Последнее обновление 24.08.2014
«Clinical manifestations and diagnosis of a palpable breast mass». UptoDate 2014
ВВЕДЕНИЕ — Обследование пальпируемого образования молочной железы требует системного подхода к истории, физикальному осмотру и рентгенографическим образным исследованиям для обеспечения корректного диагноза. Ошибочный диагноз рака молочной железы является одним из наиболее частых причин исков по поводу злоупотребления служебным положением в Соединенных Штатах [1-3].
ОПРЕДЕЛЕНИЕ — объемное образование молочной железы — это узелок или рост ткани, которая представляет агрегацию когерентного материала. Оно может быть доброкачественным или злокачественным. Доброкачественная масса может быть солидной или кистозной, злокачественная — типично солидна. Кистозная масса с солидными компонентами (сложная киста) может также быть злокачественной.
Клиническая картина — клиническая картина пальпируемого объемного образования молочной железы вариабельна. Некоторые массы выявляются во время самоосмотра груди, другие обнаруживаются в ходе рутинного клинического осмотра молочных желез. Некоторые массы могут ассоциироваться с болью и/или выделением из соска (сукровичного, зеленого, белого, желтого) [4-6].
Травма молочной железы (например, автокатастрофа с ремнем безопасности, прямым повреждением от твердого объекта) может вести к формированию масс-образования МЖ вследствие развития жирового некроза или гематомы. Кроме того, травма может способствовать детекции существующей доброкачественной или злокачественной массы. Любая масса после травмы, которая не разрешается, требует полного обследования.
Физикальный осмотр пациентов с доброкачественным заболеванием молочных желез соответствует обследованию пациентов с раком, поскольку нормальная ткань молочных желез у женщин часто несколько узловата. Первая цель физикального осмотра состоит в определении наличия доминантной массы, утолщения или асимметрии. Это особенно важно у молодых женщин, молочные железы которых, как правило, более нодулярны, чем пожилых. В ретроспективном обзоре 605 женщин моложе 40 лет, которые обращались в маммологический центр для обследования объемного образования молочной железы, доминантная масса пальпировалась хирургом в 36% самовыявленных масс (количество = 484) и в 29% выявленных врачами масс (количество= 121).
При физикальном осмотре пальпируемое образование может быть очевидным или плохо определяемым; мягким, средним или плотным по консистенции; мобильным или фиксированным к грудной клетке или коже; болезненным или безболезненным . Масса может иметь хорошо определяемые или недискретные границы и может быть ассоциирована с клиническими находками, включающими экхимозы, эритему, peaud’orange (апельсиновую корку) или изъязвление кожи; протрузию или ретракцию соска; или у массы может не быть ассоциированных клинических находок. Однако, находки при клиническом осмотре не всегда могут отличать доброкачественную массу от злокачественной опухоли, даже клиническими экспертами. Исследования, которые изучали полноценность физикального осмотра для диагностирования доброкачественных против злокачественных объемных образований молочной железы, нашли, что клиницисты часто могут ставить правильный диагноз, но не в достаточной степени для клинициста или пациента. В исследовании симптоматических женщин, опытные исследователи, которые диагностировали «дифинитивный рак» при пальпации, были точны в 93% случаев . В другой серии, физикальный осмотр имел положительное предиктивное значение 73% и негативное предиктивное значение 87% .
Imaging studies — Characteristic imaging findings of a palpable breast mass include:
- A mammogram depicts a mass as a soft tissue density. The density may have discrete or irregular spiculated margins, or demonstrate architectural distortion, and in some clinical settings, can also be associated with gross or microscopic calcifications. While a mammogram can depict a mass that is abnormal or suspicious for breast cancer, the imaging study cannot make a definitive diagnosis. In addition, not all palpable masses can be imaged by mammography, such as premenopausal women with dense breast tissue.
Further discussion on mammographic imaging is reviewed separately.
- A targeted ultrasound will show if the mass is solid or cystic, or a combination of both. An ultrasound also provides information about the margins (sharp or ill-defined) and the presence or absence of a prominent vascular supply.
- MRI imaging studies, which categorize breast lesions as mass or nonmass lesions, depict a breast mass as an enhancing or nonenhancing mass. More rapid uptake of contrast is characteristic of a malignant mass. An MRI is not a necessary study for the evaluation of a palpable breast mass. MRI interpretation is reviewed elsewhere.
Histopathology/Cytology — 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).
EVALUATION — The clinical evaluation of a palpable breast mass begins with a complete history and physical examination [4-6]. The history should include a full review of medical and surgical illnesses, medications, 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 [4,5].
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.
- 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.
- 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.
- 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.
- The precise location of any breast mass.
- 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.
Факторы риска для развития рака молочной железы — 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.
Физикальный осмотр — The breast examination includes the neck, chest wall, both breasts, and axillae, and is part of a complete physical examination [4,11,12]. 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. The evaluation of a clinically suspicious mass should not be influenced by the phase of the menstrual cycle. The timing of the breast examination is not important in postmenopausal women, or premenopausal women who are taking birth control pills or other treatments that affect ovarian suppression.
