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Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass

Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass
Literature review current through: Jan 2024.
This topic last updated: Oct 02, 2023.

INTRODUCTION — A breast mass is a nodule or growth of tissue that represents an aggregation of coherent material. A breast mass may be benign or malignant. A benign mass may be solid or cystic, whereas a malignant mass is typically solid. A cystic mass with solid components (complex cyst) can also be malignant. (See "Breast cysts: Clinical manifestations, diagnosis, and management", section on 'Complex'.)

Evaluation of a palpable breast mass requires a systematic approach to the history, physical examination, and radiographic imaging studies to ensure a correct diagnosis. A missed diagnosis of breast cancer is one of the most frequent causes of malpractice claims in the United States [1-3].

The clinical manifestations, differential diagnosis, and clinical evaluation of women with a palpable breast mass are reviewed here. Breast imaging and breast biopsy are discussed in detail separately. (See "Diagnostic evaluation of suspected breast cancer" and "Breast biopsy".)

Screening and epidemiology of breast cancer, benign breast disease, breast pain, nipple discharge, breast cysts, and breast cancer are reviewed separately:

(See "Screening for breast cancer: Strategies and recommendations".)

(See "Overview of benign breast diseases".)

(See "Breast pain".)

(See "Nipple discharge".)

(See "Breast cysts: Clinical manifestations, diagnosis, and management".)

(See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer".)

CLINICAL MANIFESTATIONS — A breast mass can be discovered by the patient incidentally or on routine examination by a patient or clinician. It is often discovered after a breast examination prompted by other symptoms (eg, pain, nipple discharge) or trauma [4,5].

On the physical examination, the palpable breast mass can be obvious or subtle; the density can be soft, firm, or hard; it can be mobile or fixed to the chest wall or skin; and it can be tender or nontender [6]. The mass may have well-defined or nondiscrete margins and be associated with clinical findings including ecchymosis, erythema, peau d'orange, or skin dimpling; nipple discharge; or nipple retraction. Often the mass has no associated clinical findings. (See 'Physical examination' below.)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of a palpable breast mass includes benign and malignant etiologies. Palpable breast masses are very common in women, and most palpable masses are benign [4,7,8]. Approximately 90 percent or more of palpable breast masses in women in their 20s to early 50s are benign; however, excluding breast cancer is a crucial step in the assessment of a breast mass in a woman of any age [9].

Benign — The following types of masses are among the most common benign breast masses palpated. A review of these and additional nonproliferative and proliferative breast lesions can be found elsewhere. (See "Overview of benign breast diseases".)

Fibroadenoma – A simple fibroadenoma is a benign solid mass. It typically is identified in young women but can also be identified as a calcified mass in older women. The mass is firm and often mobile. A fibroadenoma may be solitary, multiple, or bilateral. (See "Overview of benign breast diseases", section on 'Fibroadenomas'.)

Cyst – A simple cyst is a benign, fluid-filled mass that can be palpated as a component of fibrocystic changes of the breast or as a discrete, compressible, or ballotable solitary mass. Breast cysts are commonly found in premenopausal, perimenopausal, and occasionally postmenopausal women. (See "Breast cysts: Clinical manifestations, diagnosis, and management".)

Fibrocystic changes – Fibrocystic changes in the breast are common, particularly in premenopausal women. Palpable findings may be prominent and organized, but more likely the breast tissue tends to be more diffuse and tender and generally does not form a discrete or well-defined mass. Most patients present with breast pain that may be cyclical or constant and may be bilateral, unilateral, or focal. The breast tissue, particularly in the upper outer quadrant, may increase in size prior to the onset of menses, then return to baseline after the onset of the menstrual flow. On clinical examination, the breast tissue frequently is nodular. (See "Breast pain", section on 'Cyclical breast pain'.)

Galactocele – A galactocele is a milk retention cyst common in women who are breastfeeding. (See "Common problems of breastfeeding and weaning", section on 'Galactocele'.)

