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APPROACH TO THE DIAGNOSIS OF A BREAST

LUMP
A breast lump raises the fear of breast cancer in all women.
INES BUCCIMAZZA, MB ChB, FCS (SA)
Senior Specialist, Department of Specialised Surgery, Inkosi Albert Luthuli Central Hospital, and Head, Breast Unit, Nelson R Mandela School of Medi-
cine, University of KwaZulu-Natal, Durban
Ines Buccimazza is a Senior Specialist in the Department of Surgery and a member of the Multidisciplinary Breast Unit at the Nelson R Mandela School of Medicine,
University of KwaZulu-Natal, Durban. When not dealing with breast health matters, she is an Epicurean activist.

Correspondence to: I Buccimazza (ines@orthoserve.co.za)

Patient complaints of breast lumps or lumpiness are common, ranging distinct from surrounding tissues, and generally asymmetrical when
from 40% to 70% in women seeking advice. A breast lump, either compared with the other breast.
self detected, screen detected or clinician detected, raises the fear of
breast cancer in any woman, irrespective of age.1,2 Fortunately, the vast The following may be mistaken for a mass, e.g. normal structures
majority of breast lumps are benign, but this does not negate the need (prominent rib or costochondral junction, particularly in thin patients),
for evaluation of any palpable breast lesion. Failure to diagnose breast an illusive mass (created by improper examination by pinching of the
cancer accounts for the most frequent and expensive claims brought tissues), and nodularity.
against physicians.
Nodularity versus a discrete mass
Public education about breast cancer has heightened awareness Normal breast tissue may vary in consistency, depending on the age
regarding breast health, and it is anticipated that an increasing number of the patient and the menstrual cycle. In young patients the breast
of women will present for the evaluation of breast masses. glandular tissue is generally lumpy (nodular) and more pronounced
in the upper outer region of the breast and inframammary ridge.
Aetiology of breast lumps3 Nodularity is considered to be a physiological process. Compared with
There are many causes for breast lumps. The differential diagnosis of a persistent, discrete lump not palpated in the contralateral breast,
a dominant breast mass includes a macrocyst (clinically palpable cyst, nodularity is ill defined, often bilateral, and tends to fluctuate with the
accounting for approximately 25% of breast lesions), a fibroadenoma, menstrual cycle.
fat necrosis and cancer.
Method of assessing a breast mass
The mode of presentation, age of the patient, reproductive history, The triple assessment is a diagnostic procedure that combines a clinical
history of trauma, constitutional symptoms and previous breast examination, imaging and a tissue biopsy. It is currently the gold
pathology are helpful in elucidating the possible cause. For example, standard for the assessment of all patients presenting with symptomatic
in women <30 years of age, a single lump is most commonly a breast disease.
fibroadenoma. With increasing age, macrocysts, fat necrosis and
carcinomas are common. Individually, each has an appreciable false-negative rate, and none of
the components of the triple assessment has been found to be 100%
sensitive or specific.
The vast majority of breast lumps are
benign, but this does not negate the When adequately performed – with the three components producing
need for evaluation of any palpable concordant results – the diagnostic accuracy of the triple assessment
approaches 100%. It is generally accepted that >95% of palpable
breast lesion. malignant breast lesions can be diagnosed
Color in thisGeneric
profile: way. When all aspects
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of a triple assessment suggest
Approach2,4,5 benign disease, most large
Goal of evaluation series report a false-negative
Breast lumps cause anxiety in most patients. The goal of the diagnostic rate of 0.1 - 0.7%. The false-
evaluation of a patient with a breast mass is to rule out cancer and positive rate is around 0.4%.
address the presenting symptom. The extent of the evaluation depends
on the age and risk status of the patient as well as the type of breast Diagnosis 2-4
lesion. Clinical assessment
The initial step is to take a It's the
Generally, the older the woman, the greater the degree of suspicion and history and perform a physical shell that
the more aggressive the evaluation. examination. makes

It is challenging to achieve this while minimising unnecessary excision History safer.


