THE MANAGEMENT OF CLINICALLY EVIDENT BREAST LESIONS

THE MANAGEMENT OF CLINICALLY EVIDENT BREAST LESIONS

“LUMPS” AND BREAST PAIN

I don’t think there is a clear consensus on the role of imaging for clinically evident findings. In my experience most women who present with a lump or thickening initially “found” the area because it was sore and they carefully “examined” the area for the first time. Because of the pain, the “lumpy” normal, but “sore”, breast tissue was perceived as being abnormal to the patient. Breast cancer rarely causes pain. If there is pain associated with a cancer it may be coincidental.  

At times a patient is unable to differentiate pain in the breast from chest wall pain (eg: costochondritis). If there is pain when the breast is pushed back against the chest wall, but not when the breast is compressed side to side (or top to bottom), then it is likely chest wall pain and not breast pain.

On occasion I have seen a few cancers that were associated with a ‘‘drawing’’ sensation, as if something was pulling from within the breast. Conversely, a palpable cyst or an abscess may cause pain.  

IMAGING EVALUATION

To avoid confusion, I always begin by stating in my report, “In the area of clinical concern as indicated by the patient” or “….as indicated by the history” and then provide my assessment.  

When evaluating an area of clinical concern with imaging our first role is to try to determine if there is actually a definable lesion or are they simply feeling heterogenous, “lumpy”, breast tissue. Certainly, when the mammogram shows all fat in the area of clinical concern, a malignancy is very unlikely (I have seen one case in 40+ years). If the area is all fat on the mammogram, I do not proceed to ultrasound. 

I have never used BIRADS 3 for a clinically evident lesion. I don’t think there is much useful literature on the management of clinically evident lesions that undergo imaging and are categorized as BIRADS 3. Since I still feel that there is a role for clinical evaluation, when I evaluate a clinically evident mass and I provide my imaging analysis and explain that I am not concerned by the imaging findings, but knowing that a negative mammogram does not exclude cancer, I still qualify my report by stating:

“Any decision for further intervention, at this time, should be based on the clinical assessment”.

ULTIMATE ASSESSMENT

Years ago we found that even if the mammogrpahy and ultrasound together are negative, the likelihood of a cancer, although still very low, is not zero ¹, assuming that the area is not all fat on the mammogram. I suspect that this also goes for what seem to be BIRADS 3 lesions as well. There are a small number of malignancies in the breast that look like fibroadenomas. I personally feel that core biopsy is very safe and accurate, and I prefer to not rely on imaging findings, but would recommend an imaging guided needle biopsy to determine the pathology of a solid mass. If you have highly skilled surgeons who can perform breast surgery very safely in an outpatient setting using local anesthesia or conscious sedation and with good cosmetic results, I would urge the removal of any, indeterminate, palpable solid masses.  This is especially true in younger women with a palpable mass which is almost certainly a fibroadenoma, but who may end up with repeated imaging and needle biopsies as they age and see new physicians who cannot be certain that the lesion is stable on their clinical examination and imaging comparisons may not be available. 

THE ROLE OF IMAGING

I think it is important to recognize and emphasize that mammography is, almost exclusively, a screening test ². Its main and perhaps only (but fundamental) value is the detection of breast cancers before they become clinically evident at a time when cure is more likely. Once that is understood, we long ago established the fact that when a woman presents with a clinically evident abnormality, mammography has little value in assessing the clinically evident lesion, but it has the important role of screening the rest of that breast and the contralateral breast for unsuspected malignancies ³. The mammographic demonstration of a “classic” cancer can prevent the unlikely chance that the clinician might decide to ignore the lesion, but, in fact, with a few exceptions such as a calcified, involuting fibroadenoma; cysts defined by milk of calcium; or well marginated lesions that contain fat (eg. lipomas and hamartomas), mammography is rarely able to accurately determine that something that is clinically evident is benign. 

Ultrasound has a fairly unique role in its ability to easily demonstrate that a lesion (clinically evident or occult) is a simple cyst and therefore of no concern. This may suffice to avoid further intervention. What has been ignored is the fact that a clinically guided aspiration of a palpable lesion is usually less expensive than ultrasound, and by draining a cyst not only is a benign diagnosis established, but it removes the “lump” as a concern to the patient. Despite the safety and ease (and lower cost) of a, clinically guided, cyst aspiration I suspect that most in the U.S., nevertheless, now rely on the ultrasound results.  

TELLING BENIGN FROM MALIGNANT

Although criteria have been developed whose presence on ultrasound increase the likelihood that a finding is benign, virtually every “benign” criterion can be found, on occasion, in malignant lesions. I personally do not rely on ultrasound to differentiate benign from malignant solid masses, but there are many who do.

