Approach to a breast mass and asymmetry: Clinical sciences

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Introduction0:00–0:35

Breast mass or asymmetry can occur at any age and can be benign or malignant. Because there’s a wide range of causes for a breast mass or asymmetry, one helpful way to narrow down your differential is to categorize its onset in relation to pregnancy or lactation.
It’s important to keep in mind that a new mass or asymmetry can carry a risk of malignancy, so timely diagnosis of the underlying cause is very important.Your first step in assessing a patient with a new breast mass or asymmetry is to obtain a focused history and physical.

Focused History and Physical0:35–2:17

On history, make sure to obtain information about the onset of the mass or asymmetry, associated pain, growth or changes in shape, as well as other symptoms, like skin changes or nipple discharge.
Patients might report recent breast trauma, as well as fluctuation in size of the mass or associated symptoms with their menstrual cycle.
In patients of child bearing age, make sure to ask if they’re currently pregnant or lactating. Additionally, patients might have certain risk factors such as early menarche or late menopause, history of breast cancer, ovarian cancer or other high risk lesions, genetic mutations like BRCA1 or BRCA2, or hormone replacement therapy .
Next, let’s move on to the physical exam. Your exam should include a complete clinical breast examination.
On visual inspection you might see noticeable abnormalities or differences between the two breasts, including shape, size, dimpling, and skin or nipple changes.
On palpation, you might feel a distinct mass, hardness of the breast or even elicit nipple discharge. Additionally, you might even find palpable lymphadenopathy of the cervical, clavicular, and axillary nodes.The next step in our diagnostic work up is imaging.
You may choose to order an ultrasound or mammogram. The modality of choice will depend on one factor: is the patient currently pregnant or lactating?Alright, let’s start with patients who are pregnant or lactating.

Pregnant or lactating2:17–2:37

In this case, breast ultrasound is a safe diagnostic modality of choice. To effectively narrow down your differential diagnosis, you should always incorporate the patient’s clinical picture with your ultrasound findings.Okay, let's discuss our first set of findings that may point to galactocele.

Galactocele2:37–3:28

On history, a pregnant or lactating patient might report a breast lump that has been progressively increasing in size. Physical exam reveals a solitary, firm, mobile breast mass that might be tender.
In addition, you might see bilateral milky nipple discharge. Now, if on ultrasound, you see a solitary, thin-walled, fluid filled anechoic lesion, you should consider a galactocele.
Next, you should perform an aspiration under ultrasound guidance to provide symptom relief, and to confirm your diagnosis if the initial ultrasound findings were unclear.
A milky fluid aspirate would confirm the diagnosis of galactocele. Ok, now, let’s go over another set of findings pointing to lactational mastitis with an abscess.

Lactational Mastitis with Abscess3:28–4:40

History might reveal a progressive breast mass, mastalgia, and even a recent diagnosis of lactational mastitis that didn’t get any better with treatment.
On physical exam, the breast is tender with a fluctuant mass. The overlying skin is indurated and erythematous, and the patient may have a fever.
The initial ultrasound shows soft tissue edema and a hypoechoic fluid collection with possible loculations. At this point, you should consider lactational mastitis with an abscess.
Your next step is to collect a CBC, and perform an ultrasound guided aspiration of the abscess. If the CBC shows leukocytosis, and the aspirated fluid is purulent, your diagnosis is confirmed.
You can send the aspirate for culture to tailor your antibiotic therapy. Keep in mind that the patient could have lactational mastitis without an abscess, which can be treated similarly with antibiotics without drainage.Although galactocele and mastitis with an abscess are two of the most common causes of breast mass or asymmetry in pregnant or lactating patients, there are other important differentials to consider, especially if signs and symptoms persist with treatment.

Alternative Diagnoses4:40–5:07

Some alternative diagnoses include malignancy, simple cysts, and fibroadenoma, along with some others we will discuss next.Alright, let’s go all the way back and talk about patients who present with a breast mass that’s unrelated to pregnancy or lactation.

Unrelated to pregnancy or lactating 5:07–5:46

For these patients, breast ultrasound and sometimes a mammogram are the best initial diagnostic modalities. Always consider the patient’s age when choosing which studies to obtain.
In general, most patients under 30 will start with only an ultrasound. Also, keep in mind that these conditions may also affect pregnant or lactating patients, but the pathophysiology of the following conditions is generally unrelated to pregnancy or lactation.Okay, let’s start with the most serious type of breast mass or asymmetry, breast cancer.
On history, the patient might report a new painless mass, along with risk factors like a personal or family history of breast or ovarian cancer, age above 40, or even postmenopausal exogenous hormone use.

