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Breast cancer differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Shadan Mehraban, M.D.[2] Soroush Seifirad, M.D.[3]

Overview[edit | edit source]

Breast cancer must be differentiated from other diseases such as malignancy, cysts, inflammation and non-inflammatory solid lumps. Breast symptoms such as nipple discharge and mastalgia require assessment as well. Differentiating breast cancer different types of breast lumps are based on imaging findings and breast clinical exam results.

Differentiating Breast cancer from other Diseases[edit | edit source]

ABBREVIATIONS
LAP=Lymphadenopathy, HRT=Hormonal replacement therapy, FNA=Fine needle aspiration, DCIS=Ductal carcinoma in-situ

Diseases Benign or

Malignant

Clinical manifestation Paraclinical findings Gold standard diagnosis
Demography History Symptoms Signs Histopathology Imaging
Mass Mastalgia Nipple discharge Breast exam Skin changes LAP
Fibroadenoma[1] + ± –
  • Solitary
  • Well-defined
  • Mobile mass
 – – Ultrasound:
  • Well-defined
  • Solid mass
Breast cyst[2]
  • May resolve after aspiration
  • Further evaluation for unresolved masses
 + ± –
  • Solitary
  • Cluster of small masses or an ill-defined mass
  • Smooth, firm, and frequently tender
 – –
  • Nonproliferative breast lesions
 Ultrasound:
  • Simple cyst: Well circumscribed, posterior acoustic enhancement without internal echoes
  • Complicated cyst: Homogenous low-level internal echoes due to without solid components
  • Complex cyst: Thick walls greater than 0.5 mm with solid component
Fibrocystic change[3]
  • Unknown prevalence among adolescents
  • >50% in women of reproductive age
 + + ± – –
  • Nonproliferative breast lesions
 Ultrasound:
  • Small cysts in mammary zone
  • Fibroglandular tissue around the mass
Galactocele[4][5] + ± ± – – Mammography:
  • Intermediate mass in absence of classic fat-fluid level

Ultrasound:

  • Complex mass
Cysts of montgomery[6]
  • Most common in age of 10-20 years old
  • More than 80% resolve spontaneously
  • Drainage is essential in rare cases
 + ± ±
  • Asymptomatic subareolar mass
  • Drainage of clear to brownish fluid
 ± – Ultrasound:
  • Single cystic lesion in retroareolar area
Hamartoma[7]
  • Common in women older than 35 years old
 ± – – ± – Mammography:
  • Well-described
  • Discrete, solid, and encapsulated lesion
Breast abscess[8][9]
  • Complication of lactational mastitis in 14% of cases
  • Common among African-American women, heavy smokers , and obese patients
 + + – + – Ultrasound:
  • Fluid collection
Mastitis[10][11] ± + ± + – Breast parenchyma inflammation: Ultrasound:
  • Ill-defined area with hyperechogenicity with inflamed fat lobules
  • Skin thickening
Diseases Benign or
Malignant 		Demography History Mass Mastalgia Nipple discharge Breast exam Skin changes LAP Histopathology Imaging Gold standard diagnosis
Breast carcinoma[12][13][14]
  • Most common diagnosed cancer among women
  • Leading cause of cancer death in women 40-49 years old
 + – ±
  • Hard
  • Immobile
  • Solitary
  • Irregular margin
 ± ± Mammography:

Ultrasound:

Ductal carcinoma in situ (DCIS)[15][16] ± – ±
  • May have normal physical exam
 – – Mammography:
Microinvasive breast cancer[17]
  • Rare
  • Commonly referred to DCIS with microinvasion
  • Average age 50-60 years old
 + – ±
  • Solitary
  • Firm palpable mass
 – ±
  • Associated with high grade DCIS
 Mammography:
Breast sarcoma[18]
  • Rare type, < 1% of all breast malignancies
  • Average age of between 45-50 years
 + – –
  • Well-defined
  • Firm mass
 ± – Mammography:
  • Noncalcified oval mass Indistinct margins
Phyllodes tumor[19][20] ± – –
  • Smooth and multinodular
  • Well-defined
  • Firm mass
  • Mobile
 – –
  • Nonepithelial breast neoplasm with average size of 5 cm
 Ultrasound:
  • Solid mass
  • Hypoechoic
  • Well-circumscribed

