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Breast Mass
RylandJ.Gore
3
History
General:
• Current patient age
• Age at menarche
• Number of pregnancies
• Number of live births
• Age at rst birth
• Family history of breast or other cancers
• Oral contraceptive use
• Hormone replacement therapy use
• Recent trauma
• Systemic symptoms [Weight loss, headaches, visual
changes, bone pain, abdominal pain, shortness of breath,
cough, dyspnea with exertion]
Breast-Specic:
• When did you rst notice the breast mass
• How long has the been present
• Change in size
• Skin changes of the breast
• Breast pain
• Nipple inversion or nipple discharge
• Relation to menstrual cycle
• Prior breast imaging
• History of breast biopsies
• Personal history of breast cancer
• Size discrepancy between breasts
• Location and size of the mass
• Well vs. poorly circumscribed mass edges
• Tenderness to palpation
• Nipple discharge
• Skin dimpling or retraction
• Crusting or eczematous changes of the nipple
• Edema of the skin of the breast
• Erythema or other discoloration of the breast
• Lymphadenopathy? Mobile vs. Matted? Bulky? Tender?
Evaluate all nodal basins, including cervical, supraclavicular, and axillary
• Abdominal examination (examine the liver) if high suspicion for breast cancer
Imaging
• Bilateral diagnostic mammogram
• Unilateral ultrasound of the affected breast and axilla
• Breast MRI (evaluate extent of disease, rule out occult
contralateral disease)
Diagnosis
Ultrasound-guided core biopsy
Physical Examination
• Must be performed in the upright and supine positions
• Visualization of the breasts: symmetry, contour changes,
nipple changes/inversion
R. J. Gore (*)
Methodist Cancer Institute, Methodist LeBonheur Hospital,
Memphis, TN, USA
Northside Hospital, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_3
Dierential Diagnosis
• Fibrocystic breast disease
• Benign cyst
• Fibroadenoma
• Phyllodes tumor
• Breast cancer
• Another primary metastatic to the breast (rare, but happens lymphoma, squamous cell carcinoma)
11
12
R. J. Gore
Clinical Scenario
A 17-year-old woman presents for evaluation of an enlarging right breast mass that has been present for 2years. A
previous ultrasound and core biopsy 1 year ago demonstrated a benign broadenoma that measured 1.2 cm. She
states that over the last 6months, the right breast broadenoma has grown in size. What are your next steps?
Breast Cyst
• Fluid-lled sac in the breast
• Usually mobile and well-circumscribed
• Vary in size, but may increase in size just before a menstrual cycle
• Usually affects premenopausal women and postmenopausal women on hormone replacement therapy
• Imaging: Ultrasound
– Will be able to delineate if this is a simple vs. complex
cyst (cyst with internal septations or a solid
component)
• Treatment:
– Simple cyst
– Complex cyst Ultrasound-guided core biopsy
• The cyst aspirate is usually straw to greenish-colored. If
bloody, this is concerning for underlying malignancy and
a core-biopsy of the cyst/area of concern should be
performed
• There should be complete collapse of the cyst wall after
aspiration. If there is not, a core biopsy should be
performed.
• Non-palpable lesions (seen on ultrasound only) do not
need to be aspirated
• If the cyst aspirate is bloody, the cyst is complicated, or
the cyst recurs after several aspirations, a core biopsy is
indicated
Aspiration
Fibroadenoma
• Most common in premenopausal women, particularly
adolescent and young women
• Benign, non-cancerous solid tumor made up of glandular
and stromal connective tissue
• Mobile, smooth and well-circumscribed borders, rubbery
• May enlarge, shrink, or stay the same size
• As broadenomas enlarge, they may cause breast pain or
distortion of the breast
• 2 cm is usually the cutoff for recommending surgical
excision. Over 2 cm, broadenomas typically will not
shrink spontaneously.
