Management of the Palpable Breast Mass

Richard J. Bleicher

The breast mass is the most common symptom of women presenting to breast centers, accounting for more than half of the complaints. Although most are benign, the presence of a mass can cause considerable anxiety because of the concern for cancer. The most important task of the physician evaluating a breast mass is to exclude the presence of malignancy, and provide an accurate diagnosis.

The presence of a mass should never be dismissed because of young age, male gender, or a lack of risk factors such as a family history of cancer. Diagnostic delays of breast cancer are a common cause for litigation, and such claims are most frequently seen for non-Hispanic white women in their 40s who are premenopausal, married, have a history of fibrocystic change, and who are enrolled in an HMO. Although delays in the diagnosis of a breast cancer may need to be 8 months or longer to be detrimental, no factor should override an expeditious and thorough evaluation, which must provide an explanation that is concordant with the patient’s history, physical examination, imaging, and pathologic findings.

HISTORY

A thorough history is the first step in the proper evaluation of any breast mass. Historical elements must, at bare minimum, include a proper breast history which includes current and prior symptoms, risk factors for cancer, and the patient’s gynecologic and menstrual history. The etiology of previous masses should be detailed, and specifics about any current and prior breast problems must include the character, frequency, severity, and duration of the issue.

Breast evaluation nearly always includes diagnostic imaging. The complete history must therefore include details about mammograms, ultrasounds, and magnetic resonance imaging (MRI), including the dates, findings, and follow-up for abnormalities on these studies. Although annual mammographic screening is currently recommended for average-risk women aged 40 years and older, many patients are either not aware of this recommendation or choose not to follow it. MRI is also recommended as a screening modality only in women whose lifetime risk is =20% to 25% (1), but MRIs are still being used outside this setting.

Other symptoms such as palpable lymph nodes, breast pain, skin changes, nipple inversion, and the character of any discharge (including color, bilaterality, number of ducts involved, and spontaneity) should also be assessed, as these complete the history and may narrow the differential diagnosis. While a complete review of systems is often performed solely to satisfy reimbursement criteria, discussion of other organ systems may contribute substantially to understanding the current illness and to determine a patient’s candidacy for certain treatments, especially if a mass is found to be malignant (Table 4-1).

Past medical history may also shed light on current findings, either clarifying an ongoing process, or suggesting something that can recur over a woman’s lifetime. Mass-forming lesions are listed in Table 4-2. Certain
benign entities may present as a recurring mass, such as pseudoangiomatous stromal hyperplasia, fibroadenomas, duct ectasia, mastitis, or abscess formation.

TABLE 4-1 Examples of Potential Contributions by the Review of Systems

System	Contribution
General	Fever suggests an inflammatory process.
Neurologic	Deficits suggest metastatic disease.
Pulmonary	Cough or compromise clarify operative candidacy.
Cardiac	Compromise may contraindicate operation or anthracycline chemotherapy.
	Inability to lie flat contraindicates whole-breast radiotherapy.
Integument	Nipple changes suggest Paget’s disease. Breast erythema and edema suggest mastitis, or breast cancer that is locally advanced or inflammatory.
	Symptoms of active collagen vascular disease contraindicate radiotherapy.
Musculoskeletal	Back or bone pain suggest metastatic disease.
	Inability to abduct the arm over the head may contraindicate whole-breast radiotherapy.
Gynecologic	Active menses contraindicate aromatase inhibitor administration.
Hematologic	Frequent ecchymosis and bleeding suggest a need for preoperative evaluation.
	Deep venous thrombosis may contraindicate tamoxifen therapy.

A discussion of past surgical history, including breast surgeries and needle biopsies, often reminds patients to mention prior benign conditions such as fibrocystic change, simple cysts, fibroadenomata, and fat necrosis. Knowledge of a patient’s prior breast pathology is important for overall assessment and to help determine their risk of cancer. Often, patients are unfamiliar with specifics of their pathology and simply told that their prior biopsies are “benign,” but this lay description may encompass atypical hyperplasia (a lesion requiring further evaluation if recently diagnosed), lobular carcinoma in situ (LCIS, a high-risk marker), or other entities that confer elevated risk. Pathology reports and/or slides may be of assistance to complete the evaluation if details are uncertain.

