Aspiration of Breast Lumps Reviewed

From MedscapeCME Clinical Briefs

News Author: Laurie Barclay, MD
CME Author: Désirée Lie, MD, MSEd

03/09/2010;

March 9, 2010 — A review in the March 1 issue of the Canadian Medical Association Journal (CMAJ) describes an "in-office" approach for immediate evaluation of women who present to their family physician with a breast lump.

"As a family physician and a GP [general practice] oncologist who specializes in breast disease, I know how important it is to quickly evaluate breast lumps and reassure women who have benign cysts," lead author Ruth E. Heisey, MD, from University of Toronto, the Princess Margaret Hospital and the Women's College Hospital in Toronto, Ontario, Canada, said in a news release.

"Because 10% of malignant lesions in young women have features consistent with a fibroadenoma, new palpable masses in women of any age should be thoroughly evaluated," Dr. Heisey and coauthor David R. McCready, MD, MSc, also from the University of Toronto, write. "Cysts account for about 25% of all breast lumps and are common in premenopausal women over 35 years of age and uncommon in postmenopausal women unless they have received hormone therapy. In this article, we review an approach to the initial management of palpable breast lumps and describe several techniques for breast lump aspiration in the outpatient setting."

Women who have a breast lump and features suggesting cancer should be referred to a breast surgeon and immediately undergo mammography, ultrasonography, and core biopsy. These features include hard, irregular mass fixed to the skin; palpable ipsilateral lymph nodes; or a puckered "peau d'orange" appearance of the skin.

The family physician can begin in-office workup and management of a palpable breast lump not clinically suspicious for malignant disease. The lump should be aspirated with a fine needle because differentiating cystic from solid lesions using palpation alone can be difficult, and imaging may involve wait time, causing unnecessary anxiety for the patient. However, ultrasound is an alternative initial option to distinguish cystic from solid lumps.

Women with breast implants and those receiving anticoagulant therapy should not undergo aspiration in the family physician's office. When aspiration is performed, a local anesthetic is not needed.

A simple cyst is diagnosed when aspiration yields nonbloody fluid, and the lump completely disappears. Using clock position and distance from the nipple, the physician should precisely document the cyst's location in the breast, and the fluid may be discarded.

However, women should be referred to a surgeon if aspiration yields bloody fluid, if the lump does not disappear completely, or if the lump recurs. In these cases, the aspirate should be sent for pathologic examination by a skilled cytopathologist.

When fine-needle insertion indicates that the breast lump is solid, the needle may be removed without further aspiration, or an aspiration biopsy may be performed and the specimen sent for cytopathologic analysis.

Complications of aspiration may include local discomfort; bruising caused by blood vessel puncture; transient vasovagal reaction; or, uncommonly, a pneumothorax, which can be avoided by moving a lesion close to the chest wall over a rib before aspiration. However, immediate inspiratory and expiratory chest radiographs are indicated if air is drawn into the syringe.

Aspiration is not associated with higher rate of false-positive mammography results if the radiologist is informed about the aspiration site, nor is there any evidence that needle biopsy will cause malignant lesions to spread. Most cancers are diagnosed before surgery by needle or core biopsy.

Women who have a simple cyst should be seen in 6 to 8 weeks to be evaluated for recurrence, which, if present, mandates ultrasonography, mammography, or both, as well as surgical referral. No additional workup is needed for cysts that do not recur.

Women with solid lesions require imaging and surgical referral. Ultrasonography only is recommended for women younger than 30 years, whereas women at least 30 years old should have both mammography and ultrasonography studies.

To ensure concordance between clinical findings and the results of imaging and cytopathologic evaluation of solid breast lumps, triple assessment is recommended (examination, imaging, and aspiration).

Some clinicians opt to defer cytopathologic testing of palpable lumps presumed to be fibroadenomas, but this strategy may result in some breast cancers being missed in young women. Most delays in diagnosing breast cancer in this group occur as a result of falsely reassuring clinical or imaging findings.

"Aspiration of a palpable breast lump allows immediate reassurance for women with breast cysts and timely investigation and referral for women with solid masses," the review authors conclude. "If the lump is a cyst, the aspirated fluid may be discarded provided the fluid is not bloody and the lump disappears. If the lump is solid, triple assessment (clinical examination, breast imaging and fine-needle aspiration cytologic assessment) is warranted."

The review authors have disclosed no financial relationships.

CMAJ. Published online March 1, 2010.