Осмотр — 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.
Пальпация — 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. 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 [11-13]. 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 [11,14]. One hand stabilizes the breast while the other hand is used to perform the examination .
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 radial edge of the areola can be used to document location of the mass.
Mammography — A diagnostic mammogram is the first imaging study performed for a woman with a new, palpable breast mass, and should be performed even if a recent mammogram was negative. While the false negative rate of mammograms is less than 5% for clinically palpable breast cancers , a normal mammogram does not eliminate the need for further evaluation of a suspicious mass .
For women under age 30 years, the breasts are hypersensitive to radiation exposure ; however, if the clinical findings are suspicious, a mammogram should be performed .
Ultrasonography — For young women with a clinically benign mass, such as a fibroadenoma, and no family history of premenopausal breast cancer, an ultrasound is a useful initial diagnostic imaging study (see «Breast imaging for cancer screening: Mammography and ultrasonography» and «Diagnostic evaluation of women with suspected breast cancer» and «Overview of benign breast disease»). Targeted ultrasonography is a useful diagnostic test to evaluate a palpable mass, and is frequently ordered concurrent with the mammogram. It is particularly useful for assessing whether a mass is solid or cystic in nature.
Ultrasound is the first line of imaging in a woman who is pregnant and/or lactating.
MRI — Breast magnetic resonance imaging (MRI) is not indicated for the work-up of an undiagnosed mass. MRI is best reserved for diagnostic dilemmas and used with discretion, as there is a significant false positive rate, which dramatically increases the rate of benign biopsies. Diagnostic breast MRIs should only be performed in institutions that have the capacity for MRI-directed biopsy, as lesions seen on MRI may not be visible on other imaging modalities .
An MRI machine with a dedicated breast coil is employed for the test, and gadolinium dye is injected intravenously before the procedure. The dye can cause serious reactions in patients with underlying renal disease (nephrogenic systemic fibrosis and worsening renal failure). Baseline BUN and creatinine are routinely checked before the test is performed.
DIAGNOSIS — The diagnosis of a benign or malignant breast mass is confirmed by a breast biopsy.
The triple test or assessment refers to the concurrent use of physical examination, mammography, and needle biopsy for diagnosing palpable breast mass . Either a fine needle aspiration biopsy (FNA) or core biopsy can be employed. However, successful FNA requires experienced cytopathologists, as invasive cancers may not be differentiated from noninvasive cancers. In institutions where experienced cytopathologists are not available, the initial diagnostic procedure of choice should be core needle biopsy (CNB) rather than FNA. Another advantage of the CNB is that sufficient tissue can usually be obtained for hormone receptor analysis. Very few breast cancers are missed using the triple test.
FNA- or CNB-proven benign masses that change clinically or radiographically, such as increasing in size on annual examinations, should be reevaluated and excised.
DIFFERENTIAL DIAGNOSIS — The differential diagnosis of a palpable breast mass includes benign and malignant histologies.
Benign — Palpable breast masses are very common in women, and most palpable masses are benign [4,19,20]. Approximately 90% 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 .
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 is found elsewhere.
- 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 described as “mobile” as it can be rolled onto an edge. A fibroadenoma may be solitary, multiple, and bilateral.
- 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.
- Fibrocystic changes – Fibrocystic changes in the breast are common, particularly in premenopausal women, and may be prominent and organized. However, 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, bilateral or unilateral or focal. The breast tissue, particularly in the upper outer quadrants, may increase in size prior to the onset of menses, then return to baseline after the onset of the menstrual flow. On the clinical examination, the breast tissue frequently is nodular.
- Galactocele – A galactocele is a milk retention cyst common in women who are breast feeding.
- 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 , paraffin, or silicone [23,24]; an operative procedure such as breast reductive surgery  or autologous breast reconstruction ; and radiation therapy [27,28] to the breast. Fat necrosis from trauma is generally associated with skin ecchymosis.
Fat necrosis can often be clinically difficult to distinguish from a malignant mass.
Malignant — The differential diagnosis of a malignant breast mass includes multiple invasive histologies and noninvasive cancer. Further review of the pathology of breast cancer is discussed separately.
- The most common breast cancer is an infiltrating ductal breast carcinoma . This invasive histology accounts for approximately 70 to 80% of invasive breast cancers. Other invasive breast cancers include infiltrating lobular carcinoma and mixed ductal/lobular carcinoma. There are also variants of the invasive ductal carcinomas that can be detected as a palpable mass.
Most palpable breast cancers present as a hard mass, although some less aggressive histologies such as tubular carcinoma, may present as a very firm mass.
Infiltrating lobular carcinoma often presents as a prominent diffuse thickening of the breast rather than as a discrete mass.
