BR.1. – An 18 year old lady has a firm, rubbery mass in the left breast that moves easily with palpation.
What is it? - Fibroadenoma.
How is the diagnosis made? - The underlying concern in all breast masses is cancer. The only safe answer,
even if the presentation favors benign disease, is to get tissue diagnosis. In this case it should be done in
the least invasive way possible: If offered, FNA (fine needle aspirate for cytology). If not, core biopsy or if
it is the only choice, excisional biopsy. Reassurance alone would not be a good choice! Mammogram
alone is not the way to go, either. Mammogram is primarily for screening, not for diagnosis. At age 18,
mammograms are useless (breast to dense). Sonogram is the only imaging technique suitable for the very
young breast.
BR.2. – A 27 year old immigrant from Mexico has a 12 x 10 x 7 cm. mass in her left breast. It has been
present for seven years, and slowly growing to it’s present size. The mass is firm, rubbery, completely
movable, is not attached to chest wall or to overlying skin. There are no palpable axillary nodes.
What is it? - Cystosarcoma Phyllodes.
Management: Tissue diagnosis is needed (some of these become outright malignant sarcomas), given the
size best done with core or incisional biopsy. Margin-free resection will follow.
BR.3. – A 35 year old lady has a ten year history of tenderness in both breasts, related to menstrual cycle,
with multiple lumps on both breasts that seem to “come and go” at different times in the menstrual cycle.
Now has a firm, round, 2 cm. mass that has not gone away for 6 weeks.
What is it? - Fibrocystic disease (cystic mastitis, mammary dysplasia0, with a palpable cyst.
Management: tissue diagnosis (i.e: biopsy) becomes impractical when there are lumps every month.
Aspiration of the cyst is the answer here. If the mass goes away and the fluid aspirated is clear, that’s all.
If the fluid is bloody it goes to cytology. If the mass does not go away, or recurs she needs biopsy.
Answers that offer mammogram or sonogram in addition to the aspiration would be OK, but not as the only
choice.
BR.4. – A 34 year old lady has been having bloody discharge from the right nipple, on and off for several
months. There are no palpable masses.
What is it? - Intraductal papilloma.
What is to be done? - The old concern over cancer is the issue, and the way to detect cancer that is not
palpable is with a mammogram. That should be the first choice. If negative, one may still wish to find an
resect the intraductal papilloma to provide symptomatic relief. Resection can be guided by galactogram, or
done as a retroareolar exploration.
BR.5. – A 26 year old lactating mother has cracks in the nipple and develops a fluctuating, red, hot, tender
mass in the breast, along with fever and leukocytosis.
What is it? - Sounds like an abscess…and in this setting it is. However, only lactating breasts are
“entitled” to develop abscesses. On anybody else, a breast abscess is a cancer until proven otherwise.
Management: Incision and drainage is the Rx. For all abscesses, this one included. But, if an option
includes drainage with biopsy of the abscess wall, go for that one.
BR.6. – A 49 year old has a firm, 2cm. mass in the right breast, that has been present for 3 months.
What is it? - This could be anything. Age is the best determinant for Cancer of the breast. If she had been
72, you go for cancer. At 22, you favor benign. But they will not ask you what this is, they will ask what
do you do.
Management: You have to have tissue. Core biopsy is OK, but if negative you don’t stop there: only
excisional biopsy will rule out cancer.
BR.7 and 8. – A 69 year old lady has a 4 cm. hard mass in the right breast, with ill defined borders,
movable from the chest wall but not movable within the breast. The skin overlying the mass is retracted an
has an “orange peel” appearance…or the nipple became retracted six months ago.
What is it? - Classical cancer of the breast.
What do you do? - Establish the diagnosis with tissue, as mentioned above.
BR.9. – A 72 year old lady has a red, swollen breast. The skin over the area looks like orange peel. She is
not particularly tender, and it is debatable whether the area is hot or not. She has no fever or leukocytosis.
What is it? - Another classic for cancer of the breast.
Management: Same as above: get that tissue diagnosis (here a punch biopsy of the skin is an option. It
probably is permeated with cancer).
BR.10. – A 62 year old lady has an eczematoid lesion in the areola. It has been present for 3 months and it
looks to her like “some kind of skin condition” that has not improved or gone away with a variety of lotions
and ointments.
What is it? - Another sneaky way for cancer of the breast to show up. If you get this one in an extended
matching set, the answer is Paget’s disease of the breast-which is a cancer under the areola.
Management: same as above: get tissue! A full thickness punch biopsy of the skin would be OK, but core
biopsy or incisional biopsy of the tissue underneath would be OK also.
BR.11. – A 42 year old lady hits her breast with a broom handle while doing her housework. She noticed a
lump in that area at the time, and one week later the lump is still there. She has a 3 cm. hard mass deep
inside the affected breast, and some superficial ecchymosis over the area.