biopsies, pain, emotional trauma, invasiveness of a procedure and A complete history of the
cost. presenting complaint is vital.
In addition, the following
An expedient evaluation is important, although it should be remembered need to be documented: Safety-Coated
R

that diagnosing breast cancer is not a medical emergency. 81mg


Age is important. The younger The ORIGINAL low dose aspirin
Confirming the presence of a mass the woman, the greater the for optimum cardio-protection
When patients present with a history of a breast lump, the first crucial probability that a breast lump pH
Each tablet contains Aspirin 81mg. Reg.No.: 29/2.7/0767
Pharmafrica (Pty) Ltd, 33 Hulbert Road, New Centre, Johannesburg 2001
Under licence from Goldshield Pharmaceuticals Ltd. U.K.
step is to determine whether a discrete mass is indeed present. Discrete will be benign. The chance
masses are three-dimensional, measureable (with definable borders), that a breast mass in a woman

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Diagnosis of a breast lump

under 25 years of age is cancerous falls evaluation of a mass depends on the age and views. Additional views, tailored to a specific
between 1 in 229 and 1 in 700. risk status of the patient and the degree of problem, are occasionally required to
clinical suspicion. Generally, mammography adequately visualise the lesion.
However, with increasing age (>40 years) is performed in women aged 35 or over and
benign breast problems are less frequent and ultrasonography is the preferred modality for The sensitivity of diagnostic mammography is
all clinical abnormalities should be regarded women under 35 years of age. Other imaging around 90%, and the specificity up to 88%. The
as possible cancers until documented as modalities such as MRI are used selectively. known false-negative rate of mammography
benign. By the age of 70 more than three- is between 8% and 10%. Approximately
quarters of masses evaluated by biopsy are Palpable lesions are 1 - 3% of women with a clinically suspicious
malignant. abnormality and negative imaging (normal
always imaged before a mammogram and ultrasound) may have
A personal history of breast cancer is a risk biopsy is done. breast cancer. Therefore, in the case of a
factor for recurrence or a contralateral new negative mammogram further investigation
primary tumour. In women treated with In the case of a potential malignancy, imaging is necessary if a lump is detected on clinical
breast-conserving surgery, the incidence is studies are useful to define the extent of the examination.
1% and 2% per annum above the lifetime risk malignancy and to identify non-palpable
for invasive duct and lobular carcinomas, masses elsewhere in the breast or on the The sensitivity of mammography is
respectively. contralateral side. These findings may alter decreased by dense breast tissue obscuring a
the therapeutic approach, especially the lesion. False-negative results arise with poor
A past history of a breast biopsy showing choice of local therapy. technique and inadequate views that do not
atypical hyperplasia, a family history of include the mass, or when the findings are
breast cancer, and other risk factors for Ultrasound misinterpreted by the radiologist, notably
breast cancer should be sought. Ultrasound has become a valuable tool when there is overlap in the mammographic
in assessing breast masses, as it is widely features of benign and malignant masses.
Recent trauma to the breast, pregnancy, available, quick to perform, non-invasive
lactation, and the presence of concurrent and less expensive than other imaging In women younger than 35 years, if the results
constitutional symptoms are also important modalities. Its main advantage is that it can of the initial evaluation (triple assessment)
considerations when trying to elucidate the accurately differentiate a solid mass from a suggest malignancy, mammography is
cause of the lesion. cystic one. The specificity of ultrasound in indicated for assessment of the extent of the
