer. However, the characteristics of benign and malignant lesions, including presence or absence of risk factors, overlap considerably. For this reason and because failure to recognize cancer has serious consequences, patients require testing to exclude breast cancer more conclusively. Initially, physicians try to differentiate solid from cystic masses because cysts are rarely cancerous. Typically, ultrasonography is done first. Lesions that appear cystic may be aspirated (eg, when they cause symptoms). Fluid aspirated from a cyst is sent for cytology if It is turbid or grossly bloody. Minimal fluid is obtained. A mass remains after aspiration. If these findings are present, mammography followed by imaging-guided core needle biopsy is done. Patients are reexamined in 4 to 8 weeks. If the cyst is no longer palpable, it is considered benign. If the cyst has recurred, it is reaspirated, and any fluid is sent for cytology regardless of appearance. A third recurrence or persistence of the mass after initial aspiration (even if cytology was negative) requires biopsy. Solid masses are evaluated with mammography followed by imaging-guided core needle Breast Cancer Screening and Prevention . Surgical biopsy is done if image-guided biopsy is not possible because the lesion is too close to the skin or chest wall, if the patient cannot maintain the position needed for needle biopsy, or if the patient prefers surgical biopsy. 