• Imaging: Ultrasound +/− mammogram (if 35years old or
older)
• Diagnosis: Ultrasound-guided core biopsy to conrm
diagnosis
• Treatment: Observation or surgical excision
Clinical Scenario
A 47-year-old woman has a left breast mass that has been
enlarging over the last year. Diagnostic mammogram demonstrated an 8cm mass and core biopsy pathology demonstrated a borderline Phyllodes tumor. What are your next
steps in management?
Phyllodes Tumor
• Fibroepithelial tumor of the breast
• Represents approximately 1% of all breast tumors
• These tumors range from benign to malignant. In their
malignant form, phyllodes tumors can behave like sarcomas. They are classied as benign, borderline, or malignant based on nuclear atypia, mitosis, stromal cellularity,
and margins.
• Average age of presentation is 40–50years
• On examination, Phyllodes tumors are usually wellcircumscribed, rm, and large
• Imaging: Diagnostic mammogram and ultrasound
• Diagnosis: Ultrasound-guided core biopsy
– Benign: <5 mitoses per 10 high-powered eld (HPF)
– Borderline: 5–9 per 10 HPF
– Malignant: ≥10 per 10 HPF
• Treatment: Complete wide surgical excision
• There is a high risk of recurrence and surgical margins
should be at least 1cm
• These tumors can grow quite large and sometimes, total
mastectomy may be necessary
• Malignant phyllodes tumors almost never metastasize to
the axillary nodes and sentinel lymph node biopsy or axillary lymph node dissection are usually NOT a component
of the treatment paradigm
• Due to high risk of local recurrence with excision alone
(breast conservation), adjuvant radiation therapy is usually recommended
• These tumors are usually not responsive to chemotherapy
and this should not be a component of the treatment
pathway.
Breast Cancer
Thorough history and physical examination
Imaging: Should always include bilateral diagnostic
mammogram and a breast ultrasound.
In select cases, breast MRI is performed and gives valu-
able information regarding extent of disease
3 Breast Mass
13
Diagnosis:
• Suspicious microcalcications, asymmetry, architectural
distortion, or mass with no ultrasound correlate stereotactic core biopsy
• Breast mass ultrasound-guided core biopsy
– FNA has fallen out of favor for the diagnosis of breast
cancer. Typically, only individual cells are retrieved
and if malignancy is identied, the patient still needs a
core biopsy.
– Core biopsy gives important information on the actual
diagnosis, presence of invasion, tumor grade, and
receptor status
Clinical Staging
Remember that clinical staging is based on pretreatment
imaging and physical examination. Final staging is based
on nal surgical pathology. Unless the patient has distant
metastasis (disease outside of the breast and regional
[axillary] lymph nodes), which automatically makes them
stage 4.
T1: less than or equal to 2cm
T2: 2–5cm
T3: >5cm
T4: any size + extension to underlying chest wall and/or skin
involvement
N1: Mobile ipsilateral axillary lymphadenopathy
N2: Fixed ipsilateral axillary lymphadenopathy
N3: Ipsilateral infraclavicular (level III) nodes with or with-
out ipsilateral axillary level I or II involvement or ipsilateral internal mammary involvement with axillary level I
or II involvement or ipsilateral supraclavicular
involvement
Surgical Management
• Lumpectomy (wire-localized if lesion not palpable)+sentinel lymph node (SLN) biopsy
• Contraindications to breast conservation
– Prior breast conservation therapy with radiation ther-
apy, prior radiation therapy to the chest wall, certain
connective tissue disorders (i.e. Lupus, scleroderma),
large tumors (usually greater than 5cm), large tumor
in relation to breast size, multicentric disease, rst or
second trimester of pregnancy
• Total mastectomy + SLN biopsy (clinically node
negative)
• Margins
– Phyllodes tumor=1cm
– Non-invasive breast cancer=2mm
– Invasive breast cancer=No ink on tumor
• Axillary lymph node dissection at the time of index procedure if biopsy-proven axillary lymph node metastasis
• Return to OR for ALND if SLN is positive on nal surgical pathology
• Total mastectomy + ALND = modied radical mastectomy. Level 1 and level 2 nodes removed with an ALND.