Locally advanced breast cancer frequently presents as a large mass that may be fixed to the chest wall or skin and may be associated with matted or fixed axillary lymph nodes. Patients with inflammatory breast cancer typically present with a painful, enlarging, erythematous breast and may not have a palpable mass detected.
- Less commonly, noninvasive cancers with or without microinvasion can develop into a palpable mass.
- Second primary – For patients treated with breast conservation, a new breast mass palpated in the ipsilateral or contralateral breast may be a second primary breast cancer. The evaluation of a new breast in a breast cancer patient is performed as described. (See ‘Evaluation’ above and ‘Diagnosis’ above and «Diagnostic evaluation of women with suspected breast cancer».)
- Local recurrence – An ipsilateral palpable mass at the site of a previously treated breast cancer may represent a local recurrence. A biopsy provides the definitive diagnosis.
RADIOGRAPHICALLY IDENTIFIED MASSES — The history and physical examination described in this topic is also performed for patients who present with a mass or any other finding identified on mammography and/or ultrasound or MRI. Management of imaging detected lesions is reviewed separately.
SUMMARY AND RECOMMENDATIONS
- The clinical presentation of a palpable breast mass is variable. The characteristics of the mass to be evaluated include density (such as soft, hard, firm), as skin changes, nipple areolar changes and/or fixation to the chest wall.
- Imaging studies of a breast mass include mammography, which depicts a mass as a soft tissue density with sharp or spiculated margins. An ultrasound documents if the mass is solid or cystic and the character of the margins and presence of a blood supply. Not all palpable masses can be imaged by mammography, such as for women with dense breast tissue.
- A systematic history, including risk factors for breast cancer, and physical examination are performed for every woman who presents with a new breast mass. Diagnostic evaluation includes radiographic imaging and, frequently, a breast biopsy.
- For all women with a suspicious breast mass, a mammogram is the first diagnostic test performed. Frequently, an ultrasound is also performed concurrently as a component of the evaluation. An MRI should be reserved for diagnostic dilemmas. Breast masses in young women (under age 30 years) that are clinically consistent with a benign lesion, such as a fibroadenoma, and in whom there is no family history of breast cancer, can be first imaged by an ultrasound.
- The definitive diagnosis of a breast mass is made by a breast biopsy, which includes a fine needle aspiration, core biopsy, or an open biopsy. We prefer a core biopsy that can provide sufficient tissue for differentiation between invasive and noninvasive cancers as well as provide sufficient tissue for hormone receptor analysis.
- The differential diagnosis of a breast mass includes benign (eg, fibroadenoma, cysts) and malignant (eg, invasive, noninvasive) tissue.
Таблица 1. Risk and protective factors for developing breast cancer
|Low risk||High risk||Relative risk|
|Deleterious BRCA1/BRCA2 genes||Negative||Positive||3.0 to 7.0|
|Mother or sister with breast cancer||No||Yes||2.6|
|Age||30 to 34||70 to 74||18.0|
|Age at menarche||>14||<12||1.5|
|Age at first birth||<20||>30||1.9 to 3.5|
|Age at menopause||<45||>55||2.0|
|Use of contraceptive pills||Never||Past/current use||1.07 to 1.2|
|HRT (estrogen + progestin)||Never||Current||1.2|
|Alcohol||None||2 to 5 drinks/day||1.4|
|Breast density on mammography (percents)||0||≥75||1.8 to 6.0|
|Bone density||Lowest quartile||Highest quartile||2.7 to 3.5|
|History of a benign breast biopsy||No||Yes||1.7|
|History of atypical hyperplasia on biopsy||No||Yes||3.7|
|Breast feeding (months)||≥16||0||0.73|
|Postmenopause body mass index (kg/m2)||<22.9||>30.7||0.63|
|Oophorectomy before age 35 years||Yes||No||0.3|
|Aspirin||≥Once/week for ≥6 months||Nonusers||0.79|
- HRT: hormone replacement therapy.
- Adapted from: Clemons M, Goss P. Estrogen and the risk of breast cancer. N Engl J Med 2001; 344:276.
- The breast exam is started with the patient in a seated position with her arms relaxed. Breast inspection is aided by patient positioning. The patient is asked to raise her arms over her head so the lower part of the breasts can be inspected for asymmetry, skin changes, and nipple inversion or retraction. The patient then puts her hands on her hips and presses in to contract the pectoral muscles so that any other areas of retraction can be visualized.
- The regional lymph node exam is completed while the patient is still in the sitting position and includes the cervical, supraclavicular, infraclavicular, and axillary nodal basins.
- A bimanual examination of the breasts can be performed while the patient is still in the sitting position. This is especially useful for women with large pendulous breasts.
- The breast exam is completed with the patient in a supine position with the ipsilateral arm raised above her head. The area examined should extend from the clavicle superiorly to the rib cage inferiorly and from the sternum medially to the mid-axillary line laterally. A systematic approach ensures that the entire breast is examined. This can be accomplished with either concentric circles, a radial approach, or vertical strips, referred to as the «lawnmower» method.
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