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Breast Mass

Basics

Description

- Breast abscess - Peripartum - Milk stasis - Staphylococcus aureus

- Fibrocystic nodules - Tender nodules that wax and wane with menstrual cycle - Pruritic pain radiating to axilla

  • Breast masses are delineated into 4 categories: Acute abscesses, benign physiologic masses, benign tumors, and cancer.
  • Benign masses include cysts, galactoceles, papillomas, fibroadenomas, phyllodes tumor, and fibrocystic nodules.
  • Cancerous masses are typically painless, dominant masses that persist.

Risk Factors

  • Breast abscess
  • Galactoceles
  • Fibroadenoma, papilloma, phyllodes tumor, and fibrocystic nodules
  • CancerSee "Breast Cancer" chapter

Pathophysiology

  • Breast abscessPeripartumMilk stasisStaphylococcus aureusNon-peripartumSquamous metaplasia and chronic fibrosis
  • Galactocele

Diagnosis

History

  • Last menstrual cycle
  • Relationship to menses
  • Tenderness
  • Response to NSAIDs
  • Termination of lactation
  • Smoking
  • Family history of cancer
  • Signs and symptoms:Breast abscessPainful massFeverSwellingGalactoceleMass during or after lactationFibroadenoma and benign tumorsUsually persistent painless massFibrocystic nodulesTender nodules that wax and wane with menstrual cyclePruritic pain radiating to axillaPapilloma

Physical Exam

  • Any erythema, edema, and a tender dominant mass favor breast abscess.
  • A tender mass without erythema and edema favors a fibrocystic nodule or cyst.
  • A discreet mobile nontender nodule favors a benign tumor (i.e., fibroadenoma).

Tests

Imaging

  • Ultrasound for all ages
  • Mammogram for patients over 30 or at an age 10 years younger than the age at which a first-degree relative developed breast cancer
  • MRI for dense breasts where the clinical suspicion for cancer is high and mammogram and/or ultrasound are inconclusive.

Surgery

  • Ultrasound-guided core needle biopsy for solid masses
  • Ultrasound-guided aspiration for fluid-filled masses, including early, simple abscesses
  • Simple cysts typically do not require intervention unless palpable and/or symptomatic.
  • Incision and drainage for large or complex breast abscesses

Pathological Findings

  • Pathologic evaluation of a core needle biopsy effectively diagnoses the underlying lesion.
  • Cytologic evaluation of a fine needle aspiration for a solid mass is less accurate, and cytologic evaluation of benign cyst contents is often misleading.

If pathologic findings and imaging or physical exam are nonconcordant, then a definitive surgical biopsy is needed.

Differential Diagnosis

The diagnoses discussed represent the most common differential diagnosis.

Treatment

Medication

Tamoxifen at 10 mg/day has been used in refractory mastalgia.

Additional Treatment

General Measures

The most important intervention is an accurate diagnosis.

Issues for Referral

  • Nonresolving breast cellulitis
  • Persistent mass
  • Lack of concordance between core biopsy and exam
  • Any mass with chest wall/skin fixation
  • Recurrent breast abscess

Complementary and Alternative Medicine

  • Use of evening primrose oil (gamma linolenic acid) has been shown to have a clinically useful response rate of 58% at 3 g/day per package recommendations for cyclic mastalgia (1)[B].
  • Adverse symptoms of mild GI upset in <2% of patients.
  • Daily vitamin E has been shown to have near equivalent response rate as EPO at 1,200 IU/day (2)[B].

Surgery

Indications for surgery:

  • Phyllodes tumorsSurgical excision with margins required to define benignity and reduce recurrence
  • Fibroadenoma, papilloma, hamartoma, lipomaSurgical excision for symptoms or enlargement
  • Breast abscessSurgical incision and drainage for complex or large abscesses.
  • Fibrocystic nodules and galactocelesSurgical excision not recommended unless there is a concern for missed malignancy.
  • Lack of concordance between exam and core biopsy

Admission Criteria

Nonresolving breast cellulitis may require inpatient therapy with IV antibiotics.

Nursing

For galactoceles and postpartum breast abscess, maintenance of nursing is recommended.

