Evaluating Breast Masses in Adults

INTRODUCTION

Breast mass complaints are common in the clinical setting and physicians should be comfortable performing breast mass evalu- ations. One study found that 40% of breast complaints in women aged 40-69 were for breast lumps or masses.4 The discovery of a breast lump can cause significant anxiety and distress to the pa- tient. Fortunately, approximately 90% of masses are benign in women in there 20’s to early 50’s, with fibroadenomas and cysts being the most common benign masses.4,5 See Table 1 for types of breast masses.

The overall incidence of breast cancer has decreased by 0.9% and mortality decreased by 2.1% from 2000-2009. According to the CDC, the incidence of breast cancer still remains the most com- mon cancer diagnosed in women.6 It is important to work-up any breast mass in a thorough and concise process to prevent missed diagnoses and also to ensure an early diagnosis. Being diagnosed with a breast mass can be quite frightening to a patient and effi- cient management could greatly help alleviate worry and stress for the patient.

EVALUATION

The evaluation of a patient with a breast lump requires a thorough medical history of the lump, including when and how the patient discovered the lump, progression of size, and any associated symp- toms.8 It is also important to identify and assess any risk factors for breast cancer, including age, race, family history, smoking and various others (See Table 2). In 2009, the United States Preven- tive Services Task Force (USPSTF) recommended against routine self-breast examinations (category D). However, the January 2016 USPSTF breast cancer screening guidelines removed self-breast examination recommendations as it now supports patients being aware of changes in their bodies and discussing these changes with their clinicians.9

PHYSICAL EXAM

A thorough clinical breast exam (CBE) is imperative in assessing a breast mass. The physician should start the CBE by looking at both breasts and noting any abnormalities or asymmetry. The visual in- spection typically starts with the patient in the sitting position. The patient should be asked to place her arms above her head, as this may cause dimpling from a fixed mass. A mirror is sometimes help- ful to look at the inferior portions of the breast. The breasts should then be checked for skin color changes, texture changes, skin thick- ening, dryness, and temperature changes.11,12 The nipples should be checked for inversion and the areola should be checked for rela- tive symmetry as these may be signs of an underlying mass. Only after a thorough visual exam should the physician then palpate the breasts. The visual exam portion may give important clues to sur- face area differences and help the clinician be more specific and attentive to a certain area during palpation. The palpation portion of the CBE should be performed while the patient is in the supine position. Palpation of breasts should be performed in a systematic fashion by following a linear or circular pattern. It is considered good practice to overlap palpations so as not to miss any areas. Ax- illary, supraclavicular, and infraclavicular lymph nodes should also be palpated in this systematic process. Finally, the nipples should be expressed to check for any nipple discharge or bleeding.

IMAGING

Mammography

Plain x-ray mammography is the most common imaging modality used for both screening and diagnostic purposes. The latest 2016 breast cancer screening guidelines by the USPSTF recommends a screening mammography every two years for women aged 50 to 74 years (Grade B). For women under 50, the decision to start screening mammography should be an individual one (Grade C).9 If a mass is found on screening mammography or on the CBE, a diagnostic mammogram should be ordered as the first line testing for women over the age of 30.7,10 If a breast mass is identified in a woman under 30, mammography is not the first line choice for di- agnostic purposes due to the generally increased density of breast tissue in this group.

Mammograms can pick up two types of lesions: soft tissue mass- es and clustered micro calcification masses. Radiologists use the Breast Imaging-Reporting and Data System (BI-RADS) criteria to assess whether a mass is benign or potentially malignant.12 The BI- RADS system was developed by the American College of Radiol- ogy to describe mammographic findings (See Table 3).

Mammograms may also be useful to the surgeon in determining the location and size of the mass. Further, preoperative mammograms can aid in the follow-up assessment of the postoperative course.7

Some clinicians may tend to perform the CBE quickly due to the sensitive and potentially embarrassing nature of the exam. How- ever, it should be noted that more extensive exams tend to be more thorough and allow more masses to be identified.13 The CBE alone detects up to 10% of breast cancers while more than 90% of breast cancers are found through mammograms.14 It is impor- tant to be reminded that discovering a mass on the CBE does not mean other masses do not exist. Therefore, it is important to order a mammogram in conjunction with the CBE at all times. It is also important to note that imaging does not always detect all masses. In fact, 10-15% of breast masses are not seen on mammography.15 Therefore, both CBE and mammograms are recommended in con- junction for any breast mass evaluation.