detecting cystic lesions is 98%, and cysts disease.
Clinical breast examination (CBE) ≥2 mm can be detected.
The accuracy of palpation in evaluating Ultrasound has become
a breast mass is limited. Nevertheless, Ultrasound has a higher sensitivity than a valuable tool in
digital palpation of the breast is effective mammography in detecting lesions in women
in detecting masses and may assist in with dense breast tissue. In this setting, its assessing breast
determining whether a mass is possibly use as an adjunct to mammography may masses, as it is widely
benign or malignant. CBE can detect up to increase the accuracy by up to 7.4%. With
44% of cancers, of which up to 29% would regard to clinically palpable solid lesions, available, quick to
have been missed by mammography. the specificity of ultrasound is superior perform, non-invasive
to mammography: 97% versus 87%. It is
Generally, benign masses do not cause skin furthermore a complementary modality to an
and less expensive
change, are smooth and mobile, are soft to equivocal CBE and a normal mammogram than other imaging
firm to palpation and have well-defined in determining whether a mass is present. modalities.
margins. Malignant masses, in contrast, are Further uses include the evaluation of non-
generally hard and immobile, may be fixed palpable lesions detected on screening Digital mammography
to surrounding structures, and have poorly mammography, image-guided biopsy of This mammographic technique allows
defined or irregular margins. There is a caveat: lesions and follow-up of benign lesions such images to be enhanced and transmitted
some mobile masses can be cancerous, and as fibroadenomas. However, it is an operator- electronically. The ability to alter the contrast
not all fixed masses are cancer. dependent technique with a lower sensitivity and brightness permits the identification
than mammography. of features that are diagnostic of benign
Infections, such as mastitis, are characterised and malignant disease. The overall cancer
by signs of inflammation; however, similar Mammography detection rate is similar to that of standard
symptoms may be present in patients Mammography is an essential component film mammography.
with inflammatory breast cancer. Caution in the assessment of a palpable breast mass.
should prevail when assessing patients with It serves to characterise and determine Advantages of digital mammography include
suspected breast infections. the extent of the mass, and to evaluate the better image quality, fewer artefacts, fewer
breasts for clinically occult lesions. In the patient recalls and telemammography.
CBE alone is inadequate for the assessment of case of malignancy, multiple (multifocal/
a breast mass and the definitive diagnosis of multicentric) cancers are not unusual. Magnetic resonance imaging (MRI)
breast cancer. Cysts cannot be distinguished Bilateral synchronous cancers are reported High-resolution contrast-enhanced MRI
from solid masses and signs of cancer are in 3% of cases; approximately 65% of these has recently emerged as a sensitive imaging
not distinctive. Even among experienced are detected only by mammography. modality for the detection of breast cancer.
examiners there is a surprising lack of
agreement about physical findings. It has Diagnostic mammography requires that a The high sensitivity, which approaches
been estimated that the diagnostic accuracy radio-opaque marker is placed over the area 98%, makes MRI useful in specific clinical
of physical examination is 60 - 85%. of concern to ensure that any mammographic situations, such as evaluating patients with
abnormality corresponds with the clinical breast implants, detecting local recurrence
Imaging5-8 finding. Each breast is imaged separately after breast-conserving therapy, and detecting
Palpable lesions are always imaged before a in the craniocaudal (CC), mediolateral multifocal/multicentric disease. However,
biopsy is done. The extent of imaging for the oblique (MLO) and mediolateral (ML) the moderately low specificity of 47 - 67%