Ongoing Care

Follow-Up Recommendations

Fibroadenomas, papillomas, and hamartomas require 6-month follow-up imaging with mammogram and ultrasound to document stability at a 6-month interval for 1-2 years.

Diet

Cysts: Avoidance of products with methylxanthines has been shown to decrease mastalgia and the fibrocystic masses and gross cysts associated with the process.

Prognosis

  • FibroadenomaThe risk of a recurrence is minimal with adequate excision.For nonexcised lesionAbout 50% will disappear in 5 yearsIn postmenopausal women, they should be stable or diminish in size.
  • If a fibroadenoma in a postmenopausal woman enlarges, it should be removed.
  • Hamartomas, lipomas, and papillomas have an excellent prognosis with or without excision.
  • A breast abscess treated definitively is unlikely to recur.
  • Galactoceles usually resolve without surgical intervention.
  • Cysts seen on mammography will regress, more than 1/2 by the first year and more than 2/3 by the second year, leaving only 12% after 5 years.

Complications

Error in diagnosis is the major complication and can be avoided by a core biopsy and concordance evaluation.

References

1Gateley CA, Miers M, Mansel RE. Drug treatments for mastalgia: 17 years of experience in the Cardiff Mastalgia Clinic. J R Soc Med. 1992;85(1):12-15. [View Abstract]2Pruthi S, Wahner Roedler DL, Torkelson CJ. Vitamin E and evening primrose oil for management of cyclical mastalgia: A randomized pilot study. Altern Med Rev. 2010;15(1):59-67. [View Abstract]

Additional Reading

1Brenner RJ, Bein ME, Sarti DA. Spontaneous regression of interval benign cysts of the breast. Radiology. 1994;193:365-368. [View Abstract]2Cant PJ, Madden MV, Coleman MG. Non-operative management of breast masses diagnosed as fibroadenoma. Br J Surg. 1995;82:792-794. [View Abstract]3Cowen PN, Benson EA. Cytological study of fluid from breast cysts. Br J Surg. 1979;66:209-211. [View Abstract]4Hindle WH, Arais RD, Florentine B. Lack of utility in clinical practice of cytologic examination of nonbloody cyst fluid from palpable breast cysts. Am J Obstet Gynecol. 2000;182:1300-1305. [View Abstract]5Santeen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353:275-285.6Singletary SE, Robb GL, Hortobagyi GH Advanced therapy of breast disease, 2nd ed. Ontario, BC: Decker Inc, 2004.

Codes

ICD9

  • 217 Benign neoplasm of breast
  • 611.0 Inflammatory disease of breast
  • 611.72 Breast mass
  • 174.9 Malignant neoplasm of breast (female), unspecified
  • 610.0 Solitary cyst of breast
  • 611.5 Galactocele
  • 610.2 Fibroadenosis of breast

ICD10

  • D24.9 Benign neoplasm of unspecified breast
  • N61 Inflammatory disorders of breast
  • N63 Unspecified lump in breast
  • D24.1 Benign neoplasm of right breast
  • D24.2 Benign neoplasm of left breast
  • C50.919 Malignant neoplasm of unsp site of unspecified female breast
  • C50.911 Malignant neoplasm of unsp site of right female breast
  • C50.912 Malignant neoplasm of unspecified site of left female breast
  • N60.09 Solitary cyst of unspecified breast
  • N64.89 Other specified disorders of breast
  • N60.29 Fibroadenosis of unspecified breast

SNOMED

  • 89164003 breast lump (finding)
  • 28432003 abscess of breast (disorder)
  • 269485000 benign tumor of breast (disorder)
  • 254837009 malignant tumor of breast (disorder)
  • 399294002 cyst of breast (disorder)
  • 42385006 lactocele (disorder)
  • 254848002 duct papilloma of breast (disorder)
  • 254845004 fibroadenoma of breast (disorder)

Clinical Pearls

  • A dominant breast mass requires an ultrasound and a mammogram.
  • A solid breast mass can be diagnosed definitively by ultrasound-guided core biopsy.
  • Cystic lesions must resolve completely with aspiration, or further diagnostic intervention is required.