• Patients with stage 4 disease are not surgical candidates
Additional treatments for breast cancer
• Adjuvant chemotherapy and/or targeted immunotherapy
• Adjuvant radiation therapy
• Adjuvant endocrine therapy
Clean Kills
• Not performing an adequate physical examination that
includes both breasts and axillae
• Not examining the lymph node basins
• Not ordering breast imaging, even in a young woman
• Not excising a broadenoma in an adolescent or young
woman that is rapidly enlarging
• Not ordering a bilateral diagnostic mammogram for a
new breast mass
• Not obtaining adequate margins for a Phyllodes tumor or
breast cancer
• Not knowing the indications for ALND
• Not knowing the indications for adjuvant chemotherapy
or radiation therapy
Bonus Points
• Unless the patient is young (adolescent), all breast masses
are cancer until proven otherwise. And even then, crazy
things happen as cancer patients are getting younger and
younger. To work through this, do a thorough history and
physical examination. When it comes to breast imaging,
workup, and diagnosis, do everything in a stepwise fashion every single time.
• Watch your high-risk patients closely and know that they
will most likely need more frequent imaging and clinical
breast examinations.
Words ofWisdom
Never underestimate the power of a good physical examination. Sometimes, something that seems unimportant, like
slightly increased density in one area of the breast compared
to the same area in the contralateral breast may be a clue to
underlying pathology. Trust your gut, use your ngers, and
get imaging to back it up.
Ductal Carcinoma InSitu
RylandJ.Gore
4
Clinical Scenario
A 42-year-old woman presents for recommendations after
having her baseline screening mammogram that demonstrated branching, pleomorphic calcications spanning
9 mm and 2.5 cm deep to the nipple. A stereotactic core
biopsy was subsequently performed, and core biopsy pathology demonstrated intermediate-grade ductal carcinoma in
situ, estrogen and progesterone positive. How would you
manage this?
Potential presentations on imaging:
• Branching, clustered, heterogeneous, or pleomorphic
microcalcications (most common)
• Mass or architectural distortion
• Asymmetric density
• ADH bordering on DCIS on biopsy
• Increasing microcalcications (on short-term follow-up
imaging)
Potential presentations on breast examination:
• Normal breast examination with no palpable mass, skin
changes or rashes, nipple changes or rashes
• Palpable mass
• Nipple discharge
• Nipple rash, crusting, or eczematous changes
• Late age at menopause (>55years old)
• Previous radiation therapy to the chest wall
Breast Imaging
• DCIS is usually found on screening mammograms. If new
or suspicious ndings are found, this imaging will be considered BIRADS 0 (incomplete) and diagnostic breast
imaging is needed.
• Diagnostic mammogram
• Breast ultrasound (for further evaluation of architectural
distortion, asymmetric densities, and masses)
• If a patient has a breast MRI, DCIS usually presents as
non-mass enhancement
Breast Biopsy
1. Choice (standard of care): Stereotactic core biopsy (Note:
Ultrasound-guided core biopsy will be recommended for
ndings with an ultrasound correlate)
2. Choice: Wire-localized excision for non-palpable lesions
Denitive Management
Risk Factors forDCIS
• Advanced age
• Personal history of high-risk lesion (i.e., ADH, ALH)
• Nulliparous or increased age at rst birth
• Family history of breast cancer
• Young age at menarche (less than 12years old)
R. J. Gore (*)
Methodist Cancer Institute, Methodist LeBonheur Hospital,
Memphis, TN, USA
Northside Hospital, Atlanta, GA, USA
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_4
• DCIS must be excised with adequate margins margins
for DCIS=2mm (Morrow etal. 2016)
• If margins are close or positive after excision, must reexcise until you distort the breast, get negative margins, or
the patient decides to proceed with completion
mastectomy.
• Multifocal (multiple foci, conned to one quadrant)
breast conservation is possible depending on the size of
the area(s) of concern and the size of the area of concern
in relation to the breast size
• Multicentric disease (more than one affected quadrant)
Total mastectomy (TM)
15
16
R. J. Gore
– SLN biopsy with TM because if there is microinvasion
or foci of invasion on nal surgical pathology, you lose
the opportunity to do a SLN biopsy in the future due to
complete disruption of the lymphatics.
