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# GRF20312
Breast Mass
Evaluation
WILLIAM H. HINDLE, MD
Department of Obstetrics and Gynecology, University of Southern
California Keck School of Medicine, Los Angeles, California
A breast lump is the most common present-
ing symptom/complaint in most breast clin-
ics and centers. In the Breast Diagnostic
Center (Women’s and Children’s Hospital,
LAC+USC Medical Center, Los Angeles,
CA), statistical review of 2,458 consecutive
patients seen in 1999 revealed that 51% of
the patients presented with a palpable breast
mass. The other presenting complaints were
pain 24%, abnormal mammogram 7%,
follow-up 7%, pain and mass 6%, nipple dis-
charge 4%, and other 2% (the sum is >100%
due to rounding). Thus, 57% of patients ac-
tually presented with a possible mass (total
number with mass and pain plus mass). It is
of interest that clinical breast examination
revealed a palpable dominant breast mass in
about half of the possible breast mass cases.
These percentages are essentially the same
as a previous review covering 1995 to 1997.
A persistent dominant palpable breast
mass must be definitively diagnosed. This
can be achieved with cytology of an ad-
equate cellular sample obtained by fine-
needle aspiration (FNA) or with histology
obtained by tissue core-needle biopsy or
open surgical biopsy.1 If technically feasible
Correspondence: William H. Hindle, MD 2389-3E Via
Mariposa West, Laguna Woods, CA 92653. E-mail:
whindle@goldstate.net
CLINICAL OBSTETRICS AND GYNECOLOGY / VOLUME 45
750
CLINICAL OBSTETRICS AND GYNECOLOGY
Volume 45, Number 3, 750–757
© 2002, Lippincott Williams & Wilkins, Inc.
DOI: 10.1097/01.grf.0000022394.03824.71
and with expectation of a satisfactory cos-
metic result, the open surgical biopsy should
be the equivalent of a lumpectomy, with ex-
cision of the entire intact mass and with clear
surgical margins.2 All of these techniques
can be performed in an ambulatory setting.
FNA can be done in the office, tissue core-
needle in the office or radiology suite, and
surgery in an outpatient facility. No anesthe-
sia is required for an FNA, and usually only
minimal local anesthesia is needed for a tis-
sue core-needle biopsy. Sedation and gener-
ous local anesthesia is most commonly used
for open surgical biopsy. The residual for
FNA is a needle puncture site (the same as
for a venipuncture), usually a 0.5-cm scar
for tissue core-needle biopsy, and about a
2-cm scar for open surgical biopsy. A logical
sequence of procedures to follow would
seem to be FNA first, then tissue core-needle
biopsy, and then open surgical biopsy, the
progression proceeding step by step until a
definitive diagnosis is obtained.
A palpable dominant breast mass is a
three-dimensional distinct mass with bor-
ders that are separate from, and texture that
is different from, the surrounding breast tis-
sue. If such a mass persists, it is imperative
to obtain a definitive diagnosis in a timely
manner (eg, within 2–4 weeks). However, if
the mass is clinically suspicious of malig-
/ NUMBER 3 / SEPTEMBER 2002