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Diagnosis of a breast lump

requires MRI-guided biopsy of lesions not Not all benign lesions require excision, to be benign on clinical assessment,
seen on other imaging modalities, many of and in patients diagnosed with a breast e.g. a fibroadenoma, where it provides
which are later found to be benign. malignancy the consequences of a diagnostic an immediate definitive diagnosis. The
excisional biopsy may impact on subsequent technique can be used to triage patients
MRI avoids exposure to radiation, management options for breast cancer for conservative treatment or surgery.
has a sensitivity superior to that of treatment. Observation may be appropriate once the
mammography and is more accurate than benign nature of the lesion is confirmed,
both mammography and ultrasonography in However, when a percutaneous needle generally by correct and specific typing
determining the size of a breast cancer mass. biopsy yields a benign result discordant with on core needle biopsy. It is diagnostic and
However, the technique is cumbersome the clinical and/or radiological impression, therapeutic in the case of simple breast
and expensive, not readily available, does it is incumbent on the health care provider cysts.
not detect microcalcifications, is inferior to to pursue the situation with a different • It is also useful for diagnosing abnormal
mammography in detecting non-invasive diagnostic manoeuvre. Performing all axillary lymph nodes in patients with
cancers and requires a special coil to obtain a biopsies under image guidance (sonographic known breast cancer. The overall reported
biopsy of occult lesions. Furthermore, there or stereotactic) significantly reduces the sensitivity rate is >95% for metastatic
are concerns that MRI findings may result in frequency of false-negative results. If the malignancies.
increased mastectomy rates in patients with initial biopsy was performed as a freehand
early breast cancer, and it remains unclear procedure, then repeating it with image Core needle biopsy (CNB)
whether alterations in management based on guidance is appropriate. This allows for the histological diagnosis of a
MRI findings actually benefit patients. solid lesion by providing cores of tissue using
Fine-needle aspiration cytology (FNAC) a 14-gauge manual or automated core biopsy
The sensitivity FNAC is a simple, quick and relatively painless needle. The procedure is associated with a
procedure, where cells are aspirated using a specificity of 85 - 100% and a sensitivity of
of diagnostic 10ml syringe attached to a 23-gauge needle 80 - 95%. The sensitivity increases when
mammography is and the application of negative pressure. It is the procedure is performed under image
suitable for women of all ages, does not require guidance (99% in palpable lesions and 93%
around 90%, and the local anaesthesia, and can be performed either in impalpable lesions), and multiple cores
specificity up to 88%. freehand or using ultrasound to guide the are taken. A minimum of 4 - 5 cores are
needle into the lesion. advised to achieve greater accuracy: the
Computed tomography (CT) scanning first core from the centre of the lesion and
This modality has no established place in the When performed by trained physicians the remainder at the quadrants thereof. This
evaluation of palpable breast masses. In select (cytopathologist or clinician), it is associated improves the sensitivity from around 81% (2
cases it may be useful to provide information with a high rate of accurate diagnosis, with the cores) to 95 - 100%.
about the extent of tumour invasion into frequency of satisfactory specimens ranging
muscle and skin. from 89% to 98%. Studies have demonstrated CNB potentially overcomes several
a sensitivity of 87% and a specificity of 99.5%. shortcomings of FNAC. CNB leads to
Tissue biopsy5,9-12 In expert hands, the sensitivity of FNAC improved diagnostic accuracy as a result of
The decision to perform a biopsy is based on ranges from 96% to 98%. its superior sensitivity and specificity. With
the clinical appreciation of a palpable mass, regard to breast cancer, it permits correct
irrespective of the findings of imaging studies, A specific advantage of FNAC is the histological categorisation of lesions and
all of which have appreciable false-negative immediate evaluation of specimen adequacy confirmation of invasion, and provides the
rates. Experts are divided on whether all for cytodiagnosis in one-stop clinics, necessary prognostic and predictive marker
solid masses require a histological diagnosis: thereby reducing non-diagnostic rates due information. On the downside, it requires
some are in favour of this approach, while to inadequate sampling as the procedure is more time and training than FNAC, the
others suggest clinical follow-up for young repeatable. FNAC sampling is also useful Color profile: Generic CMYK printer profile
Composite Default screen
women with lumps of low suspicion on CBE in the case of lesions at sites inaccessible
and imaging. or unsafe for core needle biopsy, and it is
therapeutic in the management of palpable
Open surgical biopsy remains the gold cystic masses.
standard for establishing the histopathological
nature of any breast abnormality. However, On the downside, the procedure is highly
before scheduling the patient for surgical operator dependent, requires special training
excision in the operating room, every by a pathologist and is associated with an
It's the
attempt should be made to determine, appreciable false-negative rate of 9.6%.
via percutaneous biopsy techniques (fine- Inherent limitations of the technique include shell that
needle aspiration cytology or core needle the inability to distinguish invasive from makes
biopsy), whether the breast lesion is benign non-invasive carcinomas and to accurately
or malignant. These non-invasive biopsy diagnose lobular carcinomas. Cytology in safer.
techniques can frequently be facilitated by the evaluation of a palpable mass during
image guidance (stereotaxis or ultrasound). pregnancy is of low sensitivity, as atypical
A stereotactic biopsy uses mammography cytomorphological findings are encountered
to pinpoint an abnormal area demonstrated during gestation and lactation. Safety-Coated
R

on a breast-imaging test. The technique 81mg


uses stereo images, i.e. of the same area When is FNAC indicated? The ORIGINAL low dose aspirin
obtained from different angles, to locate the • Its primary use is rapid diagnosis in palpable for optimum cardio-protection
area of concern, which may be palpable or masses, although it may be insufficient to pH
Each tablet contains Aspirin 81mg. Reg.No.: 29/2.7/0767
Pharmafrica (Pty) Ltd, 33 Hulbert Road, New Centre, Johannesburg 2001
Under licence from Goldshield Pharmaceuticals Ltd. U.K.
impalpable, thus permitting the radiologist base treatment on. This form of biopsy
to perform a core needle biopsy. is generally reserved for lesions thought

