Approach to

the breast mass

By : Dr. Faramarz Shahri
Resident of surgery
 DIAGNOSING BREAST
CANCER

• In 33% of breast cancer cases, the woman

discovers a lump in her breast.
• Other less frequent presenting signs and
symptoms of breast cancer include (I) breast
enlargement or asymmetry; (2) nipple
changes, retraction, or discharge; (3)
ulceration or erythema of the skin of the
breast; (4) an axillary mass; and (5)
musculoskeletal discomfort.
• up to 50% of women presenting with breast
complaints have no physical signs of breast
pathology.
• Breast pain usually is associated with
benign disease.
• If a young woman (age 45 years or less)
presents with a palpable breast mass and
equivocal mammography finding,
ultrasound examination and biopsy are used
to avoid a delay in diagnosis.
Sab History
• The examiner should determine the patient’s
age and obtain a reproductiv history.
• The age of menarche ,menstrual
irregulaities ,and the age at menopause
should be sougth .
Sab
• Previous surgical procedures should be
recorded ,including previous breast biopsies
and their pathologies and wether the ovaries
were removed if a hysterectomy was
performed.
Sab
• Because hysterectomy is a common
procedure, accurate determination of
menopause may be difficalt .
• It is usefull to inquire abaut menopausal
symptoms in these patients .
Sab
• In younger women, a recent history of
pregnancy and lactation shoud be recorded .
• A drug history shoud pay attention to
hormone replacment therapy or the use of
hormones for contraception .
Sab
• The family history should be directed to
cancer of the breast and ovaries (parents,
siblings, offspring) .
• In questioning the patient about the specific
breast problem, it is worthwhile to inquire
about breast pain, nipple discharge, and new
masses in the breast.
Sab
• If the mass is present, it helps to know how
it was found, how long it has been present,
what has happened scince it’s discovery,
and if it changes with the menstrual cycle .
Sab
• If cancer is likely, inquiry about
constitutional symptoms, bone pain, weight
loss, respiratory changes, and similar
clinical indications of metastatic disease
may occasionally reveal unsuspected distant
spread .
Examination
 Inspection
• The surgeon inspects the woman's breast
with her arms by her side, with her arms
straight up in the air, and with her hands on
her hips (with and without pectoral muscle
contraction).
• Symmetry, size, and shape of the breast are
recorded, as well as any evidence of edema
(peau d'orange), nipple or skin retraction,
and erythema.
• With the arms extended forward and in a
sitting position, the woman leans forward to
accentuate any skin retraction.
 Palpation
• Examination of the patient in the supine
position is best performed with a pillow
supporting the ipsilateral hemithorax.
• The surgeon gently palpates the breast from
the ipsilateral side, making certain to
examine all quadrants of the breast from the
sternum laterally to the latissimus dorsi
muscle, and from the clavicle inferiorly to
the upper rectus sheath.
• A systematic search for lymphadenopathy
then is performed.
Sab Breast examination
• Breast examination shoud be done with
respect for privacy and patient comfort in a
well-lighted room , preferably whith an
available indirect light source.
Sab
• The examination begins with the patient in
the upright sitting position with careful
visual inspection for abvious masses,
asymetries,and skin changes.
Sab
• The nipples are inspected and compared for
the superficial epidermis in Paget’s disease.
• The use of indirect lighting can unmask
subtle dimpling of the skin or nipple caused
by the scirrhous reaction of a carcinoma
placing Cooper’s ligament under tention .
Sab
• Simple maneuvers such as gently lifting the
patient’s breast may accentuate asymmetries
and dimplling .
Sab
• Peau d’orang when combined with
tenderness and warmth ,these signs and
symptoms are the hallmark of Inflammatory
carcinoma and may be mistaken for acute
mastitis.
Sab
• Flattening or actual inversion of the nipple
can be caused by fibrosis in certain benign
conditions, especially subareolar duct
ectasia.
Sab
• In these cases , the finding is frequently
bilateral and the history confirms that the
condition has been present for many years.
• Unilateral retraction or retraction that