– Completion axillary lymph node dissection if SLN
biopsy is positive on nal surgical pathology
• Patients who have undergone breast conservation will
need adjuvant (postoperative) radiation therapy. Longterm follow-up from NSABP B-17 demonstrated that
lumpectomy in addition to radiation therapy decreased
the risk of non-invasive and invasive ipsilateral breast
tumor recurrences (Fisher etal. 1998).
Patients with hormone receptor-positive disease will need
adjuvant endocrine therapy for 5–10years.
Endocrine therapy: Tamoxifen (premenopausal) or aro-
matase inhibitor (post-menopausal).
Contraindications to endocrine therapy (Farrar and
Jacobs 2023):
• History of DVT/PE, stroke
• Endometrial hyperplasia or endometrial cancer
How should the patient be followed long-term?
• Clinical breast examinations every 6–12months
• Bilateral diagnostic mammogram every 6months for the
rst 1–2years post-treatment
Curveball Scenario
A 48-year-old woman had her annual screening mammogram performed 3 months ago that was unremarkable with
no abnormalities. She also had her annual breast MRI performed due to her extensive family history of breast cancer.
MRI demonstrated a 2cm area of non-mass enhancement in
the right upper outer quadrant. Subsequent MRI-guided core
biopsy demonstrated ductal carcinoma in situ. After treatment, how will this patient be screened in the future?
While most cases of non-invasive breast cancer are
detected on standard breast imaging, with increased breast
density, mammograms may miss up to 20% of breast cancers. MRI can be considered.
Clean Kills
• Forgetting to examine both breasts
• Forgetting to order a bilateral mammogram
• Forgetting ALND if SLNBx after TM is positive
• Talking about a SLNBx with lumpectomy alone
• Forgetting chemotherapy is not a part of the treatment
pathway for DCIS
• Not knowing indications for mastectomy
• Talking about “watchful waiting”; endocrine therapy
alone; any prognostic tool, precision medicine test or
nomogram to avoid/forgo adjuvant radiation therapy; or
any other new trial or novel medication for the management of DCIS
Bonus Points
• For patients who have abnormal ndings or questionable/
borderline microcalcications on a baseline screening
mammogram, err on the side of caution and do the full
workup, including stereotactic core biopsy. If the core
biopsy shows DCIS, then a delay in care is avoided. If it
is benign, you and the patient can sleep well at night
knowing the concerning nding has been evaluated
appropriately.
Words ofWisdom
Management of DCIS continues to evolve and the question
of whether surgery is necessary, or if DCIS is truly cancer,
comes up every few years. The author is a part of the group
that believes DCIS is cancer and believes it is important for
patients to know the risks and benets of “doing nothing.” If
a patient chooses to forgo surgical intervention (which does
happen on occasion), ongoing surveillance imaging every
6 months and endocrine therapy is what the author
recommends.
Bibliography
Farrar MC, Jacobs TF.Tamoxifen. In: StatPearls. Treasure Island, FL:
StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/books/
NBK532905/.
Fisher B, Dignam J, Wolmark N, et al. Lumpectomy and radiation
therapy for the treatment of Intraductal breast cancer: ndings from
National Surgical Adjuvant Breast and bowel project B-17. J Clin
Oncol. 1998;16(2):441–52.
Morrow M, Van Zee KJ, Solin LJ, etal. Society of Surgical Oncology—
American Society for Radiation Oncology—American Society of
Clinical Oncology consensus guidelines on margins for breastconserving surgery with whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol. 2016;34(33):4040–6.
National Institute of Health. n.d. https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC10200127/.
High Risk Lesions
CarlyWareham andSalvatoreNardello
5
Concept
• With any breast concern, always obtain a thorough history
and physical examination.
– Don’t forget these breast-specic questions: age of
menarche and menopause, age during rst pregnancy,
hormone use, previous cancer/radiation, presence of
breast lump, nipple discharge, nipple inversion,
detailed family history (including breast/ovarian cancers and age of diagnosis).