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Diagnosis of a breast lump

administration of local anaesthesia, and the one of which was performed under image (intracystic or partially cystic carcinoma).
results are not immediately available. guidance, are non-diagnostic, and the lesion Irrespective of this, these cases warrant
is too large for an excision biopsy with an surgical excision of the cyst.
When is a CNB indicated? acceptable cosmetic result.
• For the primary diagnosis of a suspicious Solid mass
mass, as it provides enough tissue to Management4,13 The management of a solid mass depends on
confirm the diagnosis and perform all other Cyst the degree of clinical suspicion and the age
necessary tests (tissue architecture, IHC Cysts are aspirated to dryness and the area of the patient.
staining, receptor status, HER2 status). is palpated for a residual mass. If the fluid is
• In palpable lesions of an indeterminate not bloody and the mass disappears, the fluid If a benign lesion is diagnosed after a triple
nature, to provide a definitive histological is not submitted for cytological examination assessment, the options include surgical
diagnosis and additional prognostic because of the low likelihood of cancer. excision or follow-up of the lesion. It is
factors essential for planning future Furthermore, the finding of atypical cells not necessary to excise all benign solid
management. in cyst fluid cytology is not uncommon, breast masses, and a selective policy is
• In impalpable radiologically detected resulting in a clinical dilemma when the recommended based on the nature of the
lesions, guided CNB is preferred. cyst resolves with aspiration and imaging is lesion and patient preference. In the event
normal but the cytology report indicates the of a conservative approach being preferred,
Excision biopsy need for a biopsy. there must be a defined follow-up plan to
Also known as a lumpectomy, this refers to facilitate the early detection of a missed
the removal of the entire lesion with a margin No positive cysts were found in a large study cancer. The patient is examined every 3 - 4
of normal tissue for diagnostic or therapeutic that routinely assessed non-bloody specimens, months for one year to ensure stability of the
purposes. It is performed in the operating yet atypical cells were found on cytological mass. The mass is measured at each visit and
room under local or general anaesthesia, examination in almost 25% of these cyst fluid compared with the size at initial presentation.
and is indicated in patients with a discordant aspirates. Routine cytological examination of This approach should only be undertaken by
triple assessment. With the availability of cyst fluid is not cost-effective, often results in a physician experienced in the evaluation of
more sophisticated diagnostic manoeuvres, unnecessary surgical biopsies and does not breast masses.
the need for a diagnostic excision biopsy has obviate the need for clinical follow-up.
declined. If the breast lump is found to be cancerous,
A bloody cyst aspirate, non-resolution of the staging investigations follow and the patient
Incision biopsy palpable abnormality after fluid aspiration, is managed in a multidisciplinary team.
This refers to the removal of a portion of the and a cyst that recurs within 4 - 6 weeks all Early detection affords the best chance for
lesion for tissue diagnosis, and is currently point to a pathological cause for the cyst. This successful treatment.
seldom required. The typical scenario would can either be due to a benign lesion (large
be a large tumour where at least two CNBs, intraductal papilloma) or a malignancy References available at www.cmej.org.za

In a nutshell
• A palpable mass in a woman’s breast represents a potentially serious lesion.
• All palpable lesions require evaluation.
• The triple assessment is an effective strategy in the management of breast lumps.
• The first step is to confirm the presence of a discrete mass.
• The next objective is to distinguish simple cysts from solid lesions.
• Simple cysts are aspirated to dryness and require no further treatment if they do not recur.
• Pathological cysts require surgical excision.
• A solid lesion requires a firm diagnosis, necessitating histological examination.
• Benign solid lesions may be managed expectantly, provided regular follow-up is undertaken.
• Malignant solid lesions are referred to a multidisciplinary team for further management.

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