TABLE 3:

BI-RADS Assessment Categories

Ultrasound

Any female under the age of 30 should have masses evaluated by ultrasound due to the dense nature of breasts in young females.16 Ultrasonography can help determine whether a mass is solid or fluid filled (cystic) and has been shown to be remarkably accurate. In one study, breast ultrasonography demonstrated a sensitivity of 98.4% for correctly classifying a breast mass as malignant or in- determinate.17 If found indeterminate, a mammogram should be performed next.

MRI

MRI with gadolinium enhances most invasive breast cancers.7,18-21 MRIs are probably the best radiologic method to assess the size and location of a breast mass, which would give beneficial informa- tion to the surgeon, especially if other modalities fall short.22 One study found the sensitivity of MRI for malignant breast masses to be 100%.15 However, the specificity of MRI is relatively low; around 70%.23-25 Since all suspicious breast masses should be biop- sied, the addition of an MRI is not critically necessary or cost effec- tive in the evaluation of breast masses.23

MRI does play a role for patients with silicone breast implants whose mammographic images are fully or partially obscured. MRI gives the highest spatial resolution and contrast between implants and soft tissues of the breast.

Biopsy

Fine Needle Aspiration (FNA) biopsy is commonly used as a tech- nique for breast mass biopsy because any trained clinician can perform it in the office setting. The procedure is not difficult to perform and is easily done in the family physician’s office. Most of- ten, FNA is performed with skilled palpation, but may also be per- formed under ultrasound guidance. Good FNA technique has 98% sensitivity and 97% specificity when performed by skilled opera- tors.26 The procedure is usually done with a 10-20 ml syringe with a 23-27 gauge needle. The fine needle is systematically advanced in and out of the mass multiple times, collecting tissue specimens. If aspirated fluid is clear and not bloody, the fluid does not need to be sent for cytology and can be discarded. Bloody or blood-tinged contents should be collected in a CytoLyte solution and sent for a pathologic analysis.27

Core needle biopsy is similar to the FNA biopsy but a larger needle is used, usually a 14-18 gauge cutting needle. This technique is more advantageous due to the collection of larger tissue samples. However, core needle biopsies require larger volumes of local an- esthesia and have an increased risk of bleeding compared to FNA biopsies, due to larger needle sizes. Ultrasound imaging is usually used for better accuracy and therefore, core needle biopsies are usually done by a surgeon or an interventional radiologist.

An excisional biopsy is usually performed when FNA biopsy, core needle biopsy, or imaging provides insufficient results.7,12,28 It is the most definitive method for histological analysis of a breast mass. An incisional biopsy can be done when the mass is very large and the patient is concerned about cosmetic effects. However, most patients opt for the excisional biopsy because they feel more comfortable having the mass completely removed. Cysts or micro- cysts are not indications for an excision due to possible interference with future mammograms.7,10,29 However, excision is indicat- ed whenever cysts reoccur, grow large, are complex, or if needle aspirations show malignancies.

CONCLUSION:

Although most breast masses are benign, a physician should evaluate all breast masses swiftly and properly. The incidence of breast cancer may be declining, but it still remains the second most common form of female cancer.1 The controversy of recom- mending for or against self-breast examinations has largely been resolved as both the United States Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gyne- cologists (ACOG) have recently taken more neutral positions that self-identified breast masses should be discussed with a clinician and may help in detecting breast cancer. Therefore, the authors do not recommend teaching and instructing patients to perform routine self-breast examinations. The Triple Test (clinical breast exam, imaging, and tissue samples) should be used for diagnos- ing breast masses and to alleviate any anxiety and doubt for a patient.12 Biopsy and tissue sample analysis remain the gold stan- dard for making a definitive diagnosis and can be easily performed in the outpatient setting. The evaluation of a breast mass should not be delayed. A specialist referral is not a requirement in the early stages. Any primary care physician can initiate the work-up, and with proper training perform the biopsy in the office setting. Unsuccessful biopsies or lesions suspicious for malignancy upon work-up warrant an immediate referral to a breast surgeon. See Figure 1 for evaluation algorithm.

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