develops over weeks or months is more
suggestive of carcinoma.
 FNA
• Because needle biopsy of breast masses
may produce artifacts that make
mammography assessment more difficult,
many radiologists prefer to image breast
masses before needle biopsy.
• However, in practice, the first investigation
of palpable breast masses is frequently
needle biopsy, which allows for the early
diagnosis of cysts.
• If the fluid that is aspirated is not
bloodstained, then the cyst is aspirated to
dryness, the needle is removed, and the
fluid is discarded as cytologic examination
of such fluid is not cost-effective.
• After aspiration, the breast is carefully
palpated to exclude a residual mass.
• If one exists, ultrasound examination is
performed to exclude a persistent cyst,
which is reaspirated if present.
• If the mass is solid, a tissue specimen is
obtained.
• When cystic fluid is bloodstained, 2 mL of
fluid are taken for cytology.
• The mass is then imaged with ultrasound
and any solid area on the cyst wall is
biopsied by needle.
• The presence of blood is usually obvious,
but in cysts with dark fluid, an occult blood
test or microscopy examination will
eliminate any doubt.
• The two cardinal rules of safe cyst
aspiration are (I) the mass must disappear
completely after aspiration, and (2) the fluid
must not be bloodstained.
• If either of these conditions is not met, then
ultrasound, needle biopsy, and perhaps
excisional biopsy are recommended,
Sab FNA
• Cystic fluid is usually turbid dark green or
amber and can be discarded if the mass
totally disappears and the fluid is not
bloody.
Sab
• By using fine-needle aspiration in the routin
examination of the breast ,unnecessary open
biopsy of cystic change is avoided.
Sab
• As a result of adding fine-needele aspiration
to the routin examination of breast masses ,
a restating of criteria for open biopsy is
done when :
Sab
• 1) needle aspiration prodiuces no cyst fluid
and a solid mass is diagnosed.
• 2) the cyst fluid produced is thick and blood
tinged.
• 3) fluid is prodiuced but the mass fails to
resolve completely.
Sab
• Other surgeons have added the frequent
reappearance of the cyst in the same
location and the rapid accumulation of fluid
after initial aspiration (less than 2 weeks).
Sab
• If the mass is solid and the clinical situation
is consistent with carcinoma, a cytologic
examination of the aspirated material is
performed.
Sab
• Most authors do not recommend definitive
treatment based on a cytologic examination.
• In addition,the presence of carcinoma cells
on fine-needle aspiration dose not
differentiate between in situ and invasive
breast cancer.
Sab
• However, a positive result allows for
informed discussions with the patient,
definitive plans for treatment, and
appropriate consultations or second
opinions.
 Imaging
Techniques
 Ductography
• The primary indication for ductography is
nipple discharge, particularly when the fluid
contains blood.
• With the patient in a supine position, 0.1 to
0.2 mL of dilute contrast media is injected
and CC and MLO mammography views are
obtained without compression.
• Intraductal papillomas are seen as small
filling defects surrounded by contrast
media.
• Cancers may appear as irregular masses or
as multiple intraluminal filling defects.
 Mammography
• Conventional mammography delivers a
radiation dose of 0.1 centigray (cGy) per
study.
• By comparison, a chest x-ray delivers 25%
of this dose, there is no increased breast
cancer risk associated with the radiation
dose delivered with screening
mammography.
• With screening mammography, two views
of the breast are obtained, the craniocaudal
(CC) view and the mediolateral oblique
(MLO) view.
• The MLO view images the greatest volume
of breast tissue, including the upper outer
quadrant and the axillary tail of Spence.
• Compared with the MLO view, the CC view
provides better visualization of the medial
aspect of the breast and permits greater
breast compression.
• In addition to the MLO and CC views, a
diagnostic examination may use views that
better define the nature of any
abnormalities, such as the 90-degree lateral
and spot compression views.
• The compression device minimizes motion
artifact, improves definition, separates
overlying tissues, and decreases the
radiation dose needed to penetrate the