TABLE 4-2 Breast Lesions That May Present as a Palpable Abnormality

Abscesses	Idiopathic granulomatous mastitis
Adenopathy	Idiopathic granulomatous mastitis
Amyloidosis	Invasive carcinoma
Duct ectasia	Lactating adenomas
Ductal carcinoma in situ	Lipomas
Epidermal inclusion cysts	Lymphadenopathy
Fat necrosis	Mucoceles
Fibroadenomata	Pseudoangiomatous stromal hyperplasia
Fibrocystic change	Pseudoangiomatous stromal hyperplasia
Focal fibrosis	Sarcomas, including phyllodes tumors
Galactoceles	Sarcomas, including phyllodes tumors
Gynecomastia	Sarcoidosis
Hamartomas	Seromas
Hematomas	Simple and complex cysts

In men, the history should include additional questions about hepatic dysfunction, sexual dysfunction, and current medications to rule out potential causes of gynecomastia which can present as a central breast mass. Clearance of testosterone can be impaired by hepatic dysfunction, resulting in increased peripheral conversion of testosterone to estradiol and estrone, resulting in stimulation and hypertrophy of the breast tissue. Sexual dysfunction may indicate abnormal testosterone levels. Several medications such as H₂ blockers and phenytoin, and drugs such as marijuana have also been associated with gynecomastia. Acute hypertrophy may also be painful, and associated symptoms should therefore be elicited.

PHYSICAL EXAMINATION

A presenting symptom that is designated as a new breast “mass” can span everything from a barely perceptible thickened region of the breast to a large fungating cancer or severe adenopathy. Physical examination is important prior to any diagnostic imaging so that the study can be chosen and targeted appropriately, and so that the radiologist can best assist in evaluating what has been seen on examination. Normal breast tissue can demonstrate nodularity which is difficult to distinguish from an abnormal process, causing difficulty for patients as well as physicians. One study of 542 patients under 30 years of age referred for a breast mass found that among the 80% of masses detected by self-breast examination, only 53% were true masses, underscoring the difficulties seen in younger women (2). A second study by Morrow and colleagues evaluating 605 patients under 40 years of age also found that only 27% had an identifiable etiology other than fibrocystic change (3). Among masses felt to be true abnormalities on examination by the surgeon, 28% were false positives.

In some cases, the physician will not detect any abnormality on the clinical breast examination even after focusing on the area of concern. In this situation, the patient should be reassured about the absence of worrisome findings and the physician should recheck to ensure that a screening mammogram has been performed within the past year for the average-risk patient who is 40 years of age and older. In other women, a subtle abnormality that remains ill-defined is detected. Such a lesion, sometimes referred to as a breast “thickening,” is one whose extent cannot be clearly defined in three dimensions. These poorly defined areas of prominence may represent a true parenchymal abnormality, or in many cases may reflect the prominence of an underlying rib that elevates the normally nodular breast tissue superficial to it. If there is uncertainty about whether a finding represents a true mass, the clinician should compare it to the mirror-image location in the opposite breast, and if applicable, palpate that region of breast tissue again once it has been moved off the underlying bony prominence. If any level of concern remains, further imaging evaluation is required, and for those physicians whose experience evaluating breast
masses is limited, a follow-up examination in 2 to 3 months after the initial visit is appropriate.

FIGURE 4-1 General schema for initial evaluation of a mass on examination based on its palpable characteristics. On presentation with the complaint of a mass, four findings can occur: (i) No abnormality noted, (ii) a thickening that may be either uncertain or equivocal, (iii) a clinically benign mass, or (iv) a clinically suspicious mass. These characteristics determine the next appropriate step in evaluation. When the characteristics of a thickening are equivocal or uncertain, imaging is indicated.

When the examination is complete, the patient can be characterized as having four possible findings: (i) no abnormality present, (ii) a thickening without the characteristics of a dominant mass, (iii) a dominant mass with benign characteristics on palpation, or (iv) a dominant mass with malignant characteristics (Fig. 4-1).

Documentation

The documentation of any findings present on physical examination should be performed consistently and include a description of the superficial appearance of the breasts, including the skin, nipples, and areolae, as well as whether a mass or retractions can be detected by observation alone, or with movement. Exanthems, nipple inversion, and the character of any discharge should be noted.

When documenting the characteristics of a mass, detail is of the utmost importance as it assists in the formulation of a differential diagnosis. Many women have diffusely nodular breasts and therefore the size of the mass and its location should be detailed. At minimum, the mass should be described by indicating the breast in question and the quadrant of the mass, although it is helpful to specify more detail whenever possible by utilizing tangents emanating from the nipple as numbers on the clock when facing the patient. The mass is also described by its distance from the nipple along that tangent, such as “a 2-cm left breast mass at the 4:00 position, 6 cm from the nipple.” Other characteristics that should be specified include whether its borders are smooth or irregular, details about its consistency (such as being soft, firm, or scirrhous), and whether it is discrete or an indistinct thickening. Characteristics associated with malignancy should also be noted. These include fixation to the chest wall or skin, skin satellite nodules, or edema of the skin (including peau d’orange) and ulceration. These characteristics are indicative of cancer and assist in its evaluation and staging.

