From: Subject: Best Dx/Best Rx: Breast Mass Date: Wed, 3 Jun 2009 23:03:53 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_00A1_01C9E49F.90E92020" X-MimeOLE: Produced By Microsoft MimeOLE V6.00.2900.5579 This is a multi-part message in MIME format. ------=_NextPart_000_00A1_01C9E49F.90E92020 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: mhtml:file://C:\pocketnotes\breastmass2007.mht Best Dx/Best Rx: Breast Mass

Breast = Mass

Valerie L. Staradub, = M.D.
Harvard=20 Medical School

Monica Morrow, M.D.,=20 F.A.C.S.
Foxchase Cancer Center

Defin= ition/Key=20 Clinical Features
Diffe= rential=20 Diagnosis
Best = Tests
Best = Therapy
Best = References

Definition/Key=20 Clinical Features=20

  • Changes in breast nodularity are distinguished = from=20 normal nodular breast tissue by three criteria (i.e., borders, = mobility, skin=20 changes) and a texture different from that of the adjacent normal=20 breast
Benign Mass=20
  • Well-circumscribed borders=20
  • Firm and rubbery texture=20
  • Mobile=20
  • No skin changes=20
  • No nipple changes
Malignant Mass=20
  • Irregular borders=20
  • Hard texture=20
  • Fixed to surrounding tissue=20
  • Evident dimpling and retraction=20
  • Bloody discharge from or scaling of = nipples=20

3D""bac= k to=20 top
Differential=20 Diagnosis=20
  • Breast nodularity=20
  • Cystic masses=20
  • Fibroadenomas=20
  • Phyllodes tumors
Clinical Pearls=20
  • Cysts are frequent during perimenopause =
    • Well-circumscribed, firm masses with = well-demarcated=20 borders=20
    • Associated with a history of menstrual-cycle = variation
  • Fibroadenomas are a frequent cause of breast = mass=20
    • Occur most often in younger women=20
    • Typically firm, rubbery, well-circumscribed, = nontender, and very mobile
  • Phyllodes tumors are suggested by a rapid = change in mass=20 size

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Best=20 Tests=20
  • History=20
    • Initial and most important step in diagnosis = is to=20 characterize the mass by determining its duration, fluctuation with = the=20 menstrual cycle, associated tenderness, and any changes in size = since it was=20 first identified by the patient=20
    • An evaluation of the patient's risk for = breast cancer=20 is appropriate (although breast mass characteristics rather than = patient=20 risk for cancer should be the primary determinant of the = workup)=20
  • Physical examination=20
    • To confirm the presence of a mass, the = examination=20 should be conducted in an upright sitting and supine position, with = arms=20 both relaxed and raised over the head=20
    • In the supine position, breast palpation is = performed=20 with the ipsilateral arm placed behind the head to spread the breast = tissue=20 across the chest wall=20
    • Skin or nipple retraction, edema, and = erythema should=20 be noted, as should any size discrepancies
  • Imaging evaluation=20
    • The appropriate imaging/diagnostic workup is = specific=20 to the outcome of the physical examination and should be used to=20 differentiate a cystic from a solid mass=20
    • A directed ultrasound is often the only = required study=20 in women younger than 35 yr; mammography is only recommended if the = mass is=20 considered suspicious for malignancy=20
    • In women older than 40 yr, a diagnostic = imaging workup=20 should be performed, beginning with mammography; if no abnormality = is seen,=20 directed ultrasound should be used to exclude the presence of=20 mammographically occult carcinoma
  • Biopsy=20
    • Solid masses can be diagnosed with FNA = cytology, core=20 needle biopsy, or excisional biopsy
Clinical Pearls=20
  • A triple diagnosis test using physical = examination,=20 imaging studies, and FNA cytology is an alternative to surgical = incision to=20 establish that a mass is benign=20
    • If the mass is not visualized by mammography = or if the=20 FNA contains insufficient cells for diagnosis, the triple test = cannot be=20 confirmatory for a benign lesion
  • An alternative approach is core-needle biopsy, = which=20 provides a histologic specimen that can be interpreted by a general=20 pathologist and a specific histologic diagnosis rather than a simple = =93benign=94=20 classification=20
  • If a breast mass has characteristics = suggestive of=20 carcinoma, a diagnostic mammogram that includes multiple views (not = two=20 standard views, as in screening mammography) is warranted, followed by = needle=20 biopsy (core or FNA) and surgical biopsy if diagnosis remains = unknown=20

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    Best=20 Therapy=20
    • A benign breast mass should be followed for 2 = yr, during=20 which time it is monitored for growth via serial examination and = imaging=20 studies performed every 6 mo=20
    • A suspicious dominant breast mass is best = managed by a=20 lumpectomy that includes excision of some adjacent normal breast = tissue; if=20 the margins are free of cancer, the diagnostic procedure serves as the = definitive breast procedure

    3D""bac= k to=20 top

    Best References

    Ariga R: Am J Surg 184:410, 2002 [PMID = 12433603]

    Dennis MA: Radiology 219:186, 2001 [PMID=20 11274555]

    Kerlikowske K: Ann Intern Med 139:274, 2003 [PMID = 12965983]

    Morris KT: Arch Surg 133:930, 1998 [PMID=20 9749842]

    February=20 2007

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