breast.
• Mammography also is used to guide
interventional procedures, including needle
localization and needle biopsy
• Specific mammography features that
suggest a diagnosis of a breast cancer
include a solid mass with or without stellate
features, asymmetric thickening of breast
tissues, and clustered microcalcifications.
• The presence of fine, stippled calcium in
and around a suspicious lesion is suggestive
of breast cancer and occurs in as many as
50% of nonpalpable cancers.
• These microcalcifications are an especially
important sign of cancer in younger women,
in whom it may be the only mammography
abnormality.
• That normal-risk women age 20 years or
older should have a breast exam at least
every 3 years.
• At age 40 years, breast exams should be
performed yearly along with a yearly
mammogram.
• Xeromammography techniques are identical
to those of mammography with the
exception that the image is recorded on a
xerography plate, which provides a positive
rather than a negative image
• Details of the entire breast and the soft
tissues of the chest wall may be recorded
with one exposure.
Sab Breast imaging
• Breast radiographic imaging is used to
detect small ,nonpalpable breast
abnormalities ,to evaluate clinical findings,
and to guide diagnostic procedures.
Sab
• Mamography is the most sensitive and
specific imaging test currently
available,though 10% to 15% of clinically
evident breast cancers have no
mammographic correlate.
Sab
• Digital mammography is a tecnology that
acquires digital image and stores them
electronically .
• This allows users to manipulate images of
the breast to enhance certain strictures or
densities while reducing the background of
others.
Sab
• Film screen and digital mammography are
equivalent in their ability to detect breast
cancers.
Sab Screening mammography
• It is performed in efforts to detect breast
cancer that is not clinically evident
• It identifies women whose mammograms
contain an abnormality and separates these
women from those whose mammograms are
clearly normal .
Sab
• At present , screening mammography
schoud be offered annually to women age
50and older , and at least biennialy in
women age 40 to 49 with the screening
interval made on an individual basis and
considering the risk factors for breast cancer
.
Sab
• Younger women with a significant family
history , histologic risk factor , or a history
of prior breast cancer shoud be offerrd
annual screening .
Sab Diagnostic mammography
• It is performed when there is a abnormality
on clinical exmination or screening
mammography .
Sab
• It includes magnification and compression
imaging in the MLO and CC views obtained
with screening mammography , and is
frequently supplemented by ultrasound .
Sab
• The mammographic features of malignancy
can be broadly divided into density
abnormalities (masses , architectural
distortion, and assymetries ) and
microcalcifications .
Sab
• Each mammogram is also assessed for the
presence of abnormalities in the axillary
nodes and for the presence of skin or nipple
changes , such as thickening or retraction.
 Ultrasonography
• Second only to mammography in frequency
of use for breast imaging ultrasonography is
an important method of resolving equivocal
mammography findings, defining cystic
masses, and demonstrating the echogenic
qualities of specific solid abnormalities.
• On ultrasound examination, breast cysts are
well circumscribed, with smooth margins
and an echo-free cent.
• Benign breast masses usually show smooth
contours, round or oval shapes, weak
internal echoes, and well-defined anterior
and posterior margins.
• Breast cancer characteristically has irregular
walls, but may have smooth margins with
acoustic enhancement.
• It is highly reproducible and has a high
patient acceptance rate, but does not reliably
detect lesions that are 1cm or less in
diameter.
 MRI
• In the process of evaluating MRI as a means
of characterizing mammography
abnormalities, additional breast lesions have
been detected.
• However, in the circumstance of both a
negative mammogram and a negative
physical examination, the probability of a
breast cancer being diagnosed by MRI is
extremely low.
• There is current interest in using MRI to
screen the breasts of high-risk women and
of women with a newly diagnosed breast
cancer
Sab CT.Scan

