Clinical Review

Evaluating patients with breast concerns: Lump, pain, and mastitis

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Discerning which breast conditions are benign from those that need referral to a breast specialist can be daunting. The initial assessment of the patient and their symptoms and signs can provide information that will assist the clinician in choosing the best path for the patient.



The vast majority of symptomatic breast conditions are benign, with the most common symptoms being palpable mass and breast pain. Clinicians, including primary care clinicians and gynecologists, play a crucial role by performing the initial assessment and subsequent therapies and referrals and serve as the mediator between the specialists and by being the patient’s spokesperson. It is therefore important for clinicians to be aware of the various possible causes of these breast symptoms, to know which imaging tests to order, and also to understand the indications for biopsies and surgical referral.

Common types of breast lumps: Imaging workup and management

Accounting for 8% of women who present with breast symptoms, breast lump is the second most common symptom after breast pain.1 The positive likelihood ratio of finding breast cancer is highest among women with breast lumps compared with any other breast symptoms. Therefore, anxiety is related to this symptom, and a thorough evaluation is recommended.1 Cysts, fibroadenoma, and fat necrosis are 3 common benign causes of breast lumps.2

In this section, we review clinical presentation, imaging workup, and management strategies for common types of breast lumps.

CASE 1 Woman with tender breast lump

A 45-year-old woman presents with a breast lump of 6 months’ duration that is associated with a change in size with the menstrual cycle and pain. Clinical examination reveals a 4 x 4.5–cm mass in the right breast in the retroareolar region, which is smooth with some tenderness on palpation.

Breast cyst

According to the American College of Radiology appropriateness criteria for an adult woman 40 years of age or older who presents with a palpable breast mass, the initial imaging study is diagnostic mammography with or without digital tomosynthesis, usually followed by a directed ultrasound. If the mammogram is suspicious or highly suggestive of malignancy, or in cases where the mammogram does not show an abnormality, the next recommended step is breast ultrasonography. Any suspicious findings on ultrasound or mammogram should be followed by an image guided biopsy. Ultrasonography also may be appropriate if the mammogram findings are benign or probably benign.

For an adult woman younger than age 30 who presents with a palpable breast mass, breast ultrasonography is the appropriate initial imaging study. If the ultrasound is suspicious or highly suggestive of malignancy, then performing diagnostic mammography with or without digital tomosynthesis or ultrasound-guided core needle biopsy of the mass are both considered appropriate. However, no further imaging is recommended if the ultrasound is benign, probably benign, or negative. Breast ultrasonography or mammography is appropriate as the initial imaging test for adult women aged 30 to 39 years who present with a palpable breast mass.3,4

Approximately 50% of women after age 30 may develop fibrocystic breast disease, and 20% of them can present with pain or lump due to a macrocysts. Simple cysts must be distinguished from complex cysts with the help of ultrasound as the latter are associated with 23% to 31% increased risk of malignancy.

In this 45-year-old patient, the initial mammogram demonstrated a circumscribed mass underneath the area of palpable concern (FIGURE 1a, 1b). Targeted breast ultrasonography was performed for further assessment, which depicted the mass as a benign simple cyst (FIGURE 1c).

Art Credit: Images courtesy of Leigh Neumayer, MD, MS, MBA

On ultrasound, a simple cyst is an anechoic, well-circumscribed mass with a thin capsule and with increased through transmission. Patients with small and asymptomatic simple cysts do not need imaging follow-up and can return for routine screening mammograms.

A breast surgeon, radiologist, or gynecologist can perform percutaneous aspiration if a cyst is large and symptomatic. A cyst with low-level internal echoes, fluid-fluid, or fluid-debris levels is considered a complicated cyst. Differential diagnosis also includes hematoma, fat necrosis, abscess, and galactocele, depending on the clinical presentation. Fine-needle aspiration or short-interval follow-up5,6 is appropriate for complicated cysts, while incision and drainage is indicated in patients with infected cysts and abscesses. A cyst with a solid component is considered a cystic, solid mass, and core needle biopsy is recommended. The differential diagnosis for cysts with solid components includes intracystic papilloma, papillary carcinoma, ductal carcinoma in situ, and necrotic cancers.5,6

Continue to: CASE 2 Painless breast mass in a young woman...


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