CASE 1    

          A 14-year-old female presents to your clinic with a breast lump. She reports that she
initially felt it about 2 weeks ago, and it was a bit painful when she had her cycle at that time.
She denies breast redness or trauma. She denies nipple discharge. She reports menarche at age
12, and her last menstrual period was 2 weeks ago. There is no family history of breast cancer.
Exam reveals a 2-centimeter, well-circumscribed firm rubbery mass in the lower outer quadrant
of the left breast that is slightly tender to palpation. No nipple discharge could be expressed.

1. What is the differential diagnosis for the breast mass in an adolescent?

 Adolescent benign breast masses

 Fibroadenomas – is the most common cause of adolescent breast pathology (67-
94% of all causes). There is a localized exaggerated response to estrogen where the
lesion increases in size usually over 6-12 months and then becomes stable. Most
are 2-3 cm in size.
 Fibrocystic breast disease – breast will have thickened, cord-like lesions that are
diffuse and often because larger and tender with menses. Occurs in 50% of
reproductive age women.
 Juvenile hypertrophy – extremely rapid breast growth that occurs shortly after
thelarche
 Juvenile papillomatosis – localized, proliferative lesion that is similar to a
fibroadenoma on examination
 Retroareolar cysts – also known as Cysts of Montgomery that serve in lactation –
are small raised projections at the edge of the areola which can obstruct and cause
inflammation or a mass
 Mammary duct ectasia – benign dilatation of the subareolar duct resulting in
inflammation and fibrosis, that usually has a bloody nipple discharge
 Mastitis, abscess or trauma – can cause a hematoma or fat necrosis.
 Adolescent malignant breast masses
 Phyllodes tumors – these may be benign, intermediate or malignant. They are
usually seen around 45 years of age, but have been reported in girls as young as 10.
 Primary breast carcinoma – has been reported in 39 children ages 3-19 years of
age
 Sarcoma
 Cancer metastatic to the breast – common tumors include Hodgkin’s lymphoma,
Non-Hodgkin’s lymphoma, primary hepatocellular carcinoma, neuroblastoma, and
rhabdomyosarcoma.

2. What is the most appropriate clinical approach to this patient?

 Know the History such as the characteristics of the mass, her OB history, family, history
and past medical history. A thorough patient history is necessary for the physician to
identify risk factors for breast cancer. Some risk factors are well established, and others
indicate probable or possible increased risk.
  Physical examination- A complete clinical breast examination (CBE) includes an
assessment of both breasts and the chest, axillae, and regional lymphatics through
inspection and palpation. Also note for its characteristics, apparent breast deformity,
changes in overlying skin, erythema; skin dimpling/ retractions; Peau De Orange,
tenderness, ulceration, nipple discharges and change in appearance (ulceration;
crusting; retraction), arm edema. Palpation of the axillae and neck
 Since there is a mass in the patient’s breast, we will use the diagram below. We will
obtain history and perform clinical breast examination. Since the patient is younger than
30 years old, we will suggest ultrasonography.

Approach to patient with breast mass

CASE 2

A 55-year-old female presents with a breast lump. She reports that she first felt it about 2
weeks ago, and it is nonpainful. She denies breast redness or trauma. She denies any rash on
the breast or nipple discharge. She reports menarche at age 12 and menopause at age 49. She
has no family history of breast cancer. Exam reveals a 1-centimeter well-circumscribed firm
mass in the upper outer quadrant of the right breast that is nontender to palpation. No nipple
discharge could be expressed, and there is no axillary adenopathy.

1. What is the differential diagnosis for the breast mass in this patient?
With age, there's also an increasing risk of abnormal growths in the breast. Breast lumps are
common around the menopause. They're usually cysts, which are harmless lumps filled with
fluid but breast cancer is most common in women over 50. It is indicated in the table below
that for patient’s over 50 years old, assume cancer until proven otherwise since it is the most
common pathology in that groupage.
2. What is the most appropriate diagnostic approach to this patient?

Most countries use the ‘triple test’ approach which is the combination of clinical
examination, breast imaging (mammography, ultrasound or MRI) and nonsurgical biopsy
(fine needle aspiration cytology and/or core biopsy) for a more accurate diagnosis. In
this patient a mammography and a biopsy is requested.

3. Describe 4 evaluation techniques of breast masses and when to use them

A. Mammography
 The 2 categories of mammograms are screening and diagnostic. Women
presenting with a breast mass must undergo bilateral diagnostic mammography.
Diagnostic mammography can be performed in women at any age; however, in
women younger than 40 years, the dense glandular breast tissue lowers the
sensitivity
B. Ultrasonography
 Ultrasonography can effectively distinguish solid masses from cysts. Although
ultrasonography is not considered a screening test, it is more sensitive than
mammography in detecting lesions in women with dense breast tissue. It is
useful in discriminating between benign and malignant solid masses, and it is
superior to mammography in diagnosing clinically benign palpable masses.
Ultrasonography is preferred in patients younger than 40.
C. Breast MRI (magnetic resonance imaging)
 Uses radio waves and strong magnets to make detailed pictures of the inside of
the breast. For certain women at high risk for breast cancer, a screening MRI is
recommended along with a yearly mammogram. MRI is not recommended as a
screening test by itself because it can miss some cancers that a mammogram
would find. It is sometimes used in women who already have been diagnosed
with breast cancer, to help measure the size of the cancer, look for other tumors
 in the breast, and to check for tumors in the opposite breast. But not every
woman who has been diagnosed with breast cancer needs a breast MRI.
D. Breast Biopsy
 When other tests show that you might have breast cancer, you will probably
need to have a biopsy. 
  Fine needle aspiration (FNA) biopsy- It is fairly quick, and the skin doesn’t have
to be cut, so no stitches are needed and there is usually no scar. An FNA biopsy is
the easiest type of biopsy to have, but it can sometimes miss a cancer if the
needle does not go into the cancer cells, or if it doesn't remove enough cells
 Core needle biopsy (CNB)- For a CNB, the doctor uses a hollow needle to take
out pieces of breast tissue from a suspicious area the doctor has felt or has
pinpointed on an imaging test.  The procedure itself is usually quick, though it
may take more time if imaging tests are needed or if one of the special types of
CNB described below is used.
 Surgical (open) biopsy- In some situations, such as if the results of a needle
biopsy aren’t clear, you might need a surgical (open) biopsy. During this
procedure, a doctor cuts out all or part of the lump so it can be checked for
cancer cells.

Reference:
Breast changes in older women. (n.d.). Retrieved from https://www.nhs.uk/live-well/healthy-
body/breast-changes-in-older-women/
Breast MRI: MRI For Breast Cancer. (n.d.). Retrieved from
https://www.cancer.org/cancer/breast-cancer/screening-tests-and-early-detection/breast-mri-
scans.html
Pediatric Education. (2013, November 12). What is the Differential Diagnosis of a Breast Mass?
Retrieved from https://pediatriceducation.org/2007/05/07/what-is-the-differential-diagnosis-
of-a-breast-mass/
Pruthi, S. (2001, June). Detection and evaluation of a palpable breast mass. In Mayo Clinic
Proceedings (Vol. 76, No. 6, pp. 641-648). Elsevier.
Salzman, B., Fleegle, S., & Tully, A. S. (2012). Common breast problems. American family
physician, 86(4), 343-349.
Thigpen, D., Kappler, A., & Brem, R. (2018). The role of ultrasound in screening dense breasts—
A review of the literature and practical solutions for implementation. Diagnostics, 8(1), 20.