11. Breast Lump Flashcards
Name DDX : Not a lump (4)
- Prominent rib
- Costochondral junction
- Firm margin at edge of breast
- Defect secondary to previous biopsy
Name DDX : Breast lump
- Tissu glandulaire normal (quadrant supérieur/externe)
- Modifications fibrokystiques (25%)
- Cancer (10%)
- Kyste grossier, galactocèle
- Fibroadénome
- Nécrose graisseuse
Describe : Fibrocystic changes (3)
- Nodular nondiscrete tender mass
- changes with menses
- cyclical or constant pain
Name cancer breast lumps (2)
- Infiltration canalaire (most common)
- Le cancer du sein lobulaire et inflammatoire infiltrant se présente souvent sans masse discrète
Describe : Galactocele (1)
milk retention cyst in breasfeeding women
Describe : Fat necrosis
Trauma, associated with ecchymosis
Name Risk for Malignancy (10)
- Female
- Age >70
- Prior hx of breast CA
- BRCA1/2
- Prior hx of biopsy
- 1st degree relative with breast CA
- Unopposed estrogen
- Alcohol
- Radiation (Mantle radiation in Hodgkin’s)
- Benign breast disease
Name causes Unopposed estrogen (6)
- Bone density - High (RR 2.7-3.5)
- Nulliparity/Age at first birth* >30 (RR 1.9-3.5)
- Menarche <12 (RR 1.5)
- Menopause >55yo (RR 2)
- HRT* (RR 1.2)
- OCP* (RR 1.07-1.2)
Name protective factors breast cancer (6)
- Oophorectomy <35yo
- Postmenopause BMI* <22.9
- Exercise
- Parity* ≥5
- Breastfeeding* ≥16mo
- Aspirin* ≥weekly for ≥6 mo
Describe history taking for breast lump (4)
- Change in breast mass (increase/decrease in size, change in symmetry)
- Skin changes
- Nipple discharge
- New (acquired) nipple inversion (benign vs malignant)
Malign or benign if breast mass changes during menstrual cycle ?
Changes with menstrual cycle (benign if prominent premenstrual and regress during follicular phase)
Describe nipple inversion (benign vs malignant)
- Benign (ectasia) : Central, symmetric, transverse slit with normal areola
- Malignant : Asymmetrical, areola changes, flattened nipple, varied nipple position
Describe physical exam : Breast lump (5)
- Inspection with arms by side, raised above head, pressing on hips leaning forward
- Regional lymph nodes : Cervical, supraclavicular/infraclavicular, axillary, mammary chain
- Skin changes
- Nipple/Areolar changes
- Breast mass
Describe skin changes in physical exam (4)
- Ecchymosis/erythema
- Peau d’orange
- Ulceration
- Dimpling/retraction
Describe nipple/areolar changes in physical exam (2)
- Discharge/crusting
- Inversion/retraction
Describe how to describe breast mass in physical exam (5)
- Obvious/Subtle
- Well-defined/Nondiscrete margins
- Density - Soft/Firm/Hard
- Mobile/Fixed to chest wall or skin
- Tender/Non-Tender
Describe management of breast mass
- Feature of cancer (hard irregular fixed mass, palpable ipsilateral nodes, peau d’orange) = Mammography, U/S, core biopsy, breast surgeon referral
- Benign = Ultrasound or initial aspiration to differentiate between cystic vs. solids lesions
Describe triple test
- Clinical exam
- Imaging
- Non-excision biopsy (FNAC/Core)
Any abnormal result requires surgical referral +/- further investigation
Describe First-line Imaging
- <35yo or Pregnancy/Lactation - Ultrasound. Mammography in all age groups if suspicious findings
- 35-50yo - Mammography + Ultrasound
- > 50yo - Mammography
Describe screening
Women 50-74yo routine mammography q2-3y (weak recommendation)
Describe utility Clinical breast examination and Breast self-examination
has not been shown to provide benefit (no reduction in mortality) and good evidence of harm (RR1.5 for benign biopsy)
When to consider genetics referral
If risk factors present
* Personal Hx Breast CA ≤ 40 or Ovarian CA at any age
* Fam Hx Breast CA ≤ 50
Consider what tool for women ≥ 35yo with risk factors ?
Consider Gail Model for Breast Cancer risk