Malignancy5:46–6:49

Physical exam might reveal a unilateral hard fixed breast mass with skin or nipple changes and sometimes even bloody nipple discharge.
Additionally, you might find palpable lymphadenopathy in the axilla. The ultrasound will often show a hypoechoic mass; while mammographic findings include a spiculated or irregular mass with microcalcifications and architectural distortions.
If these are your findings, you should consider malignancy and obtain a core needle biopsy. Biopsy results showing malignant epithelial cells will confirm your diagnosis of breast cancer.
Next, let’s talk about a benign and common cause, a simple cyst. In this case, patients often report a breast mass that increases in size or tenderness just before menstruation.

Simple Cyst6:49–7:39

On physical exam, you can expect to find a well-defined, firm, mobile, round mass that’s variably tender. Ultrasound and mammography will typically show a round or oval well-circumscribed anechoic mass.
This presentation should lead you to consider a simple cyst. Because these are benign, they can usually be observed.
However, in case of symptomatic cysts, ultrasound guided aspiration can be considered for relief. If this is done, aspiration of serous fluid confirms the diagnosis of a simple cyst.
Alright, let’s go over another common cause of a breast mass or asymmetry, non-proliferative fibrocystic change. This condition also tends to increase in size or tenderness just before menstruation.

Non-proliferative fibrocystic changes7:39–8:41

These patients typically present with symptoms that are multifocal, or even bilateral. Physical exam often reveals breast swelling, lumpiness, nodularity, and sometimes a discrete mass.
Ultrasound findings include prominent fibroglandular tissue that may show solitary or aggregated cysts. Mammogram may reveal heterogeneous and dense breast parenchyma, with or without cysts.
Consider fibrocystic changes of the breast if you see these findings. Sometimes, if a cyst looks suspicious, a core needle biopsy can be performed.
If it shows adenosis, stromal fibrosis, and cystically dilated ducts and lobules, you can confirm your diagnosis of non-proliferative fibrocystic changes.
Now, moving on to a benign cause that’s classically seen in younger patients, fibroadenoma. On history, patients typically report one or more slow growing breast lumps that increase in size or tenderness just before menstruation.

Fibroadenoma8:41–10:02

On average, the age at presentation is less than 30 years old. Physical exam often reveals one or multiple well-defined, firm, mobile masses that are non-tender, with a rubbery consistency, smooth borders.
Some might feel multinodular, but most are small, less than 3 centimeters in size. On ultrasound, you can expect to see a well-defined solid round or ovoid hypoechoic mass.
If the patient is age-appropriate for mammography, you can obtain one, which will show a well-circumscribed round to ovoid mass that is hypo- or isodense to surrounding glandular tissue.
If this is the case, consider fibroadenoma. Sometimes, if the mass looks suspicious, a core needle biopsy can be performed, which would show biphasic proliferation of stromal and epithelial cells growing in a pericanalicular or intracanalicular pattern.
If this is what you see, confirm your diagnosis of fibroadenoma. Okay, our last one, more common in middle-aged patients, is phyllodes tumor!
On history, the patient might report a breast mass that’s painless, with rapid growth, and that’s causing overlying skin changes, such as skin stretching.
Additionally, history might reveal certain risk factors, such as age over 40, or even genetic conditions like Li-Fraumeni syndrome.

Phyllodes Tumor 10:02–11:44

Physical exam might reveal a unilateral, well-defined, firm and mobile mass that’s non-tender, rubbery with smooth borders.
The mass could be multinodular, but an important difference with fibroadenoma is that phyllodes tumors tend to be large, usually more than 3 centimeters.
Ultrasound would show a well-defined solid lobulated mass, sometimes with heterogeneous echogenicity, and increased vascularity on Doppler.
On mammography, you can expect to find a well-circumscribed, round to ovoid, lobulated mass that’s hypo- or isodense to surrounding glandular tissue.
If this is the case, consider a phyllodes tumor. Suspicious-looking tumors should get a core needle biopsy, which typically shows a leaf-like epithelial pattern formed by intracanalicular proliferation, with variable stromal cellularity, adipose tissue infiltration, and mitotic activity.
At this point, you can confirm your diagnosis of a phyllodes tumor. An important thing to keep in mind is that phyllodes tumors are most often benign, but they can sometimes be malignant.
Because of the malignant potential, these should be surgically excised.Alright, as a quick recap… Breast mass or asymmetry is a very common presentation with a wide range of causes.
Although most are benign, it’s very important to assess and diagnose these patients in a timely manner to rule out malignancy.
The common causes related to pregnancy and lactation include a galactocele and mastitis with or without an abscess. However patients can develop breast mass or asymmetry that are unrelated to pregnancy and lactation, which includes breast cancer, simple cyst, non-proliferative fibrocystic changes, fibroadenoma, and phyllodes tumor.

Review11:44–12:16

related to pregnancy and lactation include a galactocele and mastitis with or without an abscess However patients can develop breast mass or asymmetry that are unrelated to pregnancy and lactation which includes breast cancer simple cyst