Breast: Breast Mass Evaluation

Breast Mass Evaluation

“Triple Test”

  • Physical Exam
  • Imaging
  • Core Needle Biopsy

Physical (Bimanual) Exam

  • Presentation:
    • Most are Asymptomatic
    • Pain
    • Palpable Mass
  • Suspicious Features:
    • Single Dominant Lesion
    • Hard
    • Fixed/Immobile
    • Irregular/Indistinct Borders
    • Asymmetric Breasts
    • Skin Retraction or Distortion
    • Nipple Retraction or Discharge

Imaging Approach

  • Young Women (Age < 30-35): Breast Ultrasound (US)
    • Also Consider Bilateral Diagnostic Mammogram if Examination Indeterminate or Suspicious
  • Older Women (Age > 30-35): Bilateral Diagnostic Mammogram

Breast Examination 1

Breast Mass Imaging

Mammogram

  • Test: Bilateral Diagnostic Mammogram
    • Allows Comparison Between the Two Sides
    • Never Use a Unilateral or “Screening” Mammogram in Symptomatic Patients
  • Preform Before Biopsy (Even if Palpable & Suspicious) – Goal to Identify Any Other Suspicious Areas & Biopsy May Alter Appearance
  • Minimum Size Detected: > 5 mm
  • Sensitivity/Specificity: 90%
    • Less Sensitive in Younger Patients – Higher Breast Density
  • Tomosynthesis – Three-Dimensional Mammography
  • Suspicious Features:
    • Most Specific Feature: Spiculated Soft Tissue Mass
      • 90% Represent Invasive Cancer
    • Grouped Microcalcifications
    • Distortion
    • Irregular Borders
    • Asymmetric
    • Multiple
    • Small/Thin/Linear

Mammogram 2

Normal Mammogram 3

Ultrasound

  • Indications:
    • Age < 30-35
    • Identify a Cystic Mass
    • Pregnant
    • Palpable Mass but Negative Mammogram
  • Suspicious Features:
    • Taller-Than-Wide (Against Natural Parallel Lines of Chest Wall)
    • Heterogenous
    • Hypoechoic
    • Internal Calcifications
    • Shadowing
    • Spiculated
    • Indistinct Margins

Normal Breast Ultrasound; Showing Ducts 4

MRI

  • Few Absolute Indications
  • Evaluate for Primary Cancer with Known Nodal Mets But No Obvious Breast Lesion
  • Used in Screening: *See Breast: Breast Cancer Screening
  • Better at Identifying Lesions in Dense Breast Tissue than Mammogram
  • Suspicious Features:
    • Irregular Margins
    • Spiculated
    • Heterogenous Enhancement
    • Internal Septa

Breast MRI 5

Breast Imaging Reporting and Data System (BI-RADS)

  • Used for All Imaging Modalities
  • Categories:
    • BI-RADS 0: Incomplete (From Screening Mammogram)
    • BI-RADS I: Negative
    • BI-RADS II: Benign
    • BI-RADS III: Probably Benign (< 2%)
    • BI-RADS IV: Suspicious of Malignancy (> 2%)
      • IVa: Low Suspicion (> 2%)
      • IVb: Moderate Suspicion (> 10%)
      • IVc: High Suspicion (> 50%)
    • BI-RADS V: Highly Suggestive of Malignancy (> 95%)
    • BI-RADS VI: Known Biopsy-Proven Malignancy
  • Recommendations:
    • BI-RADS 0: Further Imaging (Diagnostic Mammogram)
    • BI-RADS I/II: Routine Screening
    • BI-RADS III: Short Term (3-6 Month) Repeat Mammogram Mn
    • BI-RADS IV/V: Core Needle Biopsy (CNB)
    • BI-RADS VI: Treatment as Indicated

Breast Mass Biopsy

Core Needle Biopsy (CNB)

  • Preferred Method of Initial Biopsy
  • Evaluates: Architecture
  • Benefits:
    • Allows Appropriate Staging with SLNB
    • Allows One-Step Surgery (Avoids Two Surgeries)
  • Leaves a Marker Clip in the Sampled Region for Subsequent Management
    • Allow Radiographic Confirmation of Correct Area Excision with Later Surgery
    • Assists with Lesion Localization
  • Methods:
    • US-Guided – Preferred Method
    • Stereotactic (X-Ray-Guided) – If Calcification Alone without Associated Mass or Not Well Seen on US
    • Other Less Common Methods:
      • Tomosynthesis-Guided
      • MRI-Guided
      • By Palpation

Fine Needle Aspiration (FNA)

  • Evaluates: Cytology (Just Cells), Not Architecture
  • Generally CNB is Preferred Over FNA
    • Higher Rates of False Negative Results
    • Cannot Distinguish in Situ & Invasive Cancer
    • May Not Be Sufficient for Receptor Status Determination
  • Variable Results
    • Bloody: Cytology & CNB
    • Not Bloody (Clear/Straw-Colored/Viscous): Observe
      • If Fails to Resolve: CNB

Excisional Biopsy (EBx)

  • Excision of the Entire Suspect Area
  • Should Not Be Used as the Initial Biopsy Unless CNB is Not Feasible
  • Indications After CNB:
    • Non-Diagnostic (No Calcifications on Biopsy)
    • Indeterminate
    • Discordant/Non-Concordant (Benign But BI-RADS V)
    • Atypia or Suspicious

Core Needle Biopsy 6

Breast FNA 7

Mnemonics

BI-RADS Management

  • BI-RADS 3: 3-6 Months Repeat Mammogram
    • Below – Routine Screening (Except 0)
    • Above – Needs Biopsy/Surgery

References

  1. National Cancer Institute. Wikimedia Commons. (License: Public Domain)
  2. Blaus B. Wikimedia Commons. (License: CC BY-3.0)
  3. Sripathi S, Ayachit A, Kadavigere R, Kumar S, Eleti A, Sraj A. Spectrum of Imaging Findings in Paget’s Disease of the Breast-A Pictorial Review. Insights Imaging. 2015 Aug;6(4):419-29. doi: 10.1007/s13244-015-0415-z. Epub 2015 Jul 5. (License: CC BY-4.0)
  4. Dilmen N. Wikimedia Commons. (License: CC BY-SA-3.0)
  5. Kohara S, Ishigaki S, Satake H, Kawamura A, Kawai H, Kikumori T, Naganawa S. Background parenchymal enhancement in preoperative breast MRI. Nagoya J Med Sci. 2015 Aug;77(3):373-82. (License: CC BY-NC-ND-4.0)
  6. Dr Onco. Wikimedia Commons. (License: CC BY-SA-4.0)
  7. Blaus B. Wikimedia Commons. (License: CC BY-SA-4.0)