CT appears to be the best way to image

internal mammary nodes and to evaluate the
chest and axilla after mastectomy.
Sab MRI
• MRI is the imaging method of choice to
evaluate implant rupture.
• It may be used in efforts to identify the
primary site of cancer in the breast of a
woman who presents with malignant
axillary adenopathy in the context of an un
revealing breast physical examination and
mammogram(accult breast cancre ).
Sab
• Particularly for an invasive lobular breast
cancer diagnosed by core needle biopsy ,
where physician examination and
mammography may underestimate the
extent of disease , MRI may facilitate the
decision as to whether the patient is an
appropriate candidate for breast
conservation .
Sab
• Its efficacy as a screening tool remain
unproven , though studies in population at
increesed risk for breast cancer appear
promising .
• MRI sensitivity for invasive cancer
approches 100%, but is only 60% at best for
DCIS .
Sab
• Specificity remain low , with significant
overlap in the appearance of benign and
malignant lesions .
Breast Biopsy
 Nonpalpable Lesions
• Image-guided breast biopsies are frequently
required to diagnose nonpalpable lesions.
• Ultrasound localization techniques are
employed when a mass is present, while
stereotactic techniques are used when no
mass is present (microca1cifications only).
• The combination of diagnostic
mammography, ultrasound or stereotactic
localization, and fine-needle aspiration
(FNA) biopsy is almost 100% accurate in
the diagnosis of breast cancer.
• However, while FNA biopsy permits
cytologic evaluation, core-needle or open
biopsy also permits the analysis of breast
tissue architecture and allows the
pathologist to determine whether invasive
cancer is present.
• Core-needle biopsy is accepted as an
alternative to open biopsy for nonpalpable
breast lesions.
• The advantages of core-needle biopsy
include a low complication rate, avoidance
of scarring, and a lower cost.
Sab Non palpable mammographic
abnormalities
• Mammographic abnormalities that cannot
be detected by physical examination are
classified in three broad categoty : (1)
lesions consisting of microcalcification only
, (2)density lesions (masses ,architectural
distortion , and asymmetries),and (3)those
with both calcifications and density
abnormalities .
Sab
• The incidence of malignancy after biopsy
depends on the characteristics of the
radiographic finding .
Sab
• Lesion with microcalcification with an
assosiated mass and linear branching
calcifications carry the highest probability
of being malignant .
Sab
• However , even well-defined , smooth
densities can be malignant .
• Not every abnormalities should undergo
biopsy , and recommendation should be
made by surgeons in consultation with an
experienced radiologist .
Sab
• For some patients not undergoing biopsy , a
mammogram repeated in a shorter interval
(6months) may be recommended to
establish stability of the abnormality .
Sab
• The two methods available to evaluate a
nonpalpable mammographic abnormality
include wire localization with surgical
excisional biopsy and image-guided
stereotactic or ultrasound-guided large-core
needle biopsy .
 Sab Large core needle biopsy
(LCNB)
• Since the early 1990s,LCNB increasingly is
the diagnostic method of choice to
histologically evaluate nonpalpable
mammographic abnormalities .
• In experienced centers , it is considered the
standard of care .
Sab
• LCNB can be performed using either
mammographic (stereotactic) or ultrasound
guidance .
• Mammographic calcifications are typically
sampled using stereotactic capabilities .
Sab
• In the experienced centers , 65%of women
who undergo the procedure are found to
have a benign diagnosis and can resume
annual mammographic screening .
Sab
• 25% of patients are found to have a
malignancy.
• The diagnosis of malignancy by core biopsy
affords the apportunity to proceed with one
definitive surgery , with efforts toward
breast preservation when appropriate and
chosen by the patient.
Sab
• The remaining 10% of patients are found to
have inconclusive histology , including:
(1)atypical cells on pathology (atypical
ductal hyperplesia ),(2)biopsy result that are
discordant from the mammography findings
,(3) increased cellularity within a
fibroadenoma,or(4)inadiquate sampling of
the site.
Sab
• In these cases where the core obtained does
not contain cancer , and the histology does
not entierly explain the mammographic
finding, surgical biopsy is recommended.
Sab
• The false-negative rate of stereotactic
biopsy shoud be extremely low if these
guidelines are followed.
Sab Atypia on core needle biopsy

• For patient with atypia on core needle

biopsy ,a wire localization and excisional
biopsy are performed to clarify the
histology.
Sab DCIS on core needle biopsy