nancy, the diagnosis should be determined
more quickly. If the area of concern is an
indistinct or vague mass, it can appropri-
ately be re-evaluated in a month or more. For
instance, if the patient is having cyclic men-
strual periods and by examination it is un-
certain if the area of concern is a dominant
breast mass, the patient should be re-
examined after her next menstrual period. If
uncertainty persists, she should be referred
to a breast specialist for evaluation. Also,
even if a vague mass seems to have cleared
completely, the patient should be seen again in
a month or so to be certain that there is no re-
currence. In addition, if the patient feels by her
own examination that the mass is still there, or
that it has recurred, she should be re-evaluated
and offered referral to a breast specialist.
Breast-Oriented History and
Risk Factors
A breast-oriented history is an essential
component of breast mass evaluation. The
specific information that should be ob-
tained from the patient, and recorded in
her chart, includes the following: her spe-
cific breast complaints; the onset and
duration of her breast symptoms; her age;
the date of her last menstrual period; any
family history of breast cancer; particularly
in first-degree relatives (mother, sisters,
daughters); personal history of breast can-
cer; breast surgery (type and when per-
formed); date of her last mammogram and
the results; and hormone therapy, current or
past, oral contraceptive therapy, or any form
or regimen of estrogen and/or progesterone
therapy.
Numerous epidemiologic risk factors for
breast cancer have been reported, but most
women with breast cancer do not have any
of the identifiable risk factors except for be-
ing women and growing older. Risk factors,
present or absent, do not alter the breast
mass evaluation and the urgency to establish
a definitive diagnosis.
Breast Mass Evaluation 751
Clinical Breast Examination
A thorough and complete bilateral breast ex-
amination is mandatory when a patient
presents with a possible breast mass. The
steps of inspection and palpation for a clini-
cal breast examination are illustrated in Fig-
ures 1 and 2. Any visual sign of asymmetry,
bulging, erythema, nipple retraction, peau
d’orange, skin dimpling, skin discoloration,
skin retraction, and other skin or nipple ab-
normalities should be noted. During palpation
the size, exact location, mobility, texture, and
borders or margins of a mass should be noted.
Details and illustrations of clinical breast ex-
amination, including the precise recording of
findings, have previously been described.3
Fine-Needle Aspiration
FNA of a palpable breast mass that results in
an adequate cell sample usually provides a
definite cytologic diagnosis. 4 Different
techniques of FNA are shown in Figure 3.
FNA can readily be performed in the office
settling with equipment already available in
most medical offices. Details and illustra-
tions of various FNA techniques and the
preparation and results of the breast cytol-
ogy have previously been described.5,6
FNA can be performed on the patient’s
initial visit if there is a palpable mass. De-
pending on the logistics and the availability
of a cytopathologist, some breast clinics can
offer the patient an almost immediate (eg,
about 10 to 15 minutes) cytologic diagnosis
of the mass. Most clinics and offices have to
send the aspirates to a cytopathology labora-
tory, much like the way Pap tests are pro-
cessed. The aspirates can be made into slides
and fixed/stained on site or placed in a
liquid-based collection medium such as
ThinPrep (CYTYC Corp., Boxborough, MA).
Bleeding into the breast tissue after FNA
is a possible complication that may result in
ecchymosis of the skin and hematoma
deeper in the breast. Because a hematoma
can create a mammographic image sugges-
752 HINDLE

FIG. 1. Clinical breast examination. A. Inspection with the patient erect.

B. Inspection with the patient’s arms raised over her head. C. Inspection with
the patient pressing her hands on hips. D. Inspection with the patient leaning
forward. E. Position for palpation with the patient lying down. (Hindle WH.
The diagnostic evaluation. Obstet Gynecol Clin North Am. 1994;21:499–
517, by permission of WB Saunders.)

tive of invasive carcinoma, it is sometimes
recommended that the mammography be
performed before the FNA or more than 2
weeks afterward because falsely suspicious
images have not been perceived after 2
weeks.7 However, possibly due to differ-
ences in FNA techniques or other logistical
circumstances, some breast clinics have not
encountered difficulties with breast imaging
performed immediately or shortly after FNA
of a palpable dominant breast mass. See, for
example, the experience of 1,007 FNAs at
the Breast Diagnostic Center, Women’s and
Children’s Hospital.8
 Breast Mass Evaluation 753

FIG. 2. Clinical breast examination. A. Outline of the area of the entire

anterior chest wall to be palpated. B. Diagram of the vertical strip method of
systematically palpating the anterior chest wall. C. Pads of the middle three
fingers used for palpation. D. Rotary dime-sized motion used for palpation
with the finger pads. E. Light, medium, and firm pressure used to palpate
masses at variable depths within the breast. F. Gentle compression of the
nipple after palpation of the subareolar area. G. Palpation of the axillary area.
(Hindle WH. The diagnostic evaluation. Obstet Gynecol Clin North Am.
1994;21:499–517, by permission of WB Saunders.)
754 HINDLE

Palpable Breast Cyst warding and is not cost-effective except for

When the palpable breast mass is a cyst, bloody fluid. In a retrospective review of
FNA is not only diagnostic but can also be 689 cyst FNAs, no malignant cells were
therapeutic if the cyst is completely drained identified in the cyst fluid cytology except in
(Fig. 4). Cytology of cyst fluid is rarely re- frankly bloody fluids. The review con-

FIG. 3. Fine-needle aspiration. A. Informative tactile sensation of the

needle tip entering the mass and encountering resistance within the mass. B.
Aspiration with a small pistol-type syringe holder. C. Aspiration with a sy-
ringe and needle. D. Aspiration with a needle alone (without a syringe). E.
Sequential steps. Negative pressure within the syringe is applied only during
step 4. (Hindle WH. The diagnostic evaluation. Obstet Gynecol Clin North
Am. 1994;21:499–517, by permission of WB Saunders.)

