A 56-year-old woman presented with a new palpable lump in the left breast. Left MLO mammogram from the current study as well as a study from 4 years ago are provided. What is your BIRADS?

Underneath the area of the palpable lump in the left breast, a circumscribed isodense mass is seen with internal coarse calcifications; most likely an involuting fibroadenoma. It was also seen in the 2015 study with peripheral calcification. Though the patient may be now able to feel the same lesion (may be due to post-menopausal changes in the breast or maybe the patient has started consciously performing breast self-examination etc.) at the same time a new underlying more sinister cause that is obscured by dense breast tissue on mammogram is not ruled out,  she deserves further evaluation with cone compression view/ Tomosynthesis and ultrasound for the region of new palpable concern. That is why this mammogram should be reported as BI-RADS 0 and the patient should be further evaluated.  If the further workup confirms the palpable lump to correlate with this involuting fibroadenoma and no other suspicious feature is identified, then she can be discharged with final BI-RADS 2 after the complete work up. 

It will be a good idea to read the “Appropriateness criteria for palpable breast masses: Slanetz PJ, Moy L, Baron P, Didwania AD, Heller SL, Holbrook AI, Lewin AA, Lourenco AP, Mehta TS, Niell BL, Stuckey AR. ACR appropriateness criteria® breast imaging of pregnant and lactating women. Journal of the American College of Radiology. 2018 Nov 1;15(11):S263-75.

Causes of Palpable Breast Masses

Benign Conditions
  1. Fibroadenomas: These are common benign tumors made up of glandular and fibrous breast tissue. They are usually round, firm, and movable.
  2. Cysts: Fluid-filled sacs within the breast, which can vary in size and are often tender to touch.
  3. Fibrocystic Changes: This condition involves benign changes in the breast tissue, leading to lumps, tenderness, and sometimes nipple discharge. It’s often influenced by hormonal fluctuations.
  4. Intraductal Papillomas: These are small, benign growths in the breast ducts that can cause lumps and sometimes nipple discharge.
  5. Lipomas: Benign fatty tumors that are usually soft and non-tender.
 
Malignant Conditions
  1. Breast Cancer: Palpable masses can be a sign of breast cancer, which may present as a hard, irregular, and immovable lump. Associated symptoms can include changes in breast shape, dimpling of the skin, nipple retraction, and discharge.

Evaluation of Palpable Breast Masses

Clinical Examination
  • Physical Exam: A thorough breast examination by a healthcare provider to assess the size, shape, consistency, and mobility of the mass.
  • Medical History: Considering factors such as age, family history of breast cancer, and any previous breast conditions.
 
Imaging Studies
  • Mammography: An X-ray of the breast used to identify abnormal areas that may need further evaluation.
  • Ultrasound: Helps to distinguish between solid and cystic masses.
  • Magnetic Resonance Imaging (MRI): Provides detailed images, especially useful in dense breast tissue or when other imaging is inconclusive.
 
Biopsy

If imaging studies raise suspicion, a biopsy may be performed to obtain a tissue sample for histopathological examination. Types of biopsies include:

  • Fine-Needle Aspiration (FNA): Uses a thin needle to extract cells or fluid from the mass.
  • Core Needle Biopsy: Involves a larger needle to remove a core of tissue.
  • Surgical Biopsy: Entire lump or a part of it is surgically removed for analysis.

Biopsy

If imaging studies raise suspicion, a biopsy may be performed to obtain a tissue sample for histopathological examination. Types of biopsies include:

  • Fine-Needle Aspiration (FNA): Uses a thin needle to extract cells or fluid from the mass.
  • Core Needle Biopsy: Involves a larger needle to remove a core of tissue.
  • Surgical Biopsy: Entire lump or a part of it is surgically removed for analysis.

Management and Treatment

  • Benign Masses: Often managed conservatively with regular monitoring. Some benign masses, like large fibroadenomas or symptomatic cysts, may be surgically removed.
  • Malignant Masses: Requires a comprehensive treatment plan, which may include surgery, radiation therapy, chemotherapy, hormone therapy, and targeted therapy, depending on the stage and type of cancer.

Importance of Self-Examination and Regular Screenings

Regular breast self-examinations and screening mammograms are crucial for early detection of breast abnormalities. Women are encouraged to become familiar with the normal look and feel of their breasts to identify any changes early and seek medical evaluation promptly.

In conclusion, while palpable breast masses can be alarming, they are often benign. However, due to the potential risk of malignancy, it is essential to evaluate any new or changing breast masses thoroughly through clinical examination, imaging, and biopsy when necessary.

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