– Don’t forget to do a bilateral breast examination in
both the seated and supine positions with attention to
bilateral axillae and lymph node basins.
Lobular Carcinoma InSitu
• It is a high-risk lesion, associated with a 30% lifetime
risk of the development of invasive breast cancer, in either
breast, not specically at the site of atypia. It is characterized as intraductal proliferation that expands to involve
spaces without specic architecture.
– Buzz Word: “Lacks e-cadherin expression”
• If classic LCIS, then you can proceed with excisional
biopsy.
– Data is evolving. For the sake of the boards, we recom-
mend that classic LCIS be excised to rule out underlying cancer. This will not reduce their risk for developing
breast cancer over their lifetime.
– Classic LCIS consists of solid proliferation of small
cells, with small, uniform, round nuclei and variably
distinct cell borders.
• If pleomorphic LCIS, which has a more aggressive natural history and can also make differentiation from DCIS
challenging, PLCIS it should be surgically excised to
negative margins.
– Pleomorphic LCIS consists of larger cells that demon-
strate marked nuclear pleomorphism.
Alternate Scenario
A 48-year-old premenopausal woman re-presents to your
clinic following a partial mastectomy for ductal carcinoma
in situ (DCIS). The nal pathology demonstrates negative
margins for DCIS, but classic lobular carcinoma in situ
(LCIS) within 1 mm of the inferior margin. How do you
proceed?
A 48-year-old premenopausal woman presents for her
screening mammogram which detected new pleomorphic
microcalcications in the upper outer quadrant of the right
breast, BIRADS-4. She undergoes a stereotactic core needle
biopsy and her pathology demonstrates a focus of lobular
carcinoma in situ (LCIS). How do you manage this?
C. Wareham
Department of Surgery, Tufts Medical Center, Boston, MA, USA
e-mail: Carly.Wareham@tuftsmedicine.org
S. Nardello (
Division of Surgical Oncology and Breast Surgery, Department of
Surgery, Tufts Medical Center, Boston, MA, USA
e-mail: salvatore.nardello@tuftsmedicine.org
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_5
*)
• It is not necessary to re-excise margins for classic LCIS.
• If pleomorphic LCIS is at the margin, then re-excision to
a negative margin is recommended. The DCIS margin
should be 2 mm.
What further recommendations should you make to a
patient with LCIS?
• You should counsel her on the typical risk reduction strategies (limit alcohol, regular exercise, and maintaining a
healthy BMI < 25) as well as chemoprevention with
5 years of 20 mg/day tamoxifen. Patients may also
benet from increased screening with yearly MRI
alternating with yearly mammograms.
17
18
C. Wareham and S. Nardello
– In the National Surgical Adjuvant Breast and Bowel
Project (NSABP) P-1 trial, tamoxifen conferred a risk
reduction of 58% in women with LCIS.
What are the risks associated with tamoxifen?
• Thromboembolic events (stroke, pulmonary embolism, or
deep vein thrombosis) and uterine cancer.
What if the above patient was postmenopausal?
• You should discuss the benets of aromatase inhibitors,
like anastrozole, with the patient.
• Common side effects of aromatase inhibitors are musculoskeletal issues, like joint pain. Patients should have a
baseline bone density evaluation prior to initiating an aromatase inhibitor, given its association with loss of bone
mineral density.
How should you follow this patient long term?
• The patient should be followed with clinical examinations
every 6–12months, along with annual screening mammograms and alternating screening MRI’s.
Atypical Ductal Hyperplasia (ADH)
• What if it demonstrated a focus of ALH?
– If concordant with imaging, patients can be offered
excisional biopsy OR close clinical follow up with
interval examination and imaging, as there is a lower
percentage of upstaging to an invasive carcinoma (only
about 5%).
Alternate Scenario
A 48-year-old premenopausal woman re-presents to your
clinic following a partial mastectomy for ductal carcinoma
in situ (DCIS). The nal pathology demonstrates negative
margins for DCIS, but ADH within 1mm of the inferior margin. How do you proceed?