The Axilla

The location of some masses may be difficult to distinguish between being present in the tail of the breast or the low axilla. Although normal lymph nodes are usually not palpable, small nonsuspicious lymph nodes may be detectable especially in thin individuals, often described as “shotty” nodes (the term originating from and referring to shot or pellets of lead and not “shoddy,” as in poor quality). Lymph nodes may vary in size from several millimeters to several centimeters when abnormally enlarged, and tend to be discrete oblong nodules that have greater freedom of movement than breast parenchymal masses unless the nodes are fixed to one another or to the chest wall. These should also be described in detail, paying particular attention to the number of palpable nodes, fixation, laterality, and size.

The Male Breast

In men, there is usually less breast tissue, except in those with gynecomastia. Most of the breast tissue is located behind and concentric to the nipple-areola complex, and gynecomastia is typically described as disc-like or platelike. Eccentricity in relation to the nipple and areola should be noted as such lesions are more likely to be malignant. Despite the smaller amount of breast tissue, the examination and documentation for the male breast remains similar to the female examination.

RADIOLOGIC EXAMINATION

Mammography

Mammogram remains the standard of care for the evaluation of breast abnormalities, and is necessary even when a mass very clearly seems malignant. When a palpable abnormality is found, a diagnostic mammogram is performed that consists of at least one view in addition to those taken in a screening study. A skin marker is placed over the palpable area of interest, and additional views are taken if deemed appropriate by the radiologist. Mammographic imaging may be sufficient if a suspicious mass is found, corresponding to the area in question. If nothing is seen on mammogram or if the mass appears to be benign, characterization by ultrasound is indicated, as mammograms typically miss approximately 10% to 25% of cancers detectable by physical examination regardless of tumor size (4), and they cannot differentiate solid from cystic abnormalities.

When possible, mammograms should be obtained prior to a biopsy of any mass because of the consequent mammographic changes that may occur. The two exceptions to this are in evaluating the pregnant and very young patient
(covered below). Hann et al. reviewed mammographic results immediately after stereotactic biopsy, and demonstrated that among 113 cases, 76% demonstrated changes due to the core biopsy, with 58 (51%) having a core biopsy-induced hematoma (5). There were 31 (27%) lesions where the visualized lesion size changed, and three cases (3%) where hematoma obscured the ability to see calcifications at the site.

Prior mammograms from outside facilities should be obtained for comparison prior to any intervention. Review of all imaging by all treating physicians is critical for correlation to the palpable abnormality. If a breast cancer is diagnosed histologically without the use of bilateral imaging, the clinician should ensure that a bilateral mammogram has been obtained within the past 6 months to rule out evident multicentric or contralateral disease requiring simultaneous intervention, even if no other palpable findings are present on examination.

The inability to see a palpable mass on mammogram should prompt an ultrasound, but the inability to see the lesion on either set of imaging does not mean that the lesion should be disregarded. If the lesion is discrete, biopsy should be performed. MRI is sometimes performed as an additional step to evaluate a mass that is mammographically occult, although MRI adds little because it is a poor substitute for the required pathologic diagnosis due to its lack of specificity. A palpable mass not seen on mammogram or ultrasound should undergo needle biopsy as the next step.

Mammography in Men

Although mammography in men may confirm that a mass is of low clinical suspicion or assist in cases where body habitus makes a patient’s physical examination more difficult, it generally adds little to the workup of the palpable breast mass. The physical examination in males is particularly important, largely because of the smaller amount of breast tissue that allows a prominence of male breast cancers on examination and the low prevalence of benign breast masses other than gynecomastia. In a Mayo Clinic study evaluating mammograms performed on men, 196 were performed for breast masses and other symptomatic complaints. Among these, 1 benign-appearing mammogram among 203 missed a cancer (0.5%), but all three cancers in this series presented with a discrete palpable mass, 2 associated with overlying retractions and 1 with interval enlargement and lymphadenopathy (6). In a series of 104 male patients with cancer, Borgen et al. also reported that most patients presented with more than one symptom, including masses in 77, nipple retraction in 18, bloody discharge in 16, skin ulceration in 10, and others with Paget’s disease, clinical inflammatory carcinoma, and fixed tumors (7). These series suggest that male cancers usually present with at least one suspicious physical examination finding, and while bilateral mammography may be considered in men once a cancer is suspected or diagnosed to rule out bilaterality, its role and benefit in the routine evaluation of the male breast mass has yet to be defined.

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