Mammography:

  • Smooth mass
  • Polylobulated mass
Lymphoma[21][22]
  • Extremely rare ( 0.04%-0.5%)
  • Average age 55-60 years
 + – –
  • Well-defined, firm mass
  • Multiple
 – ± Mammography:
Duct ectasia[23]
  • Usually resolve spontaneously
 ± ± ±
  • Usually asymptomatic
 – –
  • Distention of subareolar ducts
 Ultrasound:
  • Dilated milk ducts
  • Fluid-filled ducts
Intraductal papilloma[24]
  • Common in women between 35-55 years old
 + ± ±
  • Solitary or multiple lesion
  • Large lump near nipple
 – –
  • Growth of papillary cell into a lumen
 Ultrasound:
  • Well-defined
  • Solid nodule
Lipoma[25]
  • Common between age of 40-60 years old
  • Benign tumors
  • May experience recurrence
 + – –
  • Solitary
  • Mobile
  • Soft mass
 – – Ultrasound:
  • Well-Circumscribed
  • Hypoechoic lesion
Sclerosing adenosis[26][27]
  • Recurrent pain during mensturation
  • May present as a mass or incidental finding on mammogram
  • No treatment is needed
 ± + –
  • Multiple lesion
  • Firm
  • Tender nodules
 ± –
  • Proliferative disease
 Mammography:
Pseudoangiomatous stromal hyperplasia[28][29]
  • Common in reproductive age women
 + – –
  • Solitary firm mass
  • Thickening
 – – Mammography and ultrasound:
  • Well-defined
  • Solid mass
  • Noncalcified
Mondor's disease[30][31]
  • Benign and self-limiting disease
  • Resolve after 4-6 weeks
 + + –
  • Thick and tender cord on breast skin
 + –
  • N/A
 Ultrasound:
  • Tubular anechoic structure
  • Multiple narrowing areas
Diseases Benign or
Malignant 		Demography History Mass Mastalgia Nipple discharge Breast exam Skin changes LAP Histopathology Imaging Gold standard diagnosis
Diabetic mastopathy[32]
  • Suspicious breast mass
  • After diagnosis, excision is not required
 + – –
  • Ill-defined mass
  • Immobile
 – – Ultrasound:
  • Irregular mass
  • Hypoechoic
  • Dense lesion
Gynecomastia[33][34]
  • Benign breast tissue swelling among men and boys around puberty
 + ± ±
  • Unilateral or bilateral firm mass
  • Breast swelling
  • Rubbery mass
 – – Ultrasound:
Sarcoidosis[35]
  • Rare in patients with systemic involvement
 + – –
  • Firm mass
  • Hard mass
 – – Mammography:
  • Irregular
  • Ill-defined
  • Spiculated solid mass
Fat necrosis[36] + ± –
  • Hard or smooth mass
  • Solitary mass
  • Mobile
 – –
  • Collections of liquefied fat
 Ultrasound:
  • Collections of liquefied fat
  • Oil cysts

References[edit | edit source]

