Palpable Breast Masses in Young Women

The incidence of breast carcinoma in young women is fortunately quite low, with an annual incidence of only 4.2 cases per 100,000 population in women aged 25-29, and only 0.6 cases per 100,000 in women aged 20-24. Given the low probability of malignancy, it would certainly be reasonable to reassure many patients and follow them over several menstrual cycles to see if the finding persists. If the palpable lump does not resolve, or if the patient is highly anxious or likely to be lost to follow-up, then further evaluation would be warranted. Open surgical excision is certainly definitive and may indeed be appropriate, especially if the patient wants the mass removed for cosmetic reasons. Routine surgical excision, however, is costly and invasive. In a review of 542 open surgical biopsies in women under age 30, Seltzer and Skiles found only four cases of cancer for an incidence of only 0.8%.

Oblique mammogram of a dense breast. No mass can be seen, even in retrospect.

Mammography, which is the initial imaging test of choice in older women, is of equivocal value in younger patients because these patients have very dense fibroglandular tissue which easily obscures lesions. In one study, 1016 women who had mammography before age 35 were followed, and in this group, six cancers were found. Mammography only prompted a biopsy in one case, and actually delayed the diagnosis in four of the remaining five cases of malignancy. Paradoxically, despite the fact that breast cancer is uncommon in younger women, the failure to detect a malignant mass in this age group is fraught with medicolegal peril. In a 1990 insurer's study, breast cancer was the second most common cause for suits, and resulted in the highest indemnity payments. Younger women often have more biologically aggressive breast cancers, with poor prognosis. In one study published in Surgical Oncology Clinics of North America, 39% of women who sued were less than 40 years old. Overall, these patients had a 71% false negative rate of mammography. Additionally, the risk of radiation carcinogenesis, while small, may not be negligible in younger women. For these reasons, mammography is not our first test of choice in younger women.

Scintimammography is an FDA-accepted examination, which has been shown to be about 85-95% sensitive to the detection of palpable breast carcinomas when the study is performed with optimal technique (with both planar and SPECT imaging). Scintimammography is useful for the evaluation of masses at least 1-2 cm in size, since smaller lesions are below its level of resolution. Scintimammography's positive predictive value for breast cancer in palpable masses is about 88% (compare to a valve of about 15-25% for mammography). The drawbacks include a prolonged imaging time of 3-4 hours, a cost of $800-900, and the inability to perform imaging guided biopsies with scintimammography.

Scintimammogram of above patient demonstrates a focus of abnormal increased uptake in the right breast.

Our initial imaging test of choice in younger women with palpable masses is ultrahigh-resolution ultrasound. Ultrasound has long been used to evaluate breast masses because it allows a noninvasive way to diagnose benign breast cysts, a common cause of breast masses. Ultrasound is also sensitive to the detection of invasive lobular breast carcinoma, which is typically mammographically occult. Suspicious lesions for malignancy can be easily, immediately, and accurately biopsied under US guidance for a global cost of about $400-500.

One limitation of US is that breast imaging requires extensive operator experience, and even radiologists who have had many years of US training and experience in other areas of the body may find ultrahigh resolution breast US initially challenging. As with all imaging studies, US can yield both false negative and false positive results, and the overall sensitivity of US in multicenter trials is under further review. Initial investigations found US to be 98% sensitive for malignancy when characterizing solid breast masses.

Sonogram of the same patient demonstrating the mass.

Sonogram demonstrating percutaneous biopsy, which was infiltrating ductal carcinoma.

In conclusion, physical examination and imaging findings should be used together for diagnosis. In Europe, fine needle aspiration (FNA) of suspicious palpable breast masses is routinely performed, largely replacing open surgical biopsy. FNA has also been advocated in the U.S. as a compliment to the physical exam and imaging comprising the so-called "Triple Test". When all three components of the Triple Test suggest a benign process, the diagnostic sensitivity is 98.8%, which parallels that achieved by frozen section and open surgical biopsy. Recently, the National Cancer Institute issued a special communication called The Uniform Approach to Breast Fine-needle Aspiration Biopsy, approved by a joint conference with the American Collages of Surgery, Radiology, Obstetricians and Gynecologists, Pathology and the American Academy of Family Physicians. This report makes recommendations about the appropriate role of FNA when evaluating breast masses. Open surgical biopsy will continue to play an important role in diagnostic evaluation of palpable breast masses, but patients, especially younger women, should be informed of both less invasive and noninvasive methods of evaluation.

REFERENCES:

Seltzer MH, Miles MS. Diseases of the breast in young women. Surg Gynecol Obstet 1980; 150:360-362

Williams SM, et al. Mammography in women under age 30: is there clinical benefit? Radiology 1986; 161:49-51

Basset LW, et al. Usefulness of mammography and sonography in women less than 35 years of age. Radiology 1991; 180: 831-835

Kern KA, Cady B. Medicolegal controversies in breast cancer: Biological basis and risk management. Surgical Oncological Clinics of North America. 1994; Vol 3. Number 1: 125-139

Clifford EJ,Lugo-Zamudio C. Scintimammography in the diagnosis of breast cancer. Am J Surg. 1996; 172: 483-486

Waxman AD. The role of 99m Tc Methoxisobutylisnitrile in imaging breast cancer. Seminars in Nuc Med. 1997; Vol 27: 40-54

Stavros AT, et al. Solid breast nodules: Use of sonography to distinguish between benign and malignant lesions. Radiology 1995; 196: 123-134

Shortsleeve MJ, et al. Ultrasound core biopsy- An economically advantageous method of diagnosing breast cancer. Applied Radiology 1997; June: 37-40

National Cancer Institute. The uniform approach to breast fine-needle aspiration biopsy. Diagn. Cytopathol. 1997; 16: 295-311

Layfield LJ. Can fine-needle aspiration replace open biopsy in the diagnosis of palpable breast lesions? Am J Clin Path 1992; vol 98,2: 145-147

Layfield LJ. The palpable breast nodule: a cost-effective analysis of alternate diagnostic approaches. Cancer 1993;vol 72,5: 1642-1650

Azzarelli A, Guzzon A, et al. Accuracy of breast cancer diagnosis by physical, radiological and cytological combined examination in 1498 patients. Tumori 1983; vol 69: 137-141

Rotsein S, Nilsson B, et al. Clinical examination, mammographic findings and cytological diagnosis in patients with breast disorders. Acta Oncologica 1992; vol 31,4: 393-397

Di Pieto S, Fariselli G, et al. Diagnostic efficacy of the clinical-radiological-cytological triad in solid breast lumps: results of a second prospective study on 631 patients. European J Surg Onco 1987;13:335-340

Dixon JM, Anderson TJ, et al. Fine needle aspiration cytology in relationships to clinical examination and mammography in the diagnosis of a solid breast mass. Br J Surg 1984; vol 71:593-596

Martelli G, Pilotti S, et al. Diagnostic efficacy of physical examination, mammography, FNA aspiration(Triple Test): an analysis of 1708 consecutive cases. Tumori 1990; Vol 76: 476-479

Vetto J, Pommier R, et al. Use of the "Triple Test" for palpable breast lesions yields high diagnostic accuracy and cost savings