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Approach to breast mass

This is a short video on the approach to a breast mass. This presentation was made with Google Slides. Images and figures were created or adapted from Wikimedia Commons. ADDITIONAL TAGS: Approach to a breast mass Palpable breast mass Age 30 Age =30 Mammogram +/- ultrasound Ultrasound +/- mammogram Complex: irregular/indistinct borders, thick-walled, heterogeneous mass, septated, solid and cystic components, calcifications Smooth (homogeneous), mobile, thin-walled, anechoic (fluid-filled), no echogenic debris, well-circumscribed → likely a simple cyst Tissue sampling: -Fine needle aspiration (minimally invasive) for suspected cysts or small masses -Core needle biopsy for solid, acellular masses → ER, PR, Her2/neu receptor testing -Open (excisional) biopsy for large, suspicious masses → frozen section, sentinel node biopsy Symptomatic (pain, pressure) Asymptomatic Fine needle aspiration Observation Bloody aspirate Nonbloody aspirate (clear, straw-colored, green, gray) Cyst persists / recurs Cyst resolves Ultrasound-guided core needle biopsy, consider additional imaging Done! Low risk for cancer Age: adolescent AND mass is not concerning: solitary, firm, well-circumscribed, mobile, cyclic premenstrual tenderness → likely a benign fibroadenoma. Observe and re-eval in 6 weeks. Increasing size ↓ in size, tenderness → Done! +/- surgical resection (wide local excision vs lumpectomy vs total mastectomy +/- axillary lymph node dissection) +/- chemo (ER+ or PR+ should get tamoxifen, raloxifene, or aromatase inhibitors [anastrozole, letrozole, exemestane]; Her2/neu+ get trastuzumab) +/- radiation Physical exam Inspection → palpation Signs concerning for cancer: Invasion of lactiferous ducts → nipple retraction Epidermal infiltration by neoplastic cells → scaling or ulceration Invasion of suspensory (Cooper) ligaments → skin retraction Obstruction of dermal lymphatics → peau d’orange Invasion into adjacent breast tissue → fixed mass Lymphatic spread to regional lymph nodes → axillary lymphadenopathy History HPI: SOCRATES (site, onset, character, radiation, associations, time course, exacerbating/relieving factors, severity) Change in breast appearance (size, symmetry) Single or multiple masses Change in mass appearance Skin changes Nipple inversion Discharge (uni/bilateral, timing, color) Cyclic nature with menstrual cycles (fibroadenoma or fibrocystic changes?) Tender or nontender Fluctuant (abscess?) Fixed or mobile Recent trauma / surgery (fat necrosis?) Risk factors: Amount of estrogen exposure: older age, younger menarche, older menopause, use of OCPs, obesity, high bone density, low/no parity Family history in first degree relative (mother or sister) BRCA1/2 positive Approach to a breast mass: history and physical exam