What is it? - A classical trap for the unwary. It is cancer until proven otherwise. Trauma often brings the
area to the attention of the patient…but is not cause of the lump.
BR.12. – A 58 year old lady discovers a mass in her right axilla. She has a discreet, hard, movable, 2 cm.
mass. Examination of her breast is negative, and she has not enlarged lymph nodes elsewhere.
What is it? - A tough one, but another potential presentation for cancer of the breast. In a younger patient
you would think lymphoma. It could still be lymphoma on her. She needs a mammogram (we are now
looking for an occult primary), and the node will eventually have to be biopsied.
BR.13. – A 60 year old lady has a routine, screening mammogram. The radiologist reports an irregular
area of increased density, with fine microcalcifications, that was not present two year ago on a previous
mammogram.
What do you do? - You will not be asked to read X-Rays (particularly mammograms), but you should
recognize the description of a malignant radiological image – which this one is. Thus, we go back to our
old issue: we need tissue diagnosis. In this case the first attempt should be stereotactic radiologically
guided core biopsy. If unsatisfactory, the next move would be needle localized excisional biopsy.
BR.14. – A 44 year old lady has a 2 cm. palpable mass in the upper outer quadrant of her right breast. A
core biopsy shows infiltrating ductal carcinoma. The mass is freely movable and her breast is of normal,
rather generous size. She has no palpable axillary nodes.
The question is obviously what to do. The standard option here is segemental resection (lumpectomy), to
be followed by radiation therapy to the remaining breast, as well as axillary node dissection to help
determine the need for adjuvant systemic therapy.
BR.15. – A 62 year old lady has a 4 cm. hard mass under the nipple and areola of her rather smallish left
breast. A core biopsy has established a diagnosis of infiltrating ductal carcinoma. There are no palpable
axillary nodes.
Again, a management question. Lumpectomy is an option only when the tumor is small (in absolute terms
and in relation to the breast) and located where most of the breast can be spared. A modified radical
mastectomy is the choice here. Why go after the axillary nodes when they are not palpable?: Because
palpation is notoriously inaccurate in determining the presence or absence of axillary metastasis.
BR.16. – A 44 year old lady shows up in the Emergency Room because she is “bleeding from the breast”.
Physical exam shows a huge, fungating, ulcerated mass occupying the entire right breast, and firmly
attached to the chest wall. The patient maintains that the mass has been present for only “a few weeks”, but
a relative indicates that it has been there at least two years, maybe longer.
What is it? – An all too frequent tragic case of neglect and denial. Obviously a far advanced cancer of the
breast.
Management: the tissue diagnosis is still needed, and either a core or an incisional biopsy is in order, but
the likely question here is what to do next. This is an inoperable, and incurable as well…but palliation can
be offered. Chemotherapy is the first line of treatment. In many cases the tumor will shrink enough to
become operable.
BR.17. – A 37 year old lady has a lumpectomy and axillary dissection for a 3 cm. infiltrating ductal
carcinoma. The pathologist reports clear surgical margins and metastatic cancer in four out of 17 axillary
nodes.
The question here is what to do next: Only very small tumors with negative nodes and very favorable
histological pattern are “cured” with surgery alone. More extensive tumors need adjuvant systemic
therapy, and the rule is that premenopausal women get chemotherapy and postmenopausal women get
hormonal therapy. This is one clear one for chemotherapy.
BR.18. – A 66 year old lady has a modified radical mastectomy for infiltrating ductal carcinoma of the
breast. The pathologist reports that tumor measures 4 cm. in diameter and that 7 out of 22 axillary node are
positive for metastasis. The tumor is estrogen and progesterone receptor positive.
A variation on the previous one, but here a clear choice for hormonal therapy. The agent uses is
Tamoxifen.
BR. 19. – A 44 year old lady complains bitterly of severe headaches that have been present for several
weeks and have not responded to the usual over-the-counter headache remedies. She is two years post-op.
from modified radical mastectomy for T3, N2, M0 cancer of the breast, and she had several courses of postop chemotherapy which she eventually discontinued because of the side effects.
What is it? – A classic: severe headaches in someone who a few years ago had extensive cancer of the
breast means brain mets until proven otherwise. Don’t get hung up on the TNM classification, if the
numbers are not 1 for the tumor and zero for the nodes and met, the tumor is bad.
What do yo do? CT scan of the brain.
BR.20. – A 39 year old lady completed her last course of postoperative adjuvant chemotherapy for breast
cancer six months ago. She comes to the clinic complaining of constant back pain for about 3 weeks. She
is tender to palpation over two well circumscribed areas in the thoracic and lumbar spine.
A variation on the above theme. Now bone mets, instead of brain mets…at least until proven otherwise.
What do you do?: The most sensitive test for bone mets is bone scan. If positive, X-Rays are needed to
rule out benign reasons for the scan to “light up”.