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    ACOG Guidelines at a Glance: Diagnosis and management of benign breast disorders

     

    Breast masses

    A palpable breast mass is the most common finding of symptomatic breast cancer. Evaluation of a breast mass begins with a detailed history, assessment of breast cancer risk, and physical examination and requires age-appropriate breast imaging. Breast masses are common and typically benign. Certain qualities of a mass (e.g. mobile, unattached to surrounding tissue, discrete, smooth surface) are reassuring to the provider that a mass in a young woman is benign. Based on the history and physical exam, the provider can often make the right diagnosis of benign or malignant but not necessarily to the degree that is reassuring for the provider and/or the patient.2 Cyst aspiration and cytology of the fluid is used in a more limited fashion and primarily only for larger, bothersome simple cysts. If aspiration is done, the fluid is non-bloody and the mass is gone, simple close follow-up is acceptable. If the mass does not totally resolve, recurs or the fluid is bloody with aspiration, a tissue biopsy is indicated. In the setting of a mass seen as solid on ultrasound, further imaging and likely biopsy may be merited. When imaging is ordered in the setting of a breast complaint, it should be diagnostic and not screening. Depending on the imaging unit, they may immediately proceed without additional orders to secondary imaging and even biopsy as indicated by the classification of the initial images. Providers should be aware of the reporting and diagnostic steps of the imaging group and ensure that subsequent reports are tracked and follow-up is performed. A system similar to that for Pap smear tracking may be used. Once the diagnosis is determined the treatment recommendations are nicely outlined in the bulletin.  

    Nipple discharge

    Nipple discharge can be alarming to a woman. The algorithm in the practice bulletin helps to divide this presentation into 4 groups that guide diagnostic steps. These are based on the nipple discharge being associated with: 1) a breast mass (evaluate per mass algorithm); 2) spontaneous unilateral discharge (needs imaging and biopsy); 3) bilateral milky discharge (likely endocrine); or 4) non-spontaneous, multi-ductal discharge (probably trauma or self-expression). The role of color, consistency, and presence of blood in the discharge, uniductal vs. multiductal will help direct evaluation and management.   

    Breast pain and skin lesions

    Breast pain and skin lesions are commonly manifestations of systemic dermatologic issues (e.g. eczema, monilia, hidradenitis suppurativa), trauma, inflammation and endocrine pathologies. The history and physical exam should specifically explore for these possibilities. Because these lesions may represent an underlying malignancy, recurrent skin lesions, persistent edema, peau d’orange appearance, ulcerations or erythema warrant imaging and tissue confirmation of the diagnosis. 

    NEXT: Determing breast cancer risk

    Sharon T. Phelan, MD
    Dr. Phelan is a Professor in the Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque.

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