Approach to Breast Lump

Question 1

Most important phrase for approach to breast lump

Answer 1

TRIPLE ASSESSMENT OF

• History + PE
• Radiological assessment
• Histopathology

99% specificity to rule out malignancy if all 3 indicate benign

Question 2

History to ask

Answer 2

1. History of lump

2. Assessment of risk

Question 3

What to ask for history of lump

Answer 3

Duration - when and how was it noticed

Onset - Does it come periodically

Progress - How has it changed - growth/nipple changes?

Associated symptoms of

• Skin changes
• Other symptoms (pan, nipple discharge)
• Previous history of similar incidence

Access concerns “what do you think it is?

Question 4

What is the assessment of cancer risk history?

Answer 4

1. Age and Gender
2. Personal history
3. Family history
4. Radiation exposure
5. Hormonal exposure
6. Lifestyle factors
7. Proliferative breast changes

Question 5

What are possible radiation exposure factors?

Answer 5

Hodgkin lymphoma requiring radiation of chest wall

Question 6

What are the hormonal factors affect breast cancer?

Answer 6

Early menarche (before 12)/late menopause (after 55)

Hormone replacement therapy of BOTH estrogen and progesterone (estrogen therapy no effect alone)

No children/late 1st birth (after 30)

Question 7

What previous proliferative breast disease increase risk of malignancy?

Answer 7

Proliferative change with atypia - atypical ductal hyperplasia/atypical lobular hyperplasia

Proliferative change without atypia - Fibrocystic change with accompanying hyperplasia, papilloma

Lobular carcinoma in situ and non proliferative epithelial changes (fibrocystic change without proliferative change like cysts)

Question 8

BRCA 1/BRCA 2 gene and associated cancer

Answer 8

BRCA 1 - Ovarian, endometrial, prostate Ca

BRCA 2 - Male breast cancer, stomach, pancreas, gallbladder, colon, melanoma and prostate cancer

Question 9

What are the 7 nipple changes?

Answer 9

Discharge
Deviation
Depression
Destruction
Displacement
Discoloration
Dermatitis

Question 10

What are the breast lump differentials?

Answer 10

Benign
Hyperplasia with atypia - ALH/ADH
Hyperplasia without atypia - intraductal papilloma
Non epithelial changes - cyst
Others - Lipoma, phyllodes tumour

Malignant
Non invasive (LCIS, DCIS)
Invasive (Invasive lobular/ductal carcinoma, inflammatory breast cancer)

Others
Infection
Specific scenarios (diabetes, fat necrosis, nipple adenoma

Question 11

What is a fibroadenoma

Answer 11

Abberation of normal breast development, non neoplastic lesions which change are affected by hormones

Clinically present with a well circumscribed, mobile, discrete lump of rubbery consistence. Associated with pain or tenderness, varies with hormones

Question 12

What is the investigation for fibroadenoma

Answer 12

Ultrasound and core biopsy
Core biopsy - prominent fibrous tissue compressing epithelial cells

If triple assessment is negative, can discharge patient without treatment. Symptomatic fibroadenoma can be excised

Question 13

What is a phyllodes tumour

Answer 13

Rare fibroepithelial tumour which has leaf like lobualations and irregular margins

Can grow rapidly, most benign but can also be malignant.

Imaging and core biopsy to look for leaf like architecture with papillary projection of epithelium lined stroma and varying degrees of atypia/hyperplasia

Treat with WLE, mastectomy if it is recurring.

Question 14

How to approach a breast cyst

Answer 14

Ultrasound, if its simple then leave alone.

If it is large and symptomatic, aspirate and send fluid for cytology.

After aspiration, if there’s still a lump, must go for further imaging and biopsy

Question 15

What is fibrocystic breast change

Answer 15

Lump, cobblestone, mobile mass in the breast with benign changes. Presents with premenstrual breast pain. Re-examine on 10th day of menses to reduce hormonal influence

Question 16

What investigations are used

Answer 16

Mammography

Ultrasound

Breast MRI

Question 17

Discuss mammogram

Answer 17

• Performed after 40 as fat replaces breast tissue to create a better background as fat doesn’t absorb radiation

Mostly a lateral lesion (on CC view) or in the oblique milky way on MLO view (area parallel to pectoral muscle stretching across superior/inferior views

Look for:

• Clustered microcalcifications
• Spiculated margins/stellate mass
• Focal mass with poorly defined margins
• Architectural distortion
• Asymmetric density

Benign findings - Radial scar, fat necrosis, milk of calcium

Question 18

Discuss ultrasound

Answer 18

for younger patients/pregnant/lactating

• Denser breasts have better evaluation with ultrasound
• Distinguish between solid and benign cysts
• Evaluate in mammographically difficult areas
• Guide procedures

BUT
Operator dependent, cannot detect microcalcifications

Features of malignancy
B -borders
I - Internal caclifications
T - Taller rather than wide
C - Central vascularity/compressibility
H - Hypoechoic

Benign features

• Smooth margins, well scircumscribed
• Wider rather than tall
• Thick capsule
• Macrolobulations
• Hyperechogenic
• Anechoic

Question 19

Discuss MRI breast

Answer 19

• Expensive but good soft tissue radiation
• Lower specificity
• More for those with high risk: chest radiation, BRCA carrier/BRCA family carrier
• Access response to neoadjuvant chemo

Question 20

What is the BIRADS classification

Answer 20

0 - need more info
1 - normal
2 - benign
3 - probably benign
4 - suspicious
5- probably malignant
6 - malignant with confirmation

Core biopsy for 4+
3- Watchful waiting or biopsy offered

Question 21

What are the types of breast biopsy

Answer 21

Cytology - FNAC

Histology - Core biopsy, incisional/excisional biopsy

Question 22

Compare core biopsy with FNAC

Answer 22

Core biopsy - more painful, but can appreciate tissue architecture, receptor status