Palpable breast mass

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A palpable breast mass is a distinct lesion detected during self-examination or routine breast cancer screening. The underlying etiology of palpable breast masses may be inflammatory (e.g., breast abscess, fat necrosis of the breast), neoplastic (benign breast tumors, breast cancers), or idiopathic (e.g., breast cysts). The initial workup of a breast mass should include a comprehensive history and clinical breast examination. Breast imaging is required in most patients with a palpable breast mass. Breast ultrasonography is the preferred initial imaging modality in individuals < 30 years of age, while diagnostic mammography or digital breast tomosynthesis (DBT) is preferred in individuals ≥ 30 years of age. An image-guided biopsy (usually core needle biopsy) is indicated for all patients with clinical or imaging features concerning for malignancy. Further management depends on the diagnosis and is covered in the respective articles. See “Overview of common breast conditions” for details.

The evaluation of breast masses in male individuals is not addressed in this article.

• Obtain a comprehensive clinical history
• Perform a clinical breast examination.
  • Document characteristics of the breast mass. ^[2][3]
  • Examine the draining lymph node groups.
  • See “Breast examination” for further details.
• Assess for risk factors for breast cancer. ; ^[4][5][6][7]
  • Factors associated with a decreased likelihood of malignancy
    • Age < 40 years
    • No family history of breast cancer
    • Mobile mass with well-defined borders
    • Overlying skin appears normal
    • Fluctuating size (e.g., with menstruation)
  • Factors associated with an increased likelihood of malignancy
    • Age ≥ 40 years
    • Family history of breast cancer
    • Mass that is firm, fixed, or has indistinct borders
    • Associated skin changes (e.g., peau d'orange), nipple inversion, or breast asymmetry ^[8]
    • Axillary lymphadenopathy,
    • Increasing size

A palpable breast mass should be thoroughly evaluated, regardless of patient age or risk factors for breast cancer. ^[2]

Patients < 30 years of age ^[2][6][8][9]

• High clinical suspicion for malignancy : breast ultrasound
• Low clinical suspicion for malignancy: Observe for 1–2 months.
  • Mass resolves: no further management
  • Mass persists: breast ultrasound

Patients ≥ 30 years of age ^[2][6][8][9]

• Mammography (diagnostic mammography or DBT); with or without ultrasound.
  • Clinical or imaging findings concerning for malignancy ; : biopsy
  • Imaging findings normal, benign, or probably benign : breast ultrasound

In patients with a palpable breast mass, breast ultrasound is the preferred first-line imaging modality in patients < 30 years of age; mammography or DBT is preferred in patients ≥ 30 years of age. ^[2][6]

In patients 30–39 years of age, breast ultrasound, mammography, and DBT are all appropriate first-line imaging options. ^[6]

Observation without initial breast imaging is not appropriate in patients ≥ 30 years of age. ^[2][9]

Initial age-appropriate imaging of a palpable breast mass ^[2][6]

Results of breast imaging are typically reported using the standardized American College of Radiology Breast Imaging Reporting and Data System (BI-RADS). ^[10]

• Age < 30 years: breast ultrasound
• Age ≥ 30 years: mammography or digital breast tomosynthesis (DBT)
• Age 30–39 years: any of the above modalities
• Pregnant or lactating patients: breast ultrasound ^[11]

Premenopausal women < 30 years of age and lactating women often have dense breast tissue, which decreases the diagnostic power of mammography; ultrasound is recommended in these individuals. ^[6][11][12]

MRI breast is not routinely indicated in the evaluation of a palpable breast mass. ^[6]

Findings on breast ultrasound ^[2][13]

Ultrasound is the preferred imaging modality to differentiate solid from cystic lesions and to evaluate axillary lymph nodes. ^[14][15]

Findings on mammography or digital breast tomosynthesis

Breast ultrasound is the first diagnostic step in patients < 30 years of age who have clinical features concerning for malignancy. In patients ≥ 30 years of age whose mammography or DBT findings are normal, benign, or probably benign, a breast ultrasound should be performed for further evaluation. ^[2][6][8][9]

No abnormalities ^[2][6][9]

• Low clinical suspicion of malignancy: clinical surveillance for 1–2 years
  • Increase in size and/or clinical suspicion on surveillance: biopsy
  • No change in clinical suspicion or size of the mass on surveillance: Routine breast cancer screening is sufficient.
• High clinical suspicion of malignancy
  • Patients < 30 years of age: Obtain a diagnostic mammogram, followed by a biopsy if needed.
  • Patients ≥ 30 years of age: biopsy

Solid mass ^[2][6][9]

• Clinical or ultrasound findings concerning for malignancy : biopsy
• Low clinician suspicion of malignancy and probably benign findings on ultrasound : clinical surveillance for 1–2 years
  • Increase in size or clinical suspicion on surveillance: biopsy
  • No change in clinical suspicion or size of the mass on surveillance: Routine breast cancer screening is sufficient.

Clinical surveillance includes a CBE every 3–6 months with or without breast imaging every 6–12 months. ^[2]

Breast cyst ^[2][6][9]

• Management depends on the type of breast cyst (i.e., simple, complex, or complicated).
• See “Management of breast cysts” for details.

Biopsy (performed under image guidance when possible) is indicated in all patients with clinical or imaging features concerning for malignancy. ^[2][6]

• Core needle biopsy: (CNB): is preferred for most cases. ^[6][19]
• Excisional biopsy may be considered in the following situations: ^{[2][19][20][21]}
  • CNB is not feasible.
  • CNB findings are inconclusive or discordant from imaging findings.
  • CNB findings are suggestive of radial scar, atypical hyperplasia, LCIS, or phyllodes tumor.
• Full-thickness skin biopsy: (punch biopsy): preferred if skin or nipple changes are concerning for malignancy (e.g., Paget disease of the breast) ^[2]
• Fine-needle aspiration (FNA) ^[2][9][22]
  • Used in the evaluation of complicated and complex breast cysts.
  • Hemorrhagic aspirate should be sent for cytology.
  • CNB is indicated if the lesion persists post-aspiration or if a bloody aspirate is obtained.

Image-guided biopsies are usually preferred because they are less invasive than excisional biopsies and have similar accuracy. ^[6]

CNB has a higher sensitivity and specificity than FNA, can distinguish between noninvasive and invasive carcinomas, and allows for testing receptor status if needed.

Biopsy of breast tissue can affect imaging findings. Imaging should be performed prior to biopsy. ^[6][19]

• Benign lesion: See relevant articles for details; see also “Overview of common breast conditions.”
• Indeterminate lesion or radiopathological discordance: surgical excision
• Malignancy: See “Breast cancer.”

• Benign breast conditions
  • Fibroadenoma
  • Phyllodes tumor
  • Solitary intraductal papilloma
  • Breast cysts
  • Galactocele
  • Breast abscess
  • Fat necrosis of the breast
• Breast cancer
• See “Overview of common breast conditions” for differentiating features.

The differential diagnoses listed here are not exhaustive.