Fat necrosis – Fat necrosis is a benign breast mass that can develop after blunt trauma to the breast; injection of native or foreign substances such as fat [10], paraffin, or silicone [11,12]; an operative procedure such as breast reductive surgery [13] or autologous breast reconstruction [14]; and radiation therapy [15,16] to the breast. Fat necrosis from trauma is generally associated with skin ecchymosis. Fat necrosis can often be clinically and even radiographically difficult to distinguish from a malignant mass. (See "Overview of benign breast diseases", section on 'Fat necrosis'.)

Breast abscess – A breast abscess is a localized collection of inflammatory exudate (ie, pus) in the breast tissue. Primary breast abscesses develop when mastitis or cellulitis is left untreated or does not respond to antibiotic treatment. Patients with primary breast abscess present with localized, painful inflammation of the breast associated with fever and malaise, along with a fluctuant, tender, palpable mass. The diagnosis is established via ultrasonography demonstrating a fluid collection. (See "Primary breast abscess".)

Malignant — The differential diagnosis of a malignant breast mass includes multiple invasive and noninvasive cancers. The following types of masses are among the most common malignant breast masses palpated. Further review of the pathology of breast cancer is discussed separately. (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Differential diagnosis' and "Pathology of breast cancer".)

The most common breast cancer is an infiltrating ductal breast carcinoma [8]. This invasive histology accounts for approximately 70 to 80 percent of invasive breast cancers.

Other invasive breast cancers include infiltrating lobular carcinoma and mixed ductal/lobular carcinoma. Infiltrating lobular carcinoma often presents as a prominent diffuse thickening of the breast rather than as a discrete mass. There are also variants of the invasive ductal carcinomas that can be detected as a palpable mass. (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Differential diagnosis'.)

Rarely, noninvasive cancers (ductal carcinoma in situ [DCIS]) with or without microinvasion can develop into a palpable breast mass. (See "Breast ductal carcinoma in situ: Epidemiology, clinical manifestations, and diagnosis".)

Less commonly, other malignancies may present as a breast mass including phyllodes tumors, lymphoma, sarcoma, or metastases to the breast from other primary sites.

CLINICAL EVALUATION — The clinical evaluation of a palpable breast mass begins with a complete history and physical examination, as described below [4,5]. Although some radiographically identified masses may not be palpable, the same clinical evaluation also applies.

History — The history should include a full review of medical and surgical illnesses, medications, and allergies and an assessment of risk factors for breast cancer, such as a detailed family history. In addition, for masses identified by the patient, subjective information about how and when the mass was first noted, if it is painful, and how it has changed over time should be recorded [4].

Presenting symptoms — The history of presenting symptoms includes:

Any change in the general appearance of the breast, such as an increase or decrease in size or a change in symmetry.

New or persistent skin changes.

New nipple inversion. (See "Nipple inversion".)

If nipple discharge is present, whether it is bilateral, unilateral, or from one specific duct. Other important information includes the timing, color, frequency, and spontaneity of the discharge. (See "Nipple discharge".)

The characteristics of any breast pain, the relationship of symptoms to menstrual cycles (cyclic or noncyclic), the location within the breast (or both breasts), the duration, and whether it is aggravated or alleviated by any activities or medications. (See "Breast pain".)

The presence of a breast mass and its evolution, including how it was first noted (accidentally, by breast self-examination, clinical breast examination, or mammogram), how long it has been present, and whether it has changed in size. (See 'Benign' above.)

The precise location of any breast mass. (See 'Documentation' below.)

Whether a mass waxes and wanes during the menstrual cycle. Benign cysts may be more prominent premenstrually and regress in size during the follicular phase. (See "Overview of benign breast diseases", section on 'Nonproliferative lesions' and "Breast cysts: Clinical manifestations, diagnosis, and management".)

Trauma to the breast (eg, car accident with seat belt, direct injury from a hard object) may result in a breast mass due to the development of fat necrosis or a hematoma. In addition, trauma may be the precipitating event to detection of an existing benign or malignant mass. Any mass after a trauma that fails to resolve will require a complete evaluation. (See "Overview of benign breast diseases", section on 'Fat necrosis'.)

Risk factors for breast cancer — A thorough risk assessment is part of the evaluation of women with breast complaints, and significant negative as well as positive findings should be documented in the medical record (table 1). Factors that are associated with an increased risk of breast cancer are reviewed separately. (See "Factors that modify breast cancer risk in women".)

