WIDI - R10) Enlarging breast mass in a 22-year-old female

R10) Enlarging breast mass in a 22-year-old female

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with a breast mass.
Review the DDx considerations in a breast mass.
Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with a breast mass.

History

A 22-year-old G1P0 female at 10 weeks gestation presents to the clinic with an enlarging, painless palpable mass in her left breast that has progressively enlarged over the past two months. She does not recall any physical injuries in the left upper region of her chest.

Physical Exam

BP: 128/88, HR 72, RR 14, Temp 99.2, O2 saturation 98%. Breast: The skin is normal. No abnormal discharge. Soft, mobile mass with well-defined borders on palpation of the left breast. The mass is at the 7:00 position, 6cm from the nipple.

Labs

None

Provisional Diagnosis

Select the Dx you believe is most appropriate

Fat Necrosis

Neoplastic mass

Benign Mass

The patient most likely has a benign mass considering her young age and characteristics of the mass (well defined, soft, and mobile). In this pregnant patient, this mass is most likely a fibroadenoma, which usually enlarge with higher levels of estrogen. The absence of breast trauma makes fat necrosis less likely.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient will require routine workup and management.

First Imaging Study

What is the first imaging study you will order?

MRI

Ultrasound

Mammography

A left breast ultrasound is the best option as it is noninvasive and does not subject the patient to radiation. In this young patient (age <40) with dense breast tissue, ultrasound better assesses masses than mammography.

View ACR Appropriateness Criteria

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

Ultrasound

The mass is well-circumscribed.

Yes

The mass is well-circumscribed and exhibits a “pseudo-capsule.”

The mass demonstrates heterogeneous echotexture.

Yes

The mass demonstrates homogeneous echotexture.

View Report

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View the full study if you'd like to take a look yourself.

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Second Imaging Study

What is the next imaging study you will order?

MRI

CT Scan

Mammogram

None

No further imaging is required as the diagnosis is confirmed with ultrasound.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Phyllodes tumor

Simple fibroadenoma

Juvenile fibroadenoma

Breast cancer

This patient presenting with a palpable breast mass during pregnancy with ultrasound findings of a homogeneous mass with well-defined border most likely has a fibroadenoma. Juvenile fibroadenomas occur in patients between the ages of 10-18.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient will require routine workup and management.

Assessment and Plan

Please provide your assessment and plan for this patient

This patient is a 22-year-old female at 10 weeks gestation presenting with a soft, mobile breast mass with homogeneous echotexture and well-defined borders on ultrasound consistent with a fibroadenoma. There should be a discussion with the patient as to whether she would prefer to undergo routine imaging follow-up and breast examination at 3-6 months or an ultrasound guided core-biopsy.

Lessons Learned:
- Fibroadenomas are estrogen-responsive tumors. As such, they are most likely to occur in patients who are of reproductive age, pregnant, and lactating. They enlarge in the pre-ovulation phase of the menstrual cycle.
- Most fibroadenomas occur in the upper outer quadrant and are well-circumscribed, soft, and mobile.
- The best diagnostic modality in a patient younger than 40 is an ultrasound. Younger patients are more likely to have dense breasts which can obscure lesions on mammography.
- Ultrasound findings reassuring that the mass is a benign fibroadenoma include homogeneous echotexture, well-defined margins, and sometimes a “pseudocapsule.”
- The diagnosis of a benign fibroadenomas can be confirmed with a core-needle biopsy or followed with serial short-term (3-6 month) imaging and breast examination. A complex fibroadenoma that continues to grow increases risk of breast cancer and warrants an ultrasound-guided biopsy. Fibroadenomas greater than 2.5cm without previous imaging should undergo biopsy.

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