Breast Lump Flashcards
What are the four most common diagnoses for breast lump?
- Benign cystic change
- Fibroadenoma
- Cyst
- Carcinoma
What are other diagnoses possible for breast lump in all ages?
- Fat necrosis
- Periductal mastitis
- Abscess
- Galactocele
- Phyllodes tumour
- Sarcoma
- Duct papilloma
- ‘Non breast’ lumps e.g lipoma, sebaceous cyst, prominent costal cartilage/rib
What is the most common diagnoses for breast lump if <30 years?
- physiologically normal lumpy breast
- benign cystic change
- fibroadenoma
- abscess (if breastfeeding)
- galactocele (if breast feeding)
What is the most common diagnoses for breast lump if 30-45 years?
- benign cystic change
- cyst
- abscess (especially if smokers)
- carcinoma
Why must you always rule out breast cancer?
breast cancer is possible in all ages, is common and is potentially very serious - MUST exclude it in any presentation of breast lump, regardless of how benign it seems !!!
What diagnoses only really encounter in breast feeding women?
- Galactoceles
2. Predisposed to mastitis
When could galactoceles show up?
can occur during or shortly after cessation of lactation
How can galactoceles present?
firm mass (often subareolar) caused by obstruction of lactriferous duct
What happens to the the mass in galactoceles?
- duct gradually becomes more distended with milk and epithelial cells
- may rarely be complicated with a secondary infection causing abscess formation
- similar to cyst on examination
What is mastitis caused by?
usually staph aureus or staph epi
How is periductal mastitis different from breastfeeding one?
periductal mastitis and abscess formation seen in older women, in whom anaerobic bacteria may also be implicated
What are the two greatest RF for BC?
- Female
2. Increasing age
What are other RF for BC?
- Previous BC
- FHx of BC
- Previous ovarian, endometrial or bowel cancer
- Irradiation to chest wall (mantle irradiation for Hodgkin’s lymphoma)
- Increased exposure to oestrogens, especially cyclical stimulation
When does FHx become suspicious for BC?
- 3 close blood relatives on same side of fam develop bc at any age
- 2 close blood relative develops bc before age of 60
- 1 close blood relative develops bc before age of 40
- 1 male close blood relative develops bc
- 1 close blood relative, develops bilateral bc
What are examples of increased exposure to oestrogens?
- Early menarche (<13 years)
- Late menopause (>51 years)
- Nulliparity
- Having a first child after age of about 30 years
- Non-breastfeeding
- HRT
- Use of COCP
- Obesity
What qs are important for in history of breast lump?
- How long lump been there? Why was it first noticed
- Breast trauma?
- Lump gotten bigger, smaller or stayed same size?
- Lump painful?
- Skin changes on breasts or nipples
- Any discharge from nipples?
- Patient otherwise fit and well?
- Patient have any risk factors?
What does a growing rapidly lump suggest?
abscess or cyst can appear
What does a growing more slowly lump suggest?
fibroadenomas or carcinoma
Why do you ask if any breast trauma?
accidental or iatrogenic predisposes to fat necrosis and infective sequelae such as an abscess
What would cyclical changes in size of character suggest?
more likely benign cyst breast disease than carcinoma
What would breast pain and tenderness suggest?
- benign cystic change
- acute mastitis
- abscesses
What would a non-tender lump suggest?
benign cystic change or carcinoma
What would mastalgia as an isolated symptom suggest?
rarely presenting feature of breast carcinoma
What would warm eryhtematous skin on breast suggest?
infective or inflammatory process (mastitis or abcess) or inflammatory breast carcinoma (rare)
What would puckering of the overlying skin (peu d’orange) on the breast skin suggest?
carcinoma until proven oterhwsie
What would recent distortion of the nipple suggest?
potential carcinoma
What would bloody nipple discharge suggest?
carcinoma
What would serous or serosanguinous nipple discharge suggest?
intraductal papilloma
What would green, brown, yellow nipple discharge suggest?
periductal mastitis arising from duct ectasia
What would milky nipple discharge suggest?
galactocele
What does unilateral nipple discharge suggest?
less likely to be physiological
What could a febrile patient with breast lump suggest?
- mastitis
- abscess
Does breast carcinoma present with systemic symptoms?
rarely but may have signs of metastasis e.g. back pain
What must you look for on breast inspection?
- Asymmetry
- Contours
- Skin changes
- Nipple changes or discharge
What would recent change/asymmtery suggest?
signficant
What change in contours is suspicious?
any disruption to normally smooth curvature of breast is suspicious, although could be due to fibrocystic change or naturally lumpy change
What skin changes on breast do you look for?
- erythema
- ulceration
- dimpling
- peau d’orange
- radiotherapy tattoos may be visible for patients with previous treatment
What nipple changes or discharge do you look for?
- any new inversion of nipple
- colour of discharge
What are characteristics of a solitary cyst?
- Surface: smooth
- Borders: distinct
- Consistency: firm to lax
- Mobility: no
- Fixity: no
- Lymphadenopathy: no
What are characteristics of a fibroadenoma?
- Surface: smooth
- Borders: distinct
- Consistency: rubbery
- Mobility: yes
- Fixity: no
- Lymphadenopathy: no
What are characteristics of benign cystic change?
- Surface: irregular
- Borders: indistinct
- Consistency: mixed
- Mobility: no
- Fixity: no
- Lymphadenopathy: no
What are characteristics of carcinoma?
- Surface: irregular
- Borders: indistinct
- Consistency: hard
- Mobility: no
- Fixity: maybe
- Lymphadenopathy: maybe
What is a fibroadenoma?
aberrations of normal breast development that contain both stromal and epithelial elements
How common are fibroadenomas?
7-13% of young women have fibroadenoma at some stage during teens or twenties
What actions must a GP make with someone presenting with a breast lump?
- All women with palpable breast lump should be referred to a surgical breast clinic even if you are fairly certain lump is benign
- Reassure patient
How are solid lumps investigated in breast clinic?
triple assessment
What makes up triple assessment?
- Clinical examination
- Radiological examination
- FNA or core biopsy
What is the radiological examination if <35 years?
US: breast tissue in younger women too dense to evaluate by mammography
What is the radiological examination if >35 years?
Two view mammorgram (±with US)
How is cancer suggested on a mammogram?
- increased density
- irregular
margins - spiculation (like shards of glass) and accompanying clustered irregular microcalcifications
When do you do a FNA or Core biopsy?
- FNA only provide info on type of cells (whether dysplastic or not)
- Core biopsy also provide info on local architecture (e.g. invasion of surrounding structures)
What are the treatment options for fibroadenoma?
- Resolve over several years: conservative and reassure patient
- Excisional biopsy removal
What are the indications for excisional biopsy of fibroadenoma?
- patient preference
- lump increasing in size
- lump causing discomfort
