Breast Mass in a 44-Year-Old Female (Case 11)

Chapter 21 Breast Mass in a 44-Year-Old Female (Case 11)



Roxane Weighall, DO, Jennifer L. Sabol, MD, Ari D. Brooks, MD




Differential Diagnosis




image



Speaking Intelligently


When evaluating a breast mass, I am always thinking about the triple test (clinical examination, imaging, pathology). I examine the patient paying attention to the characteristics of the mass and I review the mammogram or ultrasound to determine my level of suspicion. If my level of suspicion warrants a tissue dx, I use the least invasive biopsy technique that will yield an accurate dx. In the case of a palpable breast mass, this is most often a fine-needle aspiration biopsy or a core needle biopsy. Occasionally, though I may suspect that the mass represents benign breast nodularity, biopsy is still recommended for peace of mind (sometimes mine, often the patient’s).



PATIENT CARE



Clinical Thinking



• The triple test: clinical examination, imaging, and pathology are three important tools to determine the dx of a breast mass. If all are not concordant with your dx, further workup is needed.

• The differential dx of a breast mass stays consistent, but the likelihood of malignancy changes with the patient’s age. The older the patient, the more likely the mass is malignant.

• I try to obtain a tissue dx via a needle biopsy, avoiding open biopsy when possible. This enables me to plan a single definitive operation for cancer in many instances.


History



• Obtain information concerning the mass in question: How long has the mass been present? Has it increased or decreased in size? Is there associated pain or tenderness? Is the pain cyclical with the patient’s menstrual cycle? Are there skin changes? nipple discharge?

• When was the patient’s last menstrual period?

• Is there a personal or family hx of breast or ovarian cancer (maternal or paternal)?

• Any hx of previous breast biopsies? If so, does the patient know the pathological dx? (Look for a hx of atypical ductal or atypical lobular hyperplasia, or lobular carcinoma in situ, as these increase the patient’s risk for developing breast cancer.)

• Is the patient taking exogenous hormones?


Physical Examination



• Having a chaperone present is a good idea when performing a breast examination if you are a female, and a necessity if you are a male.

• Breast examinations should be performed both in the upright and supine positions in a gown that is open in the front.

• Examine the cervical region and supraclavicular lymph nodes. (It is often perceived as less threatening to touch the neck and supraclavicular fossa first and then the breast.)

• In the upright position, examine the axillae; push the fingertips against the chest wall after having the patient place her relaxed arm on your shoulder; now run your fingertips downward along the chest wall—this will trap any nodes against the ribs.

• While examining in the upright position, have the patient raise her arms over her head. Observe for symmetry, skin changes, or obvious masses. Have the patient place her hands on her hips and press down, looking for skin dimpling or breast distortion. Lift the breasts gently, palpating with a sweeping motion.

• Assist the patient to lie supine or in a reclining position. Examine the breast with the pads of the fingertips in an organized fashion such as in concentric circles or radially. It is important to develop a system by which you examine all of the breast tissue. Do not become distracted by an obvious abnormality and forget to examine the remaining tissue. As a rule, it is better to examine the unaffected breast first.

• Remember that breast tissue can extend to the edge of the sternum, the clavicle, below the inframammary fold and to the midaxillary line

• Determine if there are any areas that are tender, and ask the patient to show you any areas about which she may have concern. Ask if the area is best appreciated in the upright or supine position. Reexamine the patient after she identifies areas of concern.

• When you are palpating a breast mass, be thoughtful about the texture: Is it rubbery or hard, smooth or nodular? Note carefully the size and shape of any masses: discrete or nondiscrete. Note mobility: Is the lesion movable? Is it fixed to the skin overlying it or to the muscle beneath it?

• Document your findings in the chart. This should include a sketch and description of the abnormality (size, position on the clock, and distance from the nipple) as well as a plan of action.

• Be sure to discuss your findings with the patient.



IMAGING CONSIDERATIONS






























→ Bilateral screening mammography: Initial examination, two views only of each breast. Report must use BI-RADS category and assessment.
 $155

→ Diagnostic mammography: A radiologist is actively involved in a diagnostic mammogram. Magnification, spot compression, and additional views of any suspicious areas are obtained as needed.
 $265

→ Ultrasonography: Problem solver, not for screening. Handheld, high-frequency ultrasonography determines if a mass is cystic or solid. Can be used for guidance to perform a needle biopsy.
 $235

→ MRI: Problem solver, not for screening. Must use dedicated breast coils, MRI contrast, and experienced interpreters. Valuable adjunct in genetically high risk or in mammographically dense breasts. Preoperative value in planning therapeutic strategy.
 $2500

→ PET: Standard whole body PET of no value in breast diagnostics, but can be used in staging.
 $2900

→ Needle biopsy: Ultrasound guided for nonpalpable lesions. Rapid, reliable; performed in office or breast center.
 $590

→ Stereotactic biopsy: Requires specialized table and computer-guided x-ray technique. Lesion must be identified on mammogram. Outpatient hour-long procedure with immediate discharge to home from breast center.
 $2400

→ Open biopsy: The “Needle Loc,” mammographically guided placement of hooked guide wire for open surgical excision of tissue. Same-day surgery unit; takes a morning.
 $4500















Clinical Entities Medical Knowledge
Malignant Mass
PΦ The common malignant breast masses are invasive ductal carcinoma and invasive lobular carcinoma.
TP
Infiltrating (or Invasive) Ductal Carcinoma. The typical patient has a firm dominant mobile mass found by self-examination or by a health-care practitioner. May be associated with skin retraction, palpable adenopathy, and/or nipple discharge. In the more advanced stages, the mass may be fixed to surrounding structures and associated with erythema, skin edema, peau d’orange, and matted axillary nodes. A carcinoma may be nonpalpable and present as an unexpected density on the screening mammogram. Often in retrospect you can feel a vague density in the area of mammographic concern.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Breast Mass in a 44-Year-Old Female (Case 11)

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