Physical examination — The breast examination includes both breasts and the nodal basins of the neck, chest wall, and both axillae and is part of a complete physical examination (figure 1) [4,17,18].

Inspection — The patient should be examined in both the upright and supine positions. The patient must be disrobed from the waist up, allowing the examiner to visualize and inspect the breasts. The breast examination is started with the patient in a seated position with her arms relaxed. The patient is then asked to raise her arms over her head so the lower part of the breasts can be inspected. Finally, the patient should put her hands on her hips and press in to contract the pectoral muscles so that any other areas of retraction can be visualized. Inspection of the breast includes:

Asymmetry – Observe the breast outline and contour for any bulging areas.

Skin changes – Check for dimpling or retraction, edema, ulceration, erythema, or eczematous appearance, such as scaly, thickened, raw skin.

Nipples – Assess for symmetry, inversion or retraction, nipple discharge, or crusting.

Palpation — After careful inspection, proceed with the palpation of regional lymph nodes and the breasts.

Regional lymph node examination – While the patient is sitting, the regional lymph nodes are examined, with attention to the cervical, supraclavicular, infraclavicular, and axillary nodal basins. The best examination of the axillary nodes requires that the patient relax her shoulders and allow the examiner to support her arm while the axilla is palpated. This allows relaxation of the latissimus and pectoralis muscles for ease in palpating high into the axilla. It is important to note the presence of any palpable nodes and their characteristics, whether they are soft and mobile or firm, hard, tender, fixed, or matted (figure 1).

Breast examination – A bimanual examination of the breasts is performed while the patient is still in the sitting position, supporting the breast gently with one hand and examining the breast with the other hand. The examination is completed with the patient in a supine position, with the ipsilateral arm raised above her head. This allows the examiner to flatten the breast tissue against the patient's chest. It is sometimes useful to have the patient roll onto her contralateral hip to flatten the lateral part of the breast.

The entire breast must be examined, including the breast tissue that comprises the axillary tail of Spence, which extends laterally toward the axilla. To be sure that all breast tissue is included in the examination, it is best to cover a rectangular area bordered by the clavicle superiorly, the midsternum medially, the midaxillary line laterally, and the lower rib cage inferiorly (figure 1).

The examination technique should be systematic, using concentric circles, a radial approach, or vertical strips [17-19]. Palpation should be done with the finger pads rather than the fingertips. Circular motions with light, medium, and deep pressure ensure palpation of all levels of breast tissue [17,20]. One hand stabilizes the breast while the other hand is used to perform the examination [18].

Documentation — The location of the mass as well as any abnormality found on examination should be accurately documented. The size of any mass should be measured in centimeters and its location, mobility, and consistency recorded. It is helpful to record the location of any abnormality by documenting both the position on the breast and the distance in centimeters from the areola. In this manner, the precise location can be easily identified on subsequent follow-up examinations by the initial examiner as well as other practitioners.

The "clock" system can be used for documentation, comparing the breast to a clock and using the location on the clock to indicate the location of a lesion (eg, 1 o'clock position). The entire examination should be clearly and completely documented in detail, including significant negatives, even if it is completely normal. Distance from the nipple or from the radial edge of the areola can be used to document location of the mass.

Timing of examination — In premenopausal patients, the breast examination is best performed when hormonal stimulation of the breasts is minimized, which is usually seven to nine days after the onset of menses in premenopausal women. However, the evaluation of a clinically suspicious mass should not be influenced by the phase of the menstrual cycle.

Accuracy of examination — The physical examination of patients with benign breast disease parallels the examination of patients with cancer since normal breast tissue in women is often somewhat nodular. The first goal of the physical examination is to determine whether a dominant mass, thickening, or asymmetry is present. This is particularly important in younger women, whose breasts are more likely to be generally nodular than older women. In a retrospective review of 605 women under the age of 40 years who were referred to a breast clinic for evaluation of a breast mass, a dominant mass was palpated by the surgeon in 36 percent of self-detected masses (n = 484) and 29 percent of clinician-detected masses (n = 121) [21].

