Differential Diagnosis I: Simple Breast Cyst
Simple cysts are very common with a prevalence of 50-90%. Cysts are fluid-filled masses derived from the terminal duct lobular unit. Breast cysts can present as breast masses or mammographic abnormalities. Cysts are common in women between 35 and 50 years old. Acute enlargement of cysts may cause severe, localized pain of sudden onset (Laronga, Tollin, Mooney & Blaise, 2019).
Breast cysts may be found in one or both breasts. Signs and symptoms of a breast cyst include:
- A smooth, easily movable round or oval lump with distinct edges (which typically, though not always, indicates it’s benign)
- Nipple discharge that may be clear, yellow, straw colored or dark brown
- Breast pain or tenderness in the area of the breast lump
- Increase in breast lump size and breast tenderness just before your period
- Decrease in breast lump size and resolution of other symptoms after your period
A breast cyst cannot be confirmed by physical exam alone, and a breast ultrasound or fine-needle aspiration will likely be recommended. Further examination and testing is dependent on the results found with imaging and aspiration.
(Mayo Clinic, 2018)
(Mayo Clinic, 2018)
While the nodule of Mrs. B.C. exhibits similarities to that of a breast cyst – a non-tender, firm nodule, breast cysts can often move with slight palpation, while the mass Mrs. B.C. has is immobile. More so, while cysts can feel hard if embedded, they often have more of a squishy sensation. According to the Mayo Clinic, “Breast cysts are common in women before menopause, between ages 35 and 50. But they can be found in women of any age. They can also occur in postmenopausal women taking hormone therapy.” Although it is possible, Mrs B.C., a 56 year old, postmenopausal woman who is not currently taking hormone therapy, is less likely to have a breast cyst.
Differential Diagnosis II: Fibroadenoma
Fibroadenomas are the most common benign tumor in the breast and often occur in women between the ages of 15-35 years. Simple fibroadenomas contain both glandular and fibrous tissue. While the etiology of fibroadenomas is not known, a hormonal relationship is suggested as they most often occur during reproductive years and can increase in size with pregnancy or estrogen therapy (Sabel, 2018).
Fibroadenomas are classified as proliferative breast lesions. Fibroadenomas are benign, but the risk of breast cancer can be increased slightly if the adenoma is complex, there is a family history of breast cancer, and there is additional proliferative disease. The majority of women with fibroadenomas are at no increased risk for breast cancer development (Sabel, 2018).
Fibroadenomas most often present as a well-defined, mobile mass on physical examination or a well-defined solid mass on ultrasound. Definitive diagnosis can only be confirmed with a core biopsy or excision, and often imaging such as a diagnostic mammography or breast ultrasound is also recommended.
While Mrs B.C. presents with a well-defined mass and she has a history of long term estrogen therapy, the mass palpated in Mrs. B.C.’s breast is immobile, a key difference. Also, as a post-menopausal woman who is 56 years old, a fibroadenoma is less likely.
(Muniz, 2016)
Differential Diagnosis III: Intraductal Papilloma
Intraductal papillomas are a type of proliferative breast lesion without atypia that can slightly increase an individual’s risk for breast cancer. Most commonly, papillomas occur in women between the age of 35 and 55 years (Sabel, 2018). Solitary papillomas are single tumors that often grow in the large milk ducts near the nipple – they may be felt as a small lump behind or next to the nipple. Most often, solitary papillomas cause abnormal nipple discharge that can be bloody (American Cancer Society). Intraductal papillomas can often be evaluated with breast imaging such as an ultrasound or mammogram, and if the lesion is large enough, a biopsy can be performed if thought to be appropriate.
(Mount Sinai)
Mrs B.C. presents with a breast mass palpated in the upper quadrant of her breast, and although intraductal papillomas are a proliferative breast lesion, they are often located near the nipple. Additionally, Mrs. B.C. did not report any symptoms of abnormal nipple discharge, which is a common clinical manifestation associated with papillomas.