Imaging In Practice

The radiologic workup of a palpable breast mass

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ABSTRACTThe finding of a palpable breast mass on physical examination often warrants a radiologic workup including directed ultrasonography, diagnostic mammography, and, at times, biopsy with ultrasonographic guidance. The choice of initial imaging study is most often guided by the patient’s age at presentation. Communicating the clinical findings to both the patient and the radiologist helps ensure the selection of the most appropriate imaging studies and helps in the interpretation of those studies. Every woman with a palpable breast mass, regardless of her age, should undergo imaging to exclude or establish the diagnosis of cancer.

KEY POINTS

  • Typically, in women under age 30, ultrasonography is the first or the only test ordered to evaluate the abnormality. In women age 30 or older, diagnostic mammography is typically the first test ordered.
  • On mammography, a suspicious palpable mass has an irregular shape with spiculated margins. A benign mass typically has a round shape with well-circumscribed margins.
  • When mammography is required during pregnancy, the patient can be reassured that it will not jeopardize her fetus because the radiation dose is very low and the abdomen and pelvis can be shielded.


 

References

A 28-year-old woman comes in for her annual checkup. Her physician notices a palpable, painless, 1-cm, well-demarcated mass in the left breast at the 3 o’clock position 2 cm from the nipple, with no associated skin changes, nipple retraction, or discharge. The patient has no personal or family history of breast cancer.

Given the patient’s age, physical findings, and medical history, the clinician believes it unlikely that the patient has cancer. How should she proceed with the workup of this patient?

PHYSICAL FINDINGS OF A BREAST MASS ARE NOT EXCLUSIVE

Figure 1. A simple cyst in the left breast. All three mammographic views—craniocaudal (A), mediolateral oblique (B), and spot-compression (C)—show a round, well-circumscribed mass in the mid-breast. Ultrasonography (D) shows a round, well-circumscribed anechoic lesion with a sharply defined posterior wall and posterior acoustic enhancement.

Breast cancer is the most common female malignancy and the second-leading cause of cancer deaths in the United States.1 The incidence is low in young women and increases with advancing age. Benign breast disease is common in young women and less common in postmenopausal women.2,3 However, the discovery of a breast mass, whether by the woman herself or by a clinician, is a common occurrence and distressing for any woman.

Benign lesions tend to have discrete, well-defined margins and are typically mobile. Malignant lesions may be firm, may have indistinct borders, and are often immobile.2 Although most breast masses found by palpation are benign, imaging is the critical next step in the workup to help determine if the mass is benign or malignant.

Benign palpable masses include:

  • Figure 2. Fibroadenoma. On mammography, the craniocaudal (A) and mediolateral oblique (B) views with a bright metallic marker (arrows) show a round, well-circumscribed mass in the upper outer quadrant of the left breast. Ultrasonography (C) shows an oval, well-circumscribed, mildly heterogeneous, hypoechoic mass that is wider than tall, indicating a benign mass.

    Cysts (Figure 1)
  • Fibroadenomas (Figure 2)
  • Prominent fat lobules
  • Lymph nodes
  • Oil cysts
  • Lipomas
  • Hamartomas (Figure 3)
  • Hematomas
  • Fat necrosis
  • Galactoceles.

Malignant palpable masses include:

  • Figure 3. Hamartoma. Craniocaudal (A) and mediolateral oblique (B) mammographic views of the left breast show an apparently encapsulated, heterogeneous mass that contains fat mixed with fibroglandular tissue.

    Invasive ductal and lobular carcinoma (Figure 4)
  • Ductal carcinoma in situ (which rarely presents as a palpable mass.)

HISTORY AND PHYSICAL EXAMINATION

To ensure that imaging provides the most useful information about a palpable breast lump, it is important to first do a careful history and physical examination. Important aspects of the history include family history, personal history of breast cancer, and any previous breast biopsies. The onset and duration of the palpable mass, changes in its size, the relationship of these changes to the menstrual cycle, and the presence or lack of tenderness are additional important elements of the history.

Figure 4. Infiltrating ductal carcinoma. Craniocaudal (A) and mediolateral oblique (B) mammographic views of the right breast show an irregular, mildly spiculated, high-density lesion in the posterior, medial breast. Ultrasonography (C) shows an irregularly shaped hypoechoic mass which is taller than wide (a profile tending to indicate malignancy) and has mild posterior acoustic shadowing.

On examination, it is important to note the clock-face location, size, texture, tenderness, and mobility of the lump. Accompanying nipple discharge and skin erythema or retraction are also important to report. In addition to conveying the location of the mass to the radiologist, it is equally important that the patient know what features the physician feels. This way, if the clinical information from the ordering physician is not available at the time of the radiologic evaluation, the patient will be able to guide the radiologist to the region of concern.

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