Symptoms: Pain- dull or sharp, burning; diffuse or local, such as periareolar or upper outer quadrant. Sensation of fullness. The timing is typically cyclical, (increasing toward ovulation) in pre-menopausal or in relation to hormone replacement therapy schedule, in post-menopausal. A discrete mass or a generalized "thickening" may be felt by the patient especially upper outer quadrant or supra-areolarly.

Exam: bilateral diffuse tender modularity, or localized "thickening." A distinct mass may also be felt-these tend to be discrete and mobile with respect to the skin and muscle fascia, and tender. The mass on occasion however, may be indistinguishable from malignancy!

Work-up: obtain bilateral mammogram in patient over 30. Further work up in these patents dependent upon exam and mammogram and may include further testing discussed below. In younger patients the work up may be more individualized, as mammograms are not as accurate in dense breasts. This may include ultrasound, sestamibi scan, or MRI.

Treatment: If physical exam and radiographic work-up are negative, patient reassurance with explanation of the disease process is acceptable. Patients should be considered for re-examination after a couple of menstrual cycles. Other options include non-steroidal anti-inflammatory drugs, caffeine abstention, low salt diet, mild diuretics, Vitamin E, and Evening Primrose Oil.

Refer to specialist for suspicious physical and/or radiologic findings or if the pain persists through several cycles or remains unresponsive to the above measures and always, if patient expresses concern about malignancy!

Breast cysts

Masses felt to be cysts on mammogram or clinical exam should be confirmed with either an ultrasound or an aspiration. If ultrasound shows cyst, consider aspiration either free hand or under ultrasound guidance, if cyst is simple and larger than 12-15 millimeters or if complex or if symptomatic.

Refer to specialist: If cyst is complex on ultrasound
If aspiration is bloody (non-clotting)
If residual mass is present after aspiration

Cyst fluid routinely does not have to be sent for cytological evaluation.

Solid Masses

Masses felt to be solid on mammogram and ultrasound should be referred to specialist for consideration of tissue diagnosis under virtually all circumstances. Tissue can be obtained by fine needle aspiration, ultrasound directed core biopsy, or stereotactic core needle biopsy. The referring physician should have a copy of the pathology report for his records if tissue was obtained.

Breast Masses

Juvenile
Pre-menopausal women
Post-menopausal women

Issues in the management of breast lumps: 1) The possibility of breast cancer should always be considered in the latter two groups. 2) The physical exam is the major modality in diagnosing breast lumps 3) The clinical exam and diagnostic studies must be done in synchrony. A well thought out plan of follow up is imperative if tissue diagnosis is not entertained at the time. 4) Keep in mind the fear generated in the minds of women presenting with breast lumps. Repeated examination and reassurance are an integral part of the patients management 5) Refer to specialist for long term evaluation and follow up of any, abnormal mammographic, physical, or psychological finding. This includes virtually any mass which the woman finds herself (i.e. high anxiety level).

Juvenile Masses

Fibroadenoma, juvenile hypertrophy, phylloides tumor, nonspecific mastopiathy

Rx: Reassurance with interval observation possible with most of these masses. Ultrasound, not mammogram, is reasonable for work-up. Phylloides tumors diagnosed by FNA or core biopsy, should be excised.

Refer: if mass appears to be growing more rapidly than rest of breast particularly if noted by the patient. Refer if there are signs and symptoms of infection (abscess, bite marks) or signs of trauma.

Pre-menopausal breast masses Cysts, fibroadenomas, localized fibrocystic breast disease, carcinoma, abscess, fat necrosis, other

Work-up: obtain a mammogram if patient older than 30, perhaps ultrasound if younger. Consider a correlation test such as ultrasound to determine whether mass is solid or cyst. Consider tissue diagnosis, such as Fine Needle Aspiration, core needle biopsy, for solid mass and consider cyst aspiration if cyst > 12 mm. or if complex. If mass is appreciated by physician first, see above, but may safely consider an interval follow up or no longer than six months if work-up is negative. If mass was detected on screening mammogram, follow guidelines as above.

Post Menopausal Breast Masses Fibrocystic breast disease, cyst, carcinoma, lipoma, other.

Work up: mammogram and possibly ultrasound to determine whether solid or cystic. Tissue diagnosis usually obtained for all solid masses, whether seen mammographically or palpated. This may include fine needle aspiration or core biopsy for palpable masses, or image guided core biopsy (ultrasound, stereotactic, for non-palpable masses.

Special Concerns

1) Woman presents with a "thickening": H&P, mammogram. Ultrasound (although recommended by many radiologists) is frequently not helpful. Refer for tissue diagnosis if exam or mammogram is suspicious. Re-evaluate patient after a couple of menstrual cycles if work-up is negative, (**Always remember, lobular carcinoma may only present as a thickening with a negative mammogram). Be very liberal with referral to a specialist here particularly with peri or postmenopausal patient.

2) Pregnant or lactating woman who feels a lump - referral to breast specialist is mandatory, immediately!

3) Patient expresses concern about malignancy, even though the work-up is negative: Refer!

Another take-home message: It is now possible to diagnose virtually any clinically palpable mass or mammographic abnormality non-surgically. This will save an enormous amount of health care dollars. However, unless you have superb mammographic and surgical skills, and want to assume the growing liability risk of misdiagnosing a breast cancer, the diagnosis and subsequent follow up should be done by a surgical breast specialist.