cluded, “In clinical practice only frankly
bloody fluid should be submitted for cyto-
logic analysis. All other cyst fluids should
be discarded.”9 However, it is essential to
palpate the area of the cyst after aspiration
to ensure there is no residual cyst and no as-
sociated mass. If a mass is palpated, it de-
serves breast mass evaluation. Further, the
patient should be examined again in 2 to 3
months to ensure that the cyst has not re-
curred and that no palpable mass is present.
The occurrence of intracystic carcinoma
is rare, reported as 1:1,000 cysts.10 Intracys-
tic malignancies are usually associated with
frankly bloody cyst fluid and can become
large enough to be palpated. The common
papillary form of intracystic carcinoma is
soft, in contrast to the firm, hard texture of
invasive ductal carcinoma. However, the
consistency of a breast cyst by palpation is
markedly variable, from the typical soft
consistency, similar to that of a water-filled
balloon, to firm and even hard depending on
the fluid tension within the cyst. Usually a
cyst is mobile and has smooth distinct bor-
ders. It is often tender in women who are
having menstrual cycles and sometimes
painful during the premenstrual phase. If an
FNA is not performed, ultrasound can be
FIG. 3. Continued
Breast Mass Evaluation 755
used as an accurate technique for differenti-
ating a cyst from a solid mass.
Diagnostic Mammography
and the Diagnostic Triad
Diagnostic mammography, the clinical
breast examination (which includes the
breast-oriented history), and FNA are the
components of the diagnostic triad, or triple
test, of a persistent palpable dominant breast
mass. If the specific impressions in all three
tests are concordant, then the resultant diag-
nosis can be accepted with a high level of
confidence. If doubt remains, or the test re-
sults are not concordant, then a histologic di-
agnosis obtained by tissue core-needle bi-
opsy or open surgical biopsy is required.
Histologic and Cytologic
Diagnoses of Palpable Breast
Masses
An example of the palpable dominant breast
masses seen in a referral surgical clinic is
the review of 1,269 consecutive surgical
biopsy pathology reports (1993–1995) at
LAC+USC Medical Center. When summa-
756 HINDLE

FIG. 4. A. Fine-needle aspiration of a cyst. B. Therapeutic removal of cyst

fluid by fine-needle aspiration if no residual mass and no recurrence within
3 months. (Hindle WH. The diagnostic evaluation. Obstet Gynecol Clin
North Am. 1994;21:499–517, by permission of WB Saunders.)

rized, the histologic diagnoses were 33% fi-
brocystic changes/normal breast, 29% fibro-
adenoma, 20% carcinoma, and 18% other
benign lesions.11 In the same medical center
but in a separate hospital outpatient referral
clinic, a review of 3,267 consecutive FNA
cytology reports (July 1988 to June 1997)
from the Breast Diagnostic Center summa-
rized the cytologic diagnoses as 29% fibro-
adenoma, 20% fibrocystic changes/normal
breast, 13% inadequate for cytologic diag-
nosis, 7% adenocarcinoma, 6% cyst, and
25% consisting of all other diagnoses of 5%
or less. The patient population of the Breast
Diagnostic Center is 85% Hispanic, a group
known to have an incidence rate of breast
cancer of about 50% less than that of white
women.11,12 The population is also youth-
ful, with a mean age of 39 years (range
9–91). These statistics have been previously
described in detail.13
Although benign and malignant breast
lesions can occur at almost any age, fibro-
adenomas are most common during adoles-
cence and the early reproductive years, cysts
occur mostly during the later reproductive
years, and invasive cancer is most prevalent
in the postmenopausal years. In an analysis
of 227,165 women with diagnosed breast
cancer, the median age at diagnosis was
62.14
Nonpalpable Breast Masses
Nonpalpable breast masses, which are usu-
ally discovered by mammography or ultra-
sound, should have a complete imaging
workup with a definite impression and spe-
cific recommendations for treatment and/or
follow-up in the final imaging report. The
referring obstetrician-gynecologist should
make every effort to see that the recommen-
dations are carried out and, if they are not,

should record the reason in the patient’s
medical record (eg, patient refusal).
Conclusions
An obstetrician-gynecologist is often the
first physician consulted by a woman who
thinks she feels a mass in her breast and
the first physician to palpate a mass in a
woman’s breast that she was not aware of.
If examination confirms the presence of
a palpable dominant breast mass, the
obstetrician-gynecologist should either es-
tablish a definite cytologic or histologic di-
agnosis using the diagnostic triad of clinical
breast examination, mammography, and
FNA (or tissue core-needle biopsy) or refer
the patient to a breast specialist. Nonpal-
pable breast masses identified by mammog-
raphy or ultrasound should be completely
evaluated by a radiologist with a resultant
specific imaging impression and clear rec-
ommendations for further procedures and
follow-up.
A clinical breast examination is an essen-
tial component of a woman’s annual exami-
nation. The examination should be noted in
the patient’s medical record and an action
plan recorded for any abnormal findings.
When doubts about the presence or manage-
ment of a breast mass persist in the mind of
the patient or the physician, a timely referral
to a breast specialist is indicated.
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Breast Mass Evaluation 757
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