What is the assessment for a breast growth?

Assessment of Breast Growth

The assessment of breast growth should include a comprehensive clinical breast examination (CBE), diagnostic imaging with mammography and/or ultrasound based on age, and tissue biopsy if suspicious findings are identified. 1, 2

Initial Clinical Breast Examination

• Begin with a thorough clinical history that identifies screening practices, any breast changes, and risk assessment including personal history of benign breast disease, prior biopsies, cancer, surgeries, hormonal therapy use, and family history 1
• Visual inspection should assess breast symmetry, shape, contour changes, and skin changes (erythema, retraction, dimpling, and nipple changes) 1
• Palpation should be performed with the patient lying down with ipsilateral hand overhead to flatten breast tissue against the chest wall, examining all breast tissue and nearby lymph nodes 1
• Differentiate true gynecomastia (glandular tissue enlargement) from pseudogynecomastia (fatty tissue deposition), especially in patients with elevated BMI 2

Diagnostic Imaging

For patients younger than 30 years:

• Ultrasound is the initial recommended imaging study for breast masses 1, 2
• Consider diagnostic mammography only if clinically suspicious findings are present 1

For patients 30 years and older:

• Diagnostic mammography plus ultrasound is the standard approach 1
• Digital breast tomosynthesis (DBT) can improve lesion characterization compared to conventional mammography 1

Imaging findings classification:

• BI-RADS category 1-2 (negative or benign): Follow with physical exam every 3-6 months ± ultrasound every 6-12 months for 1-2 years 1
• BI-RADS category 3 (probably benign): Follow with physical exam ± ultrasound and/or diagnostic mammogram every 6 months for 1-2 years 1
• BI-RADS category 4-5 (suspicious or highly suggestive of malignancy): Proceed to tissue biopsy 1

Tissue Sampling

• Core needle biopsy is recommended for suspicious masses (BI-RADS 4-5) or clinically suspicious findings despite benign imaging 1
• For complex (cystic and solid) masses, core needle biopsy is preferred over aspiration 1
• For simple cysts, no further evaluation is typically needed 1

Follow-up After Core Needle Biopsy

• Benign and image-concordant findings: Physical exam ± ultrasound and/or mammogram at 6 or 12 months for 1 year 1
• Indeterminate findings or benign but image-discordant results: Physical exam ± ultrasound and/or mammogram at 6 or 12 months; surgical excision if significant increase in size or suspicion 1
• Atypical findings (atypical ductal hyperplasia, LCIS, ALH) or malignant findings: Surgical excision 1

Special Considerations

• Asymmetric thickening or nodularity requires the same diagnostic approach as a palpable mass 1
• MRI may be considered when conventional imaging is inconclusive, particularly for invasive lobular cancer or suspected ductal disease 1
• Ultrasound tends to underestimate breast tumor size while physical examination often overestimates small tumors and underestimates large ones 3, 4
• For men with breast growth, consider medication-induced causes such as spironolactone, and refer to endocrinology if hormonal imbalance is suspected 5, 2

Common Pitfalls to Avoid

• Do not rely solely on imaging when clinical suspicion is high; a clinically suspicious mass must be evaluated even if mammogram findings are normal 6
• Avoid unnecessary imaging in clear cases of gynecomastia as this can lead to additional unnecessary benign biopsies 2
• Remember that pregnancy and lactation cause physiologic breast changes that may mask pathologic disorders or appear as pathologic findings while being purely physiologic 7