• It is not necessary to re-excise margins for ADH or ALH.
What further recommendations should you make to either
above patient?
• As above, she should be counseled on the typical risk
reduction strategies, as well as chemoprevention with
5years of 20mg/day tamoxifen (or an aromatase inhibitor if postmenopausal).
– The National Surgical Adjuvant Breast and Bowel
Project (NSABP) P-1 trial demonstrated a signicant
risk reduction in women with ADH or ALH when
given tamoxifen.
• It is a high-risk lesion, associated with a 4–5× increased
risk of breast cancer, characterized by proliferation of
uniform epithelial cells, with round nuclei, lling and distending the ducts, with histologic features similar to
DCIS.
Atypical Lobular Hyperplasia (ALH)
• It is a high-risk lesion, associated with a 4–5× increased
risk of breast cancer characterized by uniform, evenly
spaced cells that ll part of the lobule.
A 48-year-old premenopausal woman presents to your
clinic after a routine mammogram demonstrated an area of
microcalcications at the upper outer quadrant of the right
breast, BIRADS 4. She undergoes core needle biopsy of the
area. Pathology demonstrates atypical ductal hyperplasia
(ADH). How do you manage the ADH?
• You should proceed with an excisional biopsy.
– Why? You should obtain more tissue, as it is hard to dif-
ferentiate from DCIS and there is up to a 20% chance it
is upgraded to DCIS or an invasive carcinoma.
How should you follow this patient long term?
• The patient should be followed with clinical examinations
every 6–12months, along with annual screening mammograms, and alternating breast MRI.
Clean Kills
• Failing to get a detailed history of a breast concern (i.e.,
previous radiation)
– Previous mantle radiation as a child increases the risk
of developing breast cancer by at least 2-4 fold. Some
studies demonstrate the risk is 20x higher.
• Failing to examine the axillae during a physical
examination
• You re-excise a positive margin for classic LCIS
• Failing to offer chemoprevention to patients with high
risk lesions
Inflammatory Breast Cancer
TaherehSoleimani andCarlaFisher
6
A 42-year-old, non-lactating female presents with a 3-month
history of increasing erythema of the left breast. She endorses
increasing swelling of the left breast but denies tenderness or
trauma to the breast. She is otherwise healthy with no personal or family history of cancer. On physical exam, there is
diffuse erythema and edema of the left breast with no discrete
palpable mass. A rm, mobile axillary node is palpated in
the left axilla. How would you proceed?
• As with any breast concern, always obtain a thorough history and physical exam (physical exam ndings have
been provided in this question)
• Start the workup with a diagnostic mammogram, complemented by ultrasound
• Core needle biopsy of abnormal ndings
• Do not forget to perform axillary US and biopsy
Bilateral Diagnostic mammogram reveals skin thickening
on the left breast and an architectural distortion in the upper
outer quadrant. Right breast is unremarkable. Ultrasound
reveals a 0.9cm hypoechoic mass with obscured margins,
corresponding to the architectural distortion of the left
breast. Left axillary US demonstrates a 1.2cm axillary node.
Core needle biopsy of the breast is consistent with triple negative invasive ductal carcinoma, with lymph node metastasis. What is/are your next step(s)?
• Staging work up (CT Chest/Abdomen/Pelvis with contrast plus bone scan or PET/CT).
• Treatment involves a combined modality approach with
neoadjuvant chemo, followed by modied radical mastectomy, and adjuvant radiotherapy to chest wall and
nodal basins.
• Delayed breast reconstruction.
Bonus Points
• Genetic testing
• Discuss at multidisciplinary tumor board
• Restage after neoadjuvant chemo
Words ofWisdom
• Always obtain a thorough history and physical exam for
any breast concern.
• Start the work up with a diagnostic mammogram if not
already provided.
• Do not forget to ask for receptor status for breast cancer
patients (ER, PR, HER2).
• All IBC patients need staging workup.
• Do not offer upfront surgery. They all need neoadjuvant
chemo.
