Breast Lump or Mass
A lump in the breast may be discovered by a woman on self-exam or by her health care provider during a breast examination. Imaging studies such as a mammogram are often performed to look at the mass and surrounding breast tissue, and breast ultrasound is a commonly used test as well, particularly in women with dense breast tissue. In many cases, the mammogram and ultrasound are performed at the same visit. Breast MRI is less commonly used to evaluate a breast mass, but is particularly helpful for women with a history of breast cancer.
Unless the breast lump is consistent with a cyst (a fluid filled sac) on imaging studies, a tissue biopsy is typically performed to establish the diagnosis. This is almost always done percutaneously (through the skin) with a needle after the skin has been numbed. The tissue biopsy is sent to the pathologist who looks at the cells under the microscope. A diagnosis of benign, indeterminate, or malignant mass is established.
Benign, or non-cancerous, masses may be treated with observation, follow up imaging, excision or removal with a breast biopsy. An example of a benign breast mass is a fibroadenoma.
An indeterminate mass requires further tissue sampling for diagnosis. The radiologist or pathologist may be concerned that the needle biopsy is not representative of the breast tissue of concern on the mammogram or ultrasound. A breast biopsy is usually recommended to obtain a larger specimen of breast tissue for the pathologist.
The treatment of malignant lesions, or cancer, varies from person to person. The size of the mass, involvement of any lymph nodes, tumor characteristics, and other variables are considered and discussed before designing a treatment plan with Dr. Lairet. Surgical management may include lumpectomy, mastectomy, sentinel lymph node biopsy, or axillary lymph node dissection.
A cyst is a fluid filled sac within the breast and typically feels like a smooth lump under the skin. Women may have a single cyst, or multiple cysts. On a physical exam, it may be difficult to distinguish a cyst from a solid mass, although cysts have a characteristic appearance on ultrasound. Typically a mammogram is performed along with the breast ultrasound, particularly if the woman is over the age of 40 and has not had a mammogram within the past year.
Once the cyst has been confirmed on ultrasound, the treatment is based on the appearance and symptoms caused by it. If the cyst is painful, aspiration is often performed. A needle is advanced through the skin and the cyst is drained. Aspiration is normally performed with ultrasound guidance. If the cyst recurs, has bloody contents, or is complex, surgical excision with a breast biopsy may be necessary.
Cysts that are simple and not causing pain are frequently observed with physical exam. Follow up imaging may also be ordered in certain instances.
Discharge from the nipple may be noted by a woman when she changes clothes, often with dried fluid inside of her bra. This is usually spontaneous discharge, occurring without compression of the breast. Alternately, nipple discharge may be found on self-breast examination or during a breast exam performed by a health care provider. Nipple discharge is caused by a benign (non-cancerous) condition in the majority of cases.
Common causes of nipple discharge include:
- Duct ectasia
- Hormonal changes
The first step in the diagnosis of nipple discharge is a history and physical exam. Lab tests may have been ordered by your primary care provider. Next, your provider will order or ensure you have had recent imaging of the breasts. This usually consists of a mammogram and/or breast ultrasound. A specialized test to look at the duct system of the breast, called a ductogram, if often done as well. Using a fine tip catheter, contrast is injected into the breast duct causing the nipple discharge. The radiologist then takes xrays to look for abnormalities in the duct illuminated with contrast dye. If an abnormality is found on imaging studies, a percutaneous (through the skin) needle biopsy is performed.
If a specific abnormality is discovered on imaging studies, treatment is based on the biopsy results. This may involve a breast biopsy or lumpectomy. If no abnormality is seen on the radiographic studies, a duct excision may be recommended. Removing the duct or ducts causing the discharge is both therapeutic and diagnostic.
When the breast radiologist finds an abnormality on a mammogram, he or she will compare the images to the woman’s prior mammograms, if applicable. Additional images are usually obtained with a diagnostic mammogram and/or breast ultrasound. Unless the abnormality has been previously biopsied or is stable in appearance, a percutaneous biopsy is performed. A percutaneous biopsy differs from a surgical biopsy in that the person is completely awake. The skin of the breast is numbed, and then a needle used to take a sample of tissue. The biopsy may be done stereotactically, which allows the abnormal area to be precisely targeted by the radiologist, or under ultrasound guidance.
The treatment plan is determined by the results of the biopsy. If the biopsy is benign, follow up imaging with a repeat mammogram in 6-12 months is often arranged. Sometimes the biopsy results do not appear concordant with the imaging. In these situations, a surgical breast biopsy may be recommended to ensure the abnormal appearing area is accurately sampled. When the biopsy results demonstrate malignancy, or cancer, Dr. Lairet will discuss the various surgical options for treatment with you. These options include lumpectomy, mastectomy, sentinel lymph node biopsy, or axillary lymph node dissection.
The diagnosis of breast cancer is established after a tissue biopsy is performed and the pathology demonstrates cancer cells. This percutaneous (through the skin) needle biopsy is done when an abnormal area is seen on mammogram or ultrasound, or to further evaluate a lump felt on examination of the breast. The biopsy pathology report, usually finished within 48-72 hours of the biopsy, describes the type of cancer. The pathologist will also look at the molecular characteristics of the tumor. This takes a few additional days, and will establish if the cancer is positive or negative for estrogen and progesterone receptors, as well as the HER2 oncogene. These factors will all be considered when discussing options for treatment.
Other tests may be performed once breast cancer is diagnosed. Breast MRI is another imaging study to look at the tumor, its relationship to the chest wall and the skin, the surrounding lymph nodes, and the contralateral (other side) breast. A specialized CT scan or PET scan may be done to look for spread of the cancer to other parts of the body.
Treatment of breast cancer is tailored to fit each person’s tumor, situation, and preferences. A multidisciplinary team is important in managing all facets of a person’s cancer treatment plan. This team includes a breast surgeon, medical oncologist, breast radiologist, radiation oncologist and possibly a plastic surgeon as well.
In general, surgical breast cancer treatment involves a procedure for the breast (see lumpectomy and mastectomy) and also the axillary lymph nodes (see sentinel lymph node biopsy and axillary lymph node dissection ). Dr. Lairet will discuss the risks and benefits of the different surgical treatments with each person on an individual basis.
Chemotherapy may be recommended and may occur before or after surgery. Radiation therapy may also be used, and almost all patients who undergo lumpectomy will be treated with radiation therapy. In certain cases, radiation may also be recommended after a mastectomy.
In addition to surgical treatment, physical therapy, nutrition counseling, support groups and other supportive therapies are important parts of treatment and recovery as well.