If the patient has three or more similarly benign appearing lesions, I follow Sickles’ “rule of multiplicity”. If there are three or more of the same lesion (with the exception of masses with malignant characteristics such as irregular or spiculated margins), they are almost always benign and do not require further evaluation.   

YOUNG WOMEN

The randomized controlled trials (RCT) of screening have proven that early detection saves lives for women ages 40-74 (the ages of the women who participated in the trials). There are no ungrouped/unaveraged data that show that any of the parameters of screening, including lives saved, change abruptly at the age of 50. Age 40 is the scientifically derived age to initiate screening. The age of 50 is a completely arbitrary threshold with no scientific support. 

A recent paper claiming to evaluate women under the age of 40 with a clinically evident problem concluded that ultrasound was all that was needed ⁴. I think their conclusion to use ultrasound first (and often without mammography) was misguided and not supported by their data ⁵. In fact, their mammography identified occult cancer at a similar rate to that for women being routinely screened in their early 40’s and was likely lifesaving.  Contrary to their conclusions, mammography should be done in women ages 30 and over (certainly age 35 and over) for those who present with an area of clinical concern (with a “BB” marker placed on the area of concern). Ideally, the marker should be placed so that it overlies the lesion on the CC projection and moved so that the same is true on the MLO projection. The “BB” should be “on top of the lesion” in both projections.

Questions have been raised about screening women under the age of 40.  Since there are no RCT’s of women under the age of 40 there is no “proof” that finding cancers in these women earlier will save lives, but it is likely that, were it feasible, screening younger women would also save lives. In fact, in a study from Memorial in New York years ago when we used to obtain “baseline” mammograms at the age of 35, the investigators found, not surprisingly, that the cancer detection rate for women in their late 30’s was 1.4/1000 ⁶ which was the same rate as for women in their early 40’s. Yankaskas et al had similar results ⁷. Incongruously, some have argued that mammography is not needed for women in their thirties who present with a clinical area of concern, despite the fact that they find occult cancer detection rates of up to 2/1000 found by mammography. These authors ignored the fact that, with regard to young women, imaging of the lesion itself has little added value and, once again, the discovery of an unsuspected malignancy by mammography elsewhere in the breast may be lifesaving ⁸. 

RADIATION RISK

Concerns have been raised about the radiation risk from mammogrpahy among women in their thirties. Radiation risk is a concern for women in their teens and early twenties, but it drops off rapidly by age 30 and is unmeasurable by the age of 40.  Even the extrapolated risk by age 40 is so small that it is outweighed by even the smallest benefit. Certainly, if we advocated for routine mammography screening for women ages 30-39, the radiation might be a concern, but performing mammograms on the, relatively, small number of women in this age group who present with clinical concerns is unlikely to carry any major risk and may well be lifesaving. 

CONCLUSION

Given the importance of early detection and given the ability to biopsy and/or surgically remove lesions safely and accurately, I think it is best to at least biopsy clinically evident solid lesions, or to remove solid breast lesions regardless of their appearance (particularly in women under the age of 40) unless the lesion is clearly calcified or a circumscribed fat containing benign lesion.  

REFERENCES

1.Moy L, Slanetz PJ, Moore R, Satija S, Yeh ED, McCarthy KA, Hall D, Staffa M, Rafferty EA, Halpern E, Kopans DB. Specificity of mammography and US in the evaluation of a palpable abnormality: retrospective review. Radiology. 2002 Oct;225(1):176-81. doi: 10.1148/radiol.2251010999. PMID: 12355002.

2.Kopans DB. Breast imaging and the standard of care for the symptomatic patient. Radiology. 1993 Jun; 187(3):608-11.

3.Kopans DB, Meyer JE, Cohen AM, Wood WC. Palpable breast masses. The importance of preoperative mammography. JAMA. 1981 Dec 18; 246(24):2819-22. 

4.Chen Y, Chou SS, Blaschke EM, Specht MC, Lehman CD. Va lue of Mammography for Women 30-39 Years Old Presenting With Breast Symptoms. AJR Am J Roentgenol. 2018 Dec;211(6):1416-1424. doi: 10.2214/AJR.18.19591. Epub 2018 Oct 9. PMID: 30300000.

5.Doi.org/10.2214/AJR.18.20776   AJR:212, May 2019

6.Liberman L, Dershaw DD, Deutch BM, et al. Screening mammography: value in women 35–39 years old. AJR Am J Roentgenol 1993; 161:53–56.

7.Yankaskas BC, Haneuse S, Kapp JM, Kerlikowske K, Geller B, Buist DSM, for the Breast Cancer Surveillance Consortium, Performance of First Mammography Examination in Women Younger Than 40 Years, JNCI: Journal of the National Cancer Institute, Volume 102, Issue 10, 19 May 2010, Pages 692–701

8.Doi.org/10.2214/AJR.18.20776   AJR:212, May 2019