• IBC patients are not a candidate for partial mastectomy or
sentinel lymph node biopsy.
• If reconstruction is offered, it is performed in a delayed
fashion.
Bibliography
Kell MR, Morrow M.Surgical aspects of inammatory breast cancer.
Breast Dis. 2005;22:67–73. https://doi.org/10.3233/bd- 2006- 22108.
National Comprehensive Cancer Network. Breast cancer ver-
sion 4. 2023. https://www.nccn.org/guidelines/guidelines-
detail?category=1&id=1419. Accessed 14 Oct 2023.
T. Soleimani · C. Fisher (*)
Department of Surgery, Indiana University, Indianapolis, IN, USA
e-mail: tsoleima@iu.edu; shercs@iu.edu
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_6
19
Breast Cancer inPregnancy
LucyM.de La Cruz, NathanWong,
andCarmende Carvajal
7
Concept
Breast cancer during pregnancy (PrBC) accounts for
0.2–2.6% of all breast cancer cases. It is the most common
cancer diagnosis made during pregnancy, affecting about
1in 3000 pregnant women (Boere etal. 2022). As women
more often delay childbearing, this incidence is likely to rise
in the coming years.
Management of pregnant patients should align with treatment guidelines designed for non-pregnant women; however, certain unique considerations must be considered with
respect to diagnosis, staging, oncologic therapy, and obstetrical care.
Differential diagnoses in premenopausal women presenting with complaints of breast masses are broad and contain several different entities, ranging from normal breast
tissue changes resulting from hormonal changes in pregnancy to benign or malignant masses.
• Physiologic change of the breast tissue
• Fibroadenoma
• Phyllodes tumor
• Cystic disease
• Abscess
• Lactating adenoma
• Galactocele
• Fat necrosis
• Adenocarcinoma
L. M. de La Cruz (*)
Medstar Georgetown University Hospital, Washington, DC, USA
N. Wong
Medstar Georgetown University Hospital, Washington, DC, USA
Conemaugh Memorial Medical Center, Johnstown, PA, USA
C. de Carvajal
School of Medicine, University of Navarra, Pamplona, Spain
e-mail: nathan.wong@richmond.edu
Way Question May BeAsked
A 34-year-old G2P1 Caucasian female who presented to her
primary care physician at 5weeks gestation with a palpable
right breast mass. How would you approach her initial work
up?
History
• Establish risk factors for breast cancer: menarche, breastfeeding, family history of breast/ovarian/prostate cancer,
number of children, age of rst full term birth, previous
breast cancer, prior chest radiation exposure, previous
surgeries or radiation, obesity, alcohol consumption and
smoking history.
Physical Exam
• Breast examination during the early stages of pregnancy
is of utmost importance, as it enables the detection of
solid masses that may necessitate biopsy before breast
engorgement obscures their presence.
• A comprehensive physical examination should encompass both breasts, aiming to palpate for any masses, look
for nipple or skin retraction, nipple discharge, mastalgia,
and note any changes in the appearance of the breast,
including size and symmetry alterations.
– The most common presenting symptom is a painless
breast lump.
• Assessment of clinical adenopathy status in the axilla
plays an important role in developing suspicion for axillary node positive disease.
Case continued The patient endorses that she has otherwise been healthy without any outstanding medical issues
and takes no medication. She had one cesarean section, but
no other surgery. She has specically denied any radiation
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
M. Neff et al. (eds.), Passing the General Surgery Oral Board Exam, https://doi.org/10.1007/978-3-031-78244-2_7
21
22
L. M. de La Cruz et al.
previously to the breast and has been following regularly
with her OB-GYN.On examination, the patient is found to
have a small mobile, painless mass of the right outer upper
quadrant of the breast with a small amount of overlying skin
dimpling. There was an area of axillary adenopathy noted.
What are your next steps?
