Clinical Case: Breast Mass

Interview Questions

It is important to ask the patient the following questions:

  1. Do you have now or have you ever had cancer?
  2. Have you ever been hospitalized?
  3. Do you drink alcohol? If so, what do you drink and how many drinks per day?
  4. Do you have a history of cancer in your family?
  5. Do you have any chronic conditions/illnesses?

Clinical Findings

The clinical findings present in the patient might include various types of lumps, specifically, breast lumps or lumps in the armpit (Mersin, Kınaş, Gülben, İrkin, & Berberoğlu, 2015). They might have uneven edges and are rarely painful. Changes in the nipple skin can also be present, e.g., redness or dimpling. Additionally, it is possible to observe fluid coming from the nipple that might be clear or bloody or greenish/yellow. Changes in breast size/shape, as well as nipple inversion, can also appear. Furthermore, the clinician should pay attention to such findings as bone pain, difficulties with breathing, headaches, and abdominal pain.

Diagnostic Studies

Diagnostic studies prescribed for this patient should include the triple diagnosis, namely, physical exam, diagnostic mammography, and breast biopsy performed by a surgeon with expertise in breast cancer. Physical examination can be performed independently and by a trained clinician. Breast self-exam should be performed in a sitting position or lying down; although it was shown to be effective in increasing the number of early diagnosed breast cancers, women should not rely on BSE only (Corbex, Burton, & Sancho-Garnier, 2012).

Clinical breast-exam is also important for cancer detection; “CBE has to be performed carefully, by trained personnel, taking from 7 to 10 minutes to complete” (Corbex et al., 2012, p. 430). It is recommended to examine the breast in vertical strips, starting at the axilla. Ultrasound is one of the most common methods for breast cancer screening (Ayoade, Tade, & Salami, 2012). Diagnostic mammography is more effective than BSE and CBE and has to be performed with a present radiologist, who will be able to control the visualizing process.

Berg et al. (2012) also point out that supplemental MRI screening can be advised to those at risk of developing breast cancer due to the family history or personal history of breast cancer, prior atypical biopsy, or suspected BRCA. It should be noted that patients with a breast mass who undergo ultrasound mammography might be referred to a surgeon for a core-needle biopsy because some of the cancers might not be visible on a diagnostic mammography.

Primary and Differential Diagnoses

The differential diagnoses include fibrocystic disease, fibroadenoma, and fat necrosis. The primary diagnosis is breast mass/neoplasm.

Fibrocystic disease’s symptoms include swelling or tenderness in the breasts, the presence of breast lumps (painful or not). The diagnoses can be confirmed with ultrasound, mammogram, or MRI. Sometimes, the clinician might refer the patient to breast biopsy to see if the breast mass is cancerous; the fibrocystic disease is common and usually not dangerous, although it might challenge the detection of breast cancer (Abhijit, Anantharaman, Bhoopal, & Ramanujam, 2017).

Fibroadenoma is also a common benign breast condition, which symptoms include a lump in a breast that moves upon touching, is tender or painless (sometimes painful), and can feel particularly tender before a period. To diagnose fibroadenoma, ultrasound and mammography are used. However, the patient’s lumps are not mobile.

Fat necrosis is a benign breast finding that can be caused by a recent trauma or radiation treatments, as well as breast biopsy. Fat necrosis is usually present in the form of a lump or a pseudo-mass that can be confused with another condition (including carcinoma) due to its various appearances on mammography, ultrasound, MRI, etc. (Kerridge, Kryvenko, Thompson, & Shah, 2015). Fat necrosis is harmless and can be detected via mammography or ultrasound.

The final diagnosis is breast mass/neoplasm. Due to patient’s family history of cancer, recent rapid weight loss, and history of atypical ductal hyperplasia (a direct precursor to low-grade ductal breast cancer), the proposed diagnosis appears to be the most suitable among the other differential diagnoses (Hartmann et al., 2014). The patient will need to undergo the triple diagnosis described above in order to understand whether the detected breast mass is benign or cancerous.

Management Plan

Depending on the nature of the detected breast mass (benign or malignant), the patient will need to undergo mammography, ultrasound, possibly MRI, and breast biopsy. The patient should be informed that in case of malignancy, it is possible to perform lumpectomy and radiation or mastectomy. Tumor size and tumor location, as well as patient’s aesthetic preference, are important factors that influence the intervention (Kearney & Kirstein, 2013).

The patient should provide information about any contra-indications to radiation; the number of tumors detected will also affect the process of the intervention. Follow-ups after the intervention will also be necessary; when choosing between breast conservation or mastectomy, the patient should be aware that the first option might interfere with future mammography.

In case of a benign breast mass, the patient will need to be educated about its influence on her well-being (possible recurrent pains or lack of symptoms), as well as taught breast self-examination technique. In case of any new symptoms (pain, fluids, new lumps or findings), the patient will need to visit a GP for an examination.

References

Abhijit, M. G., Anantharaman, D., Bhoopal, S., & Ramanujam, R. (2017). Benign breast diseases: Experience at a teaching hospital in rural India. International Journal of Research in Medical Sciences, 1(2), 73-78.

Ayoade, B. A., Tade, A. O., & Salami, B. A. (2012). Clinical features and pattern of presentation of breast diseases in surgical outpatient clinic of a suburban tertiary hospital in South-west Nigeria. Nigerian Journal of Surgery, 18(1), 13-16.

Berg, W. A., Zhang, Z., Lehrer, D., Jong, R. A., Pisano, E. D., Barr, R. G., & Morton, M. J. (2012). Detection of breast cancer with addition of annual screening ultrasound or a single screening MRI to mammography in women with elevated breast cancer risk. JAMA, 307(13), 1394-1404.

Corbex, M., Burton, R., & Sancho-Garnier, H. (2012). Breast cancer early detection methods for low and middle income countries, a review of the evidence. The Breast, 21(4), 428-434.

Hartmann, L. C., Radisky, D. C., Frost, M. H., Santen, R. J., Vierkant, R. A., Benetti, L. L., & Degnim, A. C. (2014). Understanding the premalignant potential of atypical hyperplasia through its natural history: A longitudinal cohort study. Cancer Prevention Research, 7(2), 211-217.

Kearney, T., & Kirstein, L. (2013). Management of common breast problems 2013 – 2014. Web.

Kerridge, W. D., Kryvenko, O. N., Thompson, A., & Shah, B. A. (2015). Fat necrosis of the breast: A pictorial review of the mammographic, ultrasound, CT, and MRI findings with histopathologic correlation. Radiology Research and Practice, 1(8), 1-9.

Mersin, H. H., Kınaş, V., Gülben, K., İrkin, F., & Berberoğlu, U. (2015). What has changed in the clinical presentation of breast carcinoma in 15 years? Turkish Journal of Surgery/Ulusal Cerrahi Dergisi, 31(3), 148-151.