• For patients with a core needle biopsy

diagnosis of DCIS , 7% have had the lesion
fully excised with the core needle .
Sab
• At the time of surgical excision ,an upgrade
of the DCIS is seen in 12% of patient who
had undergone core needle biopsy using an
11-gauge,vacum-assisted needle device .
 Palpable Lesions
• FNA biopsy of a palpable breast mass is
performed in an outpatient setting.
• The cellular material is then expressed onto
microscope slides.
• Both air-dried and 95% ethanol-fixed
microscopy sections are prepared for
analysis.
• When a breast mass is clinically and
mammographically suspicious, the
sensitivity and the specificity of FNA
biopsy approaches 100%.
• Core-needle biopsy of palpable breast
masses is performed using a 14-gauge
needle, such as the Tru Cut needle.
• Automated devices also are available.
• While the false-negative rate for core-
needle biopsy is very low, a tissue specimen
that does not show breast cancer cannot
conclusively rule out that diagnosis because
a sampling error may have occurred.
 Ph-Ex

If Discharg If Nonpalp mass If Palp mass

Ducto Mammo Sono

CT Scan MRI Solid or comb cyst

Mamo FNAB

FNAB Asp

LCNB Re Asp

Ex Biop
 ‫سنگي كه طاقت ضربه هاي تيشه را ندارد‬

‫تنديسي زيبا نخواهد شد‬

‫“حضرت زرتشت “‬
 Fibroadenomas

• Removal of all fibroadenomas has been

advocated irrespective of patient age or
other considerations, and solitary
fibroadenomas in young women are
frequently removed to alleviate patient
concern.
• Yet most fibroadenomas are self-limiting
and many go undiagnosed, so a more
conservative approach is reasonable.
• Careful ultrasound examination with core-
needle biopsy will provide for an accurate
diagnosis, Subsequently, the patient is
counseled concerning the biopsy results,
and excision of the fibroadenoma may be
avoided.
 Sclerosing Disorders

• The clinical significance of sclerosing

adenosis lies in its mimicry of cancer,
• It may be confused with cancer on physical
examination, by mammography, and at
gross pathologic examination,
• Excisional biopsy and histologic
examination are frequently necessary to
exclude the diagnosis of cancer
• The diagnostic workup for radial scars and
complex sclerosing lesions frequently
involves stereoscopic biopsy,
• It is usually not possible to differentiate
these lesions with certainty from cancer by
mammography features, so biopsy is
recommended.
 Periductal Mastitis

• Painful and tender masses behind the

nipple-areola complex are aspirated with a
12-gauge needle attached to a 10-mL
syringe.
• Any fluid obtained is submitted for
cytology and for culture using a transport
medium appropriate for the detection of
anaerobic organisms.
• In the absence of pus, women are started on
a combination of metronidazole and
dicloxacillin while awaiting the results of
culture.
• when there is considerable pus present,
surgical treatment is recommended.
• Unlike puerperal abscesses, a subareolar
abscess is usually unilocular and often is
associated with a single duct system.
• Preoperative ultrasound will accurately
delineate its extent.
• In a woman of childbearing age,
simple drainage is preferred, but if there is
an anaerobic infection, recurrent infection
frequently develops.
• Recurrent abscess with fistula is a difficult
problem and may be treated by fistulectomy
or by major duct excision, depending on the
circumstances.
• When a localized periareolar abscess recurs
at the previous site and a fistula is present,
the preferred operation is fistulectomy,
which has minimal complications and a
high degree of success.
• when subareolar sepsis is diffuse rather than
localized to one segment or when more than
one fistula is present, total duct excision is
the preferred procedure,
• fistula excision is the preferred initial
procedure for localized sepsis irrespective
of age.
• Antibiotic therapy is useful for recurrent
infection after fistula excision, and a 2- to 4-
week course is recommended prior to total
duct excision
 Nipple Inversion

• Congenital nipple inversion.

• Secondary to duct ectasia.
• Surgical complications : altered nipple
sensation, nipple necrosis, and
postoperative fibrosis with nipple retraction.
• Because nipple inversion is a result of
shortening of the subareolar ducts, a
complete division of these ducts is
necessary for permanent correction of the
disorder.