Giant breast masses are defined as breast masses >5 cm and may represent a late presentation of breast pathology, particularly in developing countries. They may be single or multiple and either benign or malignant. Many of the underlying etiologies for giant breast masses are indistinguishable on physical examination alone. Some of these lesions require a mastectomy while others can be treated by local excision, aspiration, or even conservative measures 1,2.
Pathology
A wide variety of breast conditions can result in solitary or multiple giant masses:
Radiographic features
Mammography and ultrasonography 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. Ultrasound is used primarily to determine whether the mass is simple or complex, cystic or solid.
One algorithmic approach considers whether a mass is well-circumscribed or ill-defined, and the presence or absence of fat density/echogenicity 2.
well-circumscribed masses with fat include lipomas and hamartomas
well-circumscribed masses without fat include cysts, hematomas, giant fibroadenomas, phyllodes tumors, and malignant masses such as medullary carcinoma or primary lymphoma
ill-defined masses include breast carcinoma and abscesses
Giant fibroadenoma vs phyllodes tumor
Differentiation between a giant fibroadenoma and a phyllodes tumor is done on a clinical, mammographic, and sonographic basis 2-4.
Giant fibroadenoma
occurs at a younger age (25-40 years) with no malignancy risk, may regress with age
on mammography, it is a circumscribed low or intermediate density with the incidence of calcifications being more common
on ultrasound, it has homogeneous echogenicity, with cystic changes or posterior acoustic enhancement being uncommon
is treated by simple excision with no local recurrence expected after surgical excision
Phyllodes tumor
occurs at an older age (35-55 years), and exists as a spectrum of pathology between benign and malignant; it has a rapidly progressive course
on mammography, it is a circumscribed high-density mass with a less common incidence of calcifications than giant fibroadenoma
on ultrasound, it is a well-defined mass with low-level uniform or scattered internal echoes, and fluid-filled, elongated spaces or clefts within
it is treated by wide local excision or mastectomy with a high rate of recurrence after surgery of up to 20%
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