However, the physical examination findings cannot always distinguish between a benign mass and a malignancy, even for clinical experts, as the findings may be subtle. Studies that have examined the usefulness of the physical examination for diagnosing benign versus malignant breast masses have found that clinicians can often make the right diagnosis but are not perfect. In one report, from a study of symptomatic women, experienced examiners who diagnosed "definite cancer" on palpation were correct in 93 percent of cases [22]. In another series, the physical examination had a positive predictive value of 73 percent and a negative predictive value of 87 percent [23].

DIAGNOSTIC EVALUATION — Imaging options include diagnostic mammography, including tomosynthesis where available, and targeted breast ultrasound, the choice of which depends on patient age and the degree of clinical/radiologic suspicion. There is little role for advanced imaging modalities such as breast magnetic resonance imaging. (See "Diagnostic evaluation of suspected breast cancer", section on 'Our approaches'.)

The diagnosis of a benign or malignant breast mass is confirmed by a breast biopsy. The definitive diagnosis of a benign or malignant breast mass is based upon the histopathology from a core, incisional, or excisional tissue biopsy or a fine needle aspiration (cytologic evaluation). (See "Breast biopsy" and "Overview of benign breast diseases" and "Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Pathology'.)

FOLLOW-UP OF BENIGN BREAST MASS — The appropriate interval of follow-up for patients with benign biopsy is controversial and depends on the histology. Although various intervals (four or six months) have been proposed, no evidence-based guidelines are available to aid this decision [24].

For patients with a benign biopsy, we suggest repeating clinical examination and imaging every six months for two years, and if stable, patients may return to routine screening after that. Biopsy-proven benign masses that change clinically or radiographically, such as increasing in size on follow-up examinations, should be reevaluated and excised.

Whether a short follow-up interval is necessary has been questioned [25,26]. A study using the Breast Cancer Surveillance Consortium (BCSC) registry compared cancer detection rates and stage for patients with short-interval follow-up (three to eight months) with those who returned to routine screening (9 to 18 months) following benign core breast biopsy (stereotactic or ultrasonography guided) [24]. A total of 17,631 biopsies with benign findings were identified. Similar cancer detection rates were found for the short-interval follow-up and routine screening groups with no significant differences in stage, tumor size, or nodal status. Thus, it may be safe for those with a benign radiologic-pathologic-concordant percutaneous breast biopsy to return to routine screening; however, the study did not identify the spatial relationship between the finding that prompted the initial biopsy and the site of the subsequent cancer (which could have represented a false-negative result). (See "Screening for breast cancer: Strategies and recommendations".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Evaluation of breast problems".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or email these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Common breast problems (The Basics)")

Beyond the Basics topic (see "Patient education: Common breast problems (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Clinical manifestations – A breast mass can be discovered by the patient incidentally or on routine examination by a patient or clinician. It is often discovered after a breast examination prompted by other symptoms (eg, pain, nipple discharge) or trauma. The characteristics of the mass to be evaluated include density (such as soft, hard, or firm), skin changes, nipple-areolar changes, and/or fixation to the chest wall. (See 'Clinical manifestations' above.)

Differential diagnosis – The differential diagnosis of a palpable breast mass includes benign (eg, fibroadenoma, cysts) and malignant (eg, invasive and noninvasive cancer) etiologies. Although most palpable breast masses are benign, especially in young women, it is crucial to exclude breast cancer in a woman of any age. (See 'Differential diagnosis' above.)

Clinical evaluation – A systematic history including risk factors for breast cancer and physical examination are performed for every woman who presents with a new breast mass, whether it is palpable or only recognized radiographically. (See 'Clinical evaluation' above.)

Imaging – Because physical examination alone is usually insufficient to distinguish between a benign mass and a malignancy, diagnostic evaluation including radiographic imaging and, frequently, a breast biopsy is required. Breast imaging and breast biopsy are discussed in other topics. (See "Diagnostic evaluation of suspected breast cancer" and "Breast biopsy".)

Follow-up after benign biopsy – For patients with a benign breast biopsy, we suggest repeating clinical examination and imaging every six months for two years, and if stable, patients may return to routine screening after that. Biopsy-proven benign masses that change clinically or radiographically, such as increasing in size on follow-up examinations, should be reevaluated and excised. (See 'Follow-up of benign breast mass' above.)

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