Breast Mass in Pregnancy
Karen Y. Oh, MD
DIFFERENTIAL DIAGNOSIS
Common
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Normal Fibroglandular Tissue
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Fibroadenoma
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Simple Cyst
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Complicated Cyst
Less Common
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Breast Cancer
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Lactating Adenoma
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Abscess
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Phyllodes Tumor
ESSENTIAL INFORMATION
Key Differential Diagnosis Issues
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Start with breast ultrasound for palpable lumps in pregnancy
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Differentiate whether cystic or solid
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Simple vs. complicated cyst (both benign)
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Complicated cyst could be galactocele
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Solid mass requires more careful evaluation
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If benign-appearing, may follow in a young patient, though even benign lesions may grow in pregnancy
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If suspicious do not hesitate to perform mammogram and ultrasound-guided core biopsy
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If ultrasound negative, clinical follow-up warranted to assess for any changes
Helpful Clues for Common Diagnoses
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Normal Fibroglandular Tissue
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Slightly more echogenic parenchyma
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Usually very dense on mammographic imaging due to hormonal stimulation of tissue and milk production
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Fibroadenoma
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Most common breast mass across all age groups
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Peak age of occurrence → 20-30 years old
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Can significantly enlarge during pregnancy
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Many involute postpartum or after menopause
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Circumscribed homogeneous mass growing parallel to breast tissues
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“Wider than tall”
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Isoechoic or slightly hypoechoic to fat
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Variable effect on acoustic transmission
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May have posterior acoustic shadowing, no effect, or increased posterior enhancement
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If involuted fibroadenoma, may see echogenic, internal coarse “popcorn” calcifications
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Atypical fibroadenomas may also have irregular or microlobulated margins
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Should be sampled at any age if appears atypical
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Simple Cyst
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Presents as painful palpable mass, often with acute onset
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Anechoic circumscribed mass
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Smooth wall without irregularities or solid components
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Increased through transmission
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May have thin nonvascular septa
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Complicated Cyst
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Low-level internal echoes
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Proteinaceous debris, cellular debris, or cholesterol crystals
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Movement often visible with realtime imaging
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Consider galactocele (cyst filled with milk) if during lactation
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Can have fluid-debris level
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Color or power Doppler ultrasound can show active swirling of debris
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Benign finding; not an indication for removal or biopsy unless patient symptomatic and desires aspiration
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Aspiration may require 18-gauge needle as fluid can be tenacious
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Helpful Clues for Less Common Diagnoses
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Breast Cancer
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˜ 3% of breast cancers occur during pregnancy or lactation
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Cancers are considered pregnancy-associated if occurs during pregnancy or within 1 year of delivery
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Palpable hypoechoic, irregular mass; no specific appearance in pregnancy
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May have posterior acoustic shadowing and echogenic halo
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Do not hesitate to biopsy if lesion suspicious
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Breast cancer can occur at any age
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Late diagnosis common when found during pregnancy
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Could be due to difficult breast exam, age of patient, rapid growth in setting of many physiologic changes
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Treatment should be initiated despite pregnancy
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Including surgery and chemotherapy
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No significant known risk to the fetus in the 2nd-3rd trimester
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Radiation therapy usually deferred
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Most report similar outcome to patients with breast cancer diagnosed outside of pregnancy
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If compare patients with similar age and stage at diagnosis
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Some studies suggest prognosis worse during pregnancy if advanced stage at diagnosis
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If chemotherapy given, can cause premature menopause
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Lactating Adenoma
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Not sonographically distinguishable from fibroadenoma
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Abundant proliferative changes on histology, without atypia
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Pregnancy-associated changes with secretory activity
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Occurs during pregnancy and lactation
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More commonly occurs during pregnancy than lactation
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Abscess
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Correlate with clinical history of infection
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Usually erythematous/edematous overlying skin
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Focal, complicated fluid collection on ultrasound
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Can have irregular margins and echogenic halo of surrounding inflammation
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May be difficult to distinguish from neoplasm unless correlated with clinical history
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Ultrasound-guided drainage indicated to aid in resolution of infection
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May require multiple aspirations during course of treatment until resolution
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