Breast Lump

Question 1

34F presents c/o being able to palpate 1cm breast lump, present for four weeks. Hx of PCOS. Meds include estrogen/levenogestrol 30/150. Maternal grandma died at 89yo of breast cancer.

Impression/Goals/DDx

Answer 1

Impression:
Provisionally concerned of a breast malignancy such as ductal or lobular carcinoma, however would need to consider other common causes of breast lumps, particularly in younger patients including
Benign: Fibrocystic change, Fibroadenoma, simple cyst, phyllodes tumor, haematoma
Infective: Abscess, Mastitis

Rule out: Invasive lobular/invasive ductal carcinoma

Goals:

• Assess to rule out life threatening diagnosis.
• Promptly grade, stage, type the cancer if necessary
• Appropriately manage breast lump aetiology

Question 2

Breast Lump - History

Answer 2

History:

• Sx (characterise lump): pain, course of growth, tethered to surrounding structures
• Sx of malignancy (weight-loss, night sweats, fevers)
• Risk factors for malignancy: fam hx, PCOS, older age, smoking/alcohol, medications
• Past history, SNAP

Question 3

Breast lump - Examination

Answer 3

Examination:
- Inspection: skin/nipple involvement (peau d’orange, lymphoedema, swelling, etc)
- Palpation: mobile, spiculated, attached to deeper/superficial structures, rubbery
Extras
- Contralateral breast assessment
- Lymph nodes exam
- Systemic assessment: signs of metastasis: bone pain, gastro masses, organomegaly

Question 4

Breast lump - Investigations

Answer 4

Investigations:

• Triple assessment: Hx/ex, ultrasound/mammography, biopsy (would use mammography in patient over age of 50 as increased sensitivity).
• Bedside: obs → (febrile for infective causes)
• Bloods: FBC, UEC, CMP
• Imaging: CT CAP/PET for ?distant mets. Mammogram (stellate lesions, shadowing, microcalcifications), US (Hypoechoic regions, vascularity, irregularity)

Special tests:

• Biopsy - Fine needle, core biopsy, lumpectomy
• Consider referral to genetic counsellor for BRCA gene testing - young age of patient

Question 5

Breast Lump - Management

Answer 5

Benign:
Watch/wait, regular follow up.
Patient education for self-examination
Simple cyst aspiration

Malignant:
Would involve MDT comprising medical & radiation oncologists, allied health, GP.

Treatment depends on stage/grade, available treatment modalities for breast cancer include;

Surgical (different combinations with adjuvant/neoadjuvant therapies dependent on patient and disease factors)

• Lumpectomy
• Mastectomy
• Radiation - can be used as adjuvant treatment

Medical (depends on cancer subtype)

• Chemotherapy (triple negative cancers)
• Hormone therapy (for ER/PR positive)
• SERMs
• Herceptin (NEU/HER2 positive)

Consider;
Palliation: pain relief, quality of life surgery/medication
Referral to clinical geneticist for BRCA1/2 investigation given younger age

Long term management:
Regular screening as per Australian guidelines - 50-72, 