creation date: 2026-01-05 14:53
tags: Workups
Breast Mass
Background
A palpable breast mass is the most common presenting symptom of breast cancer although many cases are benign. As such, careful evaluation is warranted.
It should be noted that while the majority of breast masses are present in adult women, children and men are also affected and thus suspicion should be maintained.
Pathophysiology
Pathophysiology depends on the condition. Notably, two anatomical/physiologic factors contribute to evaluation of the masses:
- Density variation: denser breasts, which is associated with younger patients, make evaluation with mammography more difficult
- Hormonal changes: such as menstrual cycle may be involved in etiology
Differential Diagnosis
Benign
The majority of cases are:
- Fibroadenoma - smooth, round, rubbery, mobile mass; typically young woman
- Breast cyst - mobile, often tender; fluctuates with menstrual cycle and high suspicious for malignancy in postmenopausal women
Less common causes are:
- Fat necrosis
- Intraductal papilloma
- Phyllodes tumour
- Breast abscess
Premalignant
- Atypical ductal hyperplasia
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
Invasive Cancer
Types of breast cancer include:
- Ductal carcinoma (most common)
- Lobular carcinoma
- Medullary carcinoma
- Tubular carcinoma
Two rare and differently presenting types are:
- Inflammatory breast cancer (lymphatic invasion causing erythema, pain, peau d’orange)
- Paget’s disease (unilateral nipple-areolar dermatitis/ezcema)
Initial Evaluation
History
History should include:
- Lump characteristics including changes in size, changes relative to menstrual cycle, associated symptoms (pain, swelling, redness, fever, discharge)
- Diet and medications (incl. HRT)
Risk factors for cancer should be determined including:
- Family history
- Personal medical and surgical history
- Menstrual and childbearing history
- Trauma and radiation therapy
Physical Exam
A complete clinical breast exam should be performed. This is best done the week following menses when breast tissue is least engorged.
Reassuring findings include:
- No skin changes
- Mass is smooth, soft-to-firm, mobile, with well-defined margins
- DIffuse symmetric thickening in upper outer quadrants may suggest fibrocystic changes
Findings suggestive of malignancy include:
- Mass is hard, immobile, fixed to surrounding skin and soft tissue, with poorly defined or irregular margins
Investigations
Imaging
If a patient age <30 years:
- Return 3-10 days following onset of menses for possible regression
- Ultrasound (can consider mammogram but not ideal due to breast density)
If a patient is age >30 years: - Mammography + ultrasound
Ultrasound
- Effective for distinguishing solid masses from cysts
- Sensitivity 89%, specificity 78% for detecting abnormalities
Simple cysts (well-circumsized, anechoic, round or oval, with thin walls) are typically benign while complex cysts or solid masses may be malignant and warrant further workup.
Mammography
- Distinguishes malignancy and screens for occult disease in surrounding tissue
- Sensitivity 87%, specificity 88% for detecting cancer
Biopsy
If suspected malignancy, follow-up evaluation may consist of:
- Fine-needle aspiration
- Core-needle biopsy
- Excisional biopsy (gold standard)
Findings
The triple test, which combines the results of the clinical breast exam, imaging, and biopsy, has nearly 100% diagnostic accuracy.
A triple test score (TTS) can be used to combine results.