Approach to Breast Lump Flashcards
Most important phrase for approach to breast lump
TRIPLE ASSESSMENT OF
- History + PE
- Radiological assessment
- Histopathology
99% specificity to rule out malignancy if all 3 indicate benign
History to ask
- History of lump
2. Assessment of risk
What to ask for history of lump
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?
What is the assessment of cancer risk history?
- Age and Gender
- Personal history
- Family history
- Radiation exposure
- Hormonal exposure
- Lifestyle factors
- Proliferative breast changes
What are possible radiation exposure factors?
Hodgkin lymphoma requiring radiation of chest wall
What are the hormonal factors affect breast cancer?
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)
What previous proliferative breast disease increase risk of malignancy?
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)
BRCA 1/BRCA 2 gene and associated cancer
BRCA 1 - Ovarian, endometrial, prostate Ca
BRCA 2 - Male breast cancer, stomach, pancreas, gallbladder, colon, melanoma and prostate cancer
What are the 7 nipple changes?
Discharge Deviation Depression Destruction Displacement Discoloration Dermatitis
What are the breast lump differentials?
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
What is a fibroadenoma
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
What is the investigation for fibroadenoma
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
What is a phyllodes tumour
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.
How to approach a breast cyst
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
What is fibrocystic breast change
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
What investigations are used
Mammography
Ultrasound
Breast MRI
Discuss mammogram
- 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
Discuss ultrasound
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
Discuss MRI breast
- 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
What is the BIRADS classification
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
What are the types of breast biopsy
Cytology - FNAC
Histology - Core biopsy, incisional/excisional biopsy
Compare core biopsy with FNAC
Core biopsy - more painful, but can appreciate tissue architecture, receptor status