  1. ↑ Pinto, Joana; Aguiar, Ana Teresa; Duarte, Hálio; Vilaverde, Filipa; Rodrigues, Ângelo; Krug, José Luís (2014). "Simple and Complex Fibroadenomas". Journal of Ultrasound in Medicine. 33 (3): 415–419. doi:10.7863/ultra.33.3.415. ISSN 0278-4297.
  2. ↑ Courtillot C, Plu-Bureau G, Binart N, Balleyguier C, Sigal-Zafrani B, Goffin V; et al. (2005). "Benign breast diseases". J Mammary Gland Biol Neoplasia. 10 (4): 325–35. doi:10.1007/s10911-006-9006-4. PMID 16900392.
  3. ↑ Templeman C, Hertweck SP (2000). "Breast disorders in the pediatric and adolescent patient". Obstet Gynecol Clin North Am. 27 (1): 19–34. PMID 10693180.
  4. ↑ Yu JH, Kim MJ, Cho H, Liu HJ, Han SJ, Ahn TG (2013). "Breast diseases during pregnancy and lactation". Obstet Gynecol Sci. 56 (3): 143–59. doi:10.5468/ogs.2013.56.3.143. PMC 3784111. PMID 24327995.
  5. ↑ Sabate JM, Clotet M, Torrubia S, Gomez A, Guerrero R, de las Heras P; et al. (2007). "Radiologic evaluation of breast disorders related to pregnancy and lactation". Radiographics. 27 Suppl 1: S101–24. doi:10.1148/rg.27si075505. PMID 18180221.
  6. ↑ De Silva NK, Brandt ML (2006). "Disorders of the breast in children and adolescents, Part 2: breast masses". J Pediatr Adolesc Gynecol. 19 (6): 415–8. doi:10.1016/j.jpag.2006.09.002. PMID 17174833.
  7. ↑ Tse GM, Law BK, Ma TK, Chan AB, Pang LM, Chu WC; et al. (2002). "Hamartoma of the breast: a clinicopathological review". J Clin Pathol. 55 (12): 951–4. PMC 1769817. PMID 12461066.
  8. ↑ D'Alfonso TM, Ginter PS, Shin SJ (2015). "A Review of Inflammatory Processes of the Breast with a Focus on Diagnosis in Core Biopsy Samples". J Pathol Transl Med. 49 (4): 279–87. doi:10.4132/jptm.2015.06.11. PMC 4508565. PMID 26095437.
  9. ↑ Dixon JM (2007). "Breast abscess". Br J Hosp Med (Lond). 68 (6): 315–20. doi:10.12968/hmed.2007.68.6.23574. PMID 17639835.
  10. ↑ Dixon JM, Ravisekar O, Chetty U, Anderson TJ (1996). "Periductal mastitis and duct ectasia: different conditions with different aetiologies". Br J Surg. 83 (6): 820–2. PMID 8696751.
  11. ↑ Committee on Health Care for Underserved Women, American College of Obstetricians and Gynecologists (2007). "ACOG Committee Opinion No. 361: Breastfeeding: maternal and infant aspects". Obstet Gynecol. 109 (2 Pt 1): 479–80. PMID 17267864.
  12. ↑ Siegel RL, Miller KD, Jemal A (January 2018). "Cancer statistics, 2018". CA Cancer J Clin. 68 (1): 7–30. doi:10.3322/caac.21442. PMID 29313949.
  13. ↑ Li CI, Uribe DJ, Daling JR (October 2005). "Clinical characteristics of different histologic types of breast cancer". Br. J. Cancer. 93 (9): 1046–52. doi:10.1038/sj.bjc.6602787. PMC 2361680. PMID 16175185.
  14. ↑ Parise CA, Bauer KR, Brown MM, Caggiano V (2009). "Breast cancer subtypes as defined by the estrogen receptor (ER), progesterone receptor (PR), and the human epidermal growth factor receptor 2 (HER2) among women with invasive breast cancer in California, 1999-2004". Breast J. 15 (6): 593–602. doi:10.1111/j.1524-4741.2009.00822.x. PMID 19764994.
  15. ↑ Virnig BA, Tuttle TM, Shamliyan T, Kane RL (February 2010). "Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes". J. Natl. Cancer Inst. 102 (3): 170–8. doi:10.1093/jnci/djp482. PMID 20071685.
  16. ↑ Brinton LA, Sherman ME, Carreon JD, Anderson WF (November 2008). "Recent trends in breast cancer among younger women in the United States". J. Natl. Cancer Inst. 100 (22): 1643–8. doi:10.1093/jnci/djn344. PMC 2720764. PMID 19001605.
  17. ↑ Sue GR, Lannin DR, Killelea B, Chagpar AB (October 2013). "Predictors of microinvasion and its prognostic role in ductal carcinoma in situ". Am. J. Surg. 206 (4): 478–81. doi:10.1016/j.amjsurg.2013.01.039. PMID 23791403.
