be obtained.
Solid Breast Lumps
Fibroadenoma: Benign
As previously noted, benign breast lumps are usually smooth, round, and mobile. As with any lump, the ultrasound exam is key to making an accurate diagnosis. The most common benign solid breast mass is the fibroadenoma. How we treat women with this suspected condition illustrates our general approach to breast lumps that are thought to be benign.
Young women with breast lumps often show up in my office with a bored expression and an anxious mother. The daughters seem to know intuitively that the overwhelming probability is that their lump is not cancer. Thank God for moms, though, because despite the odds, sometimes a lump in a young woman will be malignant—as was the case of Michelle in chapter one who was only twenty-one when she discovered her lump.
However, in most cases, my young patients felt their nodule by chance as opposed to discovering it in their monthly self-exam. Usually the patient was aware of the problem weeks before telling her mom, hoping it would just go away.
On physical examination, the lump typically meets all the criteria for being benign—and the ultrasound shows a round or oval mass with smooth edges. The inside is gray to white in contrast to the interior of a cyst, which is black.
A small fibroadenoma can be safely observed as long as the patient is willing to come back at regular intervals or return immediately if there are signs of growth. When there is doubt about the diagnosis, or the family is anxious, an ultrasound-guided core needle biopsy (see chapter seven) typically confirms the diagnosis.
Once a benign diagnosis has been established, the pressure is off. Elective surgical removal can be performed if desired. Knowing that the spot is benign allows the surgeon to remove it with a small cosmetic incision on the border of the areola (the pigmented tissue surrounding the nipple), in the armpit, or in the skin fold below the breast (inframammary fold). There is no need to do the incision directly over the mass if a benign diagnosis has been established.
Cystosarcoma Phyllodes (CSP): Low-Grade Malignancy
Phyllodes tumors of the breast are unusual. Though considered malignant, they are curable in most cases. On examination they can look much like a fibroadenoma, which is one reason we prefer to do a core needle biopsy before removing a suspected fibroadenoma. The one clue that a lump may be a phyllodes tumor is rapid growth. When a patient notes that her lump has increased in size over the past several months, a phyllodes tumor should be suspected.
Again, a core needle biopsy makes the diagnosis. These tumors require complete surgical excision, which includes a thin rim of normal breast tissue. Failure to completely remove the tumors sets the stage for recurrence, so doing the surgery right the first time is the key to success. It takes a surgeon who is experienced in dealing with challenging breast problems to deal with cases of CSP.
If a cystosarcoma phyllodes proves to be malignant, patients are typically referred to both a medical and a radiation oncologist, although chemotherapy is not usually given and radiation is of limited benefit. Wide removal with the rim of normal breast tissue is the treatment of choice.
Next Steps for Possibly Malignant Solid Lumps
Solid lumps that are clinically suspicious are common in our practice. They are typically hard, non-mobile, and painless. After a careful exam of the breast and armpit, an ultrasound is ordered, along with a diagnostic mammogram.
FIBROCYSTIC DISEASE: NOT A DISEASE
During the early years of my practice we did not have ultrasound, and mammography was in its infancy. Core needle biopsies were primitive and clumsy and used sparingly, primarily to diagnose larger breast cancers.
The vast majority of biopsies in the early 1970s were still being done by surgically removing the entire breast mass. The most common diagnosis of a surgically removed breast lump was “fibrocystic disease.”
Back then we did not have the tools to evaluate the nature of a lump without doing an open biopsy. The decision to do such a biopsy was based primarily on whether or not we could feel a distinct mass. An anxious patient would often prompt us to be more aggressive about surgical removal.
All of the removed lumps were sent to the pathologist. In many cases the pathologist gave us a specific diagnosis, such as fibroadenoma or invasive breast cancer. However, it happened frequently that a specific diagnosis could not be made. Rather than calling the excised material normal breast tissue, it was commonly referred to as fibrocystic disease—when in fact it was just a variant of normal breast tissue.
We now substitute the term “fibrocystic changes” to imply a benign condition noted on core needle biopsy. Once the biopsy establishes the diagnosis of a fibrocystic condition, an open biopsy can usually be avoided.
The next step, once again, is a core needle biopsy using an ultrasound for guidance. Several samples are taken and a small titanium tissue marker is placed in the center of the mass. The “cores” are sent to pathology for analysis.
The challenge with suspicious breast lumps is making the diagnosis without delay. All too often in my practice I see a patient who has detected a small lump in her breast and her physician told her not to worry. The following is a list of common statements by physicians that should be ignored by patients:
• You’re too young to get breast cancer.
• Don’t worry; it doesn’t run in your family.
• Your mammogram was normal, so it can’t be cancer.
• It’s just hormonal changes, or it’s just fibrocystic disease.
• Breast cancer doesn’t cause breast pain.
• You need an open biopsy to make the diagnosis.
Women who suspect a breast lump must be on guard. This is a classic situation in which the woman must be better informed than the average physician, who often doesn’t have the time or experience to properly address her concerns.
When a woman suspects a lump, she must tell her physician that she insists on a directed ultrasound and a diagnostic mammogram if needed. If there are abnormal findings, she must demand a core biopsy. If the workup is negative, she should require follow-up visits two, four, and six months after the ultrasound. If there are still questions, she must insist on referral to a breast surgeon.
MAKING A DIAGNOSIS UNDER REAL-LIFE CONDITIONS
Janine found a small nodular prominence in her left breast. She was twenty-eight at the time and was planning her wedding.
On exam, I could feel her lump and it had all the features of a fibroadenoma. The ultrasound appearance was consistent with that diagnosis. She was in a rush and did not have time for a fine needle biopsy.
I explained that the overwhelming odds were that it was a fibroadenoma and could be safely followed. She promised to see me again soon after returning from her honeymoon.
One month later our reminder system indicated that she had not made a follow-up appointment. Our office made a call. I saw her the following day. On exam, her lump seemed
