Giant breast masses

Many patients, particularly in developing countries, can present late with giant breast masses. They may be single or multiple and either benign or malignant. Many of these conditions are indistinguishable on physical examination alone. Some of these lesions require mastectomy while others can be treated by local excision, aspiration or even conservative measures.

Terminology

Giant breast masses are those larger than 5 cm in maximum dimension.

Pathology

A wide variety of breast conditions can result in solitary or multiple giant masses:

• abscess
• carcinoma
• cyst
• fibroadenoma
• hamartoma
• hematoma
• lipoma
• phyllodes tumor

Radiographic features

Ultrasonography (US) and mammography are the two basic imaging techniques for routine diagnostic imaging of breast diseases. For women over the age of 35 years presenting with a palpable or suspected breast mass, mammography is often the first imaging investigation to be performed. The US is used to determine whether the mass is a simple cyst or a complex or solid mass.

An algorithmic approach based on mammographic features, i.e. whether a mass is well-circumscribed or not, and the presence of fat density is proposed by Muttarak M and Chaiwun B with ultrasound used to determine whether the mass is a simple cyst, a complex mass, or a solid mass

Well circumscribed masses with fat density on mammogram include lipoma and hamartoma and without fat density include a cyst, hematoma, giant fibroadenoma, Phyllodes tumor and malignant masses as medullary carcinoma and primary lymphoma.

Ill defined mass on mammogram included breast carcinoma and breast abscess.

Differentiation between giant fibroadenoma and Phyllodes tumor is done on a clinical, mammographic and sonographic basis.

Giant fibroadenoma occurs at a younger age (25-40 years) with no malignancy risk, possible regression with age,  treated by simple excision and no local recurrence after surgical excision.On the mammogram, it will appear as a circumscribed low or intermediate density with the incidence of calcifications being more common.On sonography, it appears as homogeneous echogenicity with uncommon cystic changes or posterior acoustic enhancement.

Phyllodes tumor occurs at an older age (35-55 years) with pathology divided into benign-borderline-Malignant. It has a rapidly progressive course with a high rate of recurrence after surgery up to 20 %. It is treated by wide local excision or mastectomy. On mammography it appears as a circumscribed high-density mass with a less common incidence of calcifications than giant fibroadenoma. On sonography, it appears as a well-defined mass with low-level uniform or scattered internal echoes, fluid-filled, elongated spaces or clefts within.