  18. ↑ Smith TB, Gilcrease MZ, Santiago L, Hunt KK, Yang WT (April 2012). "Imaging features of primary breast sarcoma". AJR Am J Roentgenol. 198 (4): W386–93. doi:10.2214/AJR.11.7341. PMID 22451578.
  19. ↑ Geisler DP, Boyle MJ, Malnar KF, McGee JM, Nolen MC, Fortner SM, Broughan TA (April 2000). "Phyllodes tumors of the breast: a review of 32 cases". Am Surg. 66 (4): 360–6. PMID 10776873.
  20. ↑ Chaney AW, Pollack A, McNeese MD, Zagars GK, Pisters PW, Pollock RE, Hunt KK (October 2000). "Primary treatment of cystosarcoma phyllodes of the breast". Cancer. 89 (7): 1502–11. PMID 11013364.
  21. ↑ Brogi E, Harris NL (June 1999). "Lymphomas of the breast: pathology and clinical behavior". Semin. Oncol. 26 (3): 357–64. PMID 10375092.
  22. ↑ Barişta I, Baltali E, Tekuzman G, Kars A, Ruacan S, Ozişik Y, Güler N, Güllü IH, Atahan IL, Firat D (2000). "Primary breast lymphomas--a retrospective analysis of twelve cases". Acta Oncol. 39 (2): 135–9. PMID 10859001.
  23. ↑ Schwartz GF (June 1982). "Benign neoplasms and "inflammations" of the breast". Clin Obstet Gynecol. 25 (2): 373–85. PMID 6286199.
  24. ↑ Wen X, Cheng W (January 2013). "Nonmalignant breast papillary lesions at core-needle biopsy: a meta-analysis of underestimation and influencing factors". Ann. Surg. Oncol. 20 (1): 94–101. doi:10.1245/s10434-012-2590-1. PMID 22878621.
  25. ↑ Guray M, Sahin AA (May 2006). "Benign breast diseases: classification, diagnosis, and management". Oncologist. 11 (5): 435–49. doi:10.1634/theoncologist.11-5-435. PMID 16720843.
  26. ↑ Jensen RA, Page DL, Dupont WD, Rogers LW (1989). "Invasive breast cancer risk in women with sclerosing adenosis". Cancer. 64 (10): 1977–83. PMID 2804888.
  27. ↑ Wang J, Costantino JP, Tan-Chiu E, Wickerham DL, Paik S, Wolmark N (2004). "Lower-category benign breast disease and the risk of invasive breast cancer". J Natl Cancer Inst. 96 (8): 616–20. PMID 15100339.
  28. ↑ Celliers L, Wong DD, Bourke A (2010). "Pseudoangiomatous stromal hyperplasia: a study of the mammographic and sonographic features". Clin Radiol. 65 (2): 145–9. doi:10.1016/j.crad.2009.10.003. PMID 20103437.
  29. ↑ Salvador R, Lirola JL, Domínguez R, López M, Risueño N (2004). "Pseudo-angiomatous stromal hyperplasia presenting as a breast mass: imaging findings in three patients". Breast. 13 (5): 431–5. doi:10.1016/j.breast.2003.10.011. PMID 15454202.
  30. ↑ Becker L, McCurdy LI, Taves DH (2001). "Superficial thrombophlebitis of the breast (Mondor's disease)". Can Assoc Radiol J. 52 (3): 193–5. PMID 11436415.
  31. ↑ Catania S, Zurrida S, Veronesi P, Galimberti V, Bono A, Pluchinotta A (1992). "Mondor's disease and breast cancer". Cancer. 69 (9): 2267–70. PMID 1562972.
  32. ↑ Kudva YC, Reynolds C, O'Brien T, Powell C, Oberg AL, Crotty TB (2002). ""Diabetic mastopathy," or sclerosing lymphocytic lobulitis, is strongly associated with type 1 diabetes". Diabetes Care. 25 (1): 121–6. PMID 11772912.
  33. ↑ Draghi F, Tarantino CC, Madonia L, Ferrozzi G (2011). "Ultrasonography of the male breast". J Ultrasound. 14 (3): 122–9. doi:10.1016/j.jus.2011.06.004. PMC 3558246. PMID 23397020.
  34. ↑ Braunstein GD (2007). "Clinical practice. Gynecomastia". N Engl J Med. 357 (12): 1229–37. doi:10.1056/NEJMcp070677. PMID 17881754.
  35. ↑ Lower EE, Hawkins HH, Baughman RP (2001). "Breast disease in sarcoidosis". Sarcoidosis Vasc Diffuse Lung Dis. 18 (3): 301–6. PMID 11587103.
  36. ↑ Soo MS, Kornguth PJ, Hertzberg BS (1998). "Fat necrosis in the breast: sonographic features". Radiology. 206 (1): 261–9. doi:10.1148/radiology.206.1.9423681. PMID 9423681.


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