Diagnostic Tests
• Breast ultrasound, which includes examination for loco-
regional adenopathies, is the initial imaging method of
choice. It is preferred because it does not employ ionizing
radiation and can promptly identify benign lesions that do
not require further assessment. The effectiveness of the US
in detecting breast cancer during pregnancy has been
rmly established, with studies reporting a sensitivity of
100% (Ahn etal. 2003; Robbins etal. 2011). As a result, it
is strongly recommended that patients with palpable breast
masses persisting for 2 weeks longer during pregnancy
undergo ultrasound examination (Boere etal. 2022).
• Digital mammography has a lower sensitivity compared
to ultrasound (Ahn etal. 2003), possibly due to increased
parenchymal density arising from hormonal changes in
pregnancy. However, demonstration of microcalcications, architectural distortion or skin thickening can aid in
the diagnosis of PrBC.Consequently, the recommendation for pregnant women who exhibit abnormal clinical or
ultrasound ndings is to undergo mammography. With
adequate abdominal shielding, mammography poses little
risk of radiation exposure to the fetus and is considered
safe in pregnancy (Sabate etal. 2007).
• Outside of pregnancy, magnetic resonance imaging
(MRI) with gadolinium contrast is frequently used in
patients with dense breasts, suspicion of multicentricity/
multifocality, or in patients with a high-risk history.
However, during pregnancy, contrast-enhanced MRI is
not recommended due to the classication of gadoliniumbased contrasts as pregnancy category C (risk cannot be
ruled out). The fetal effects of gadolinium exposure
remain uncertain. It crosses the placenta and is teratogenic in rats, but there are no documented teratogenic
effects in humans nor any prospective controlled studies
in humans assessing the fetal impact of these agents
(Vashi etal. 2013). Therefore, contrast-enhanced MRI is
not routinely performed for the diagnostic work up of
breast masses in pregnant patients.
• US guided core biopsy stands as the gold standard procedure for assessing breast tumors in pregnancy. It is a safe
procedure, with the most common complications being
risk of bleeding and infection.
– Pathological ndings in cases of PrBC closely resem-
ble those found in young breast cancer patients. These
tumors typically present as aggressive inltrating ductal adenocarcinomas. In comparison to non-pregnant
women, PrBC is more often associated with highgrade tumors, a lack of hormone receptors, and classication as triple-negative breast cancers.
Additionally, there is an increased incidence of lymphovascular invasion (Amant etal. 2013; Middleton
etal. 2003).
Case continued The patient undergoes a bilateral diagnostic
mammogram and a focused right breast ultrasound of the palpable mass. Imaging of the left breast was unremarkable.
Imaging of the right breast demonstrated a 2cm×1.5cm×1cm
hypoechoic, irregular mass without internal vascularity. Noted
to be taller than broader. Axillary ultrasound was performed
that showed cortical thickening of a singular right lymph node.
These lesions were classied as BIRADS-4 ndings, suspicious
and the patient underwent biopsies of the breast and axilla.
Final pathology of the right breast mass demonstrated an
Estrogen receptor negative, Progesterone receptor negative,
HER2/Neu Negative, high grade Invasive Ductal Carcinoma.
Final pathology of the lymph node demonstrated metastatic
invasive ductal carcinoma. Clips were left in place from the
biopsy.
Staging
• Staging is important in patients with suspected axillary
adenopathy or invasive cancers.
• PrBC typically presents at a more advanced stage at diagnosis than breast cancer in the general population, as
physiologic breast changes associated with pregnancy
such as hypertrophy, engorgement and presence of discharge tend to obscure detection.
• Ultrasound is appropriate for abdominal and pelvic staging, while chest X-rays with abdominal shielding can be
employed for chest staging.
• In T3 or clinically node-positive patients, liver ultrasound
and whole-body diffusion-weighted MRI are advised
(Han etal. 2018; Dwyer 2023).
• Generally, computed tomography, bone scans, and positron emission tomography should be avoided during pregnancy to avoid the risk of fetal radiation exposure.
Treatment
Surgery
• Surgery is generally considered safe at any stage of pregnancy, with no known teratogenic effects associated with
general anesthesia. The safest time to perform surgery during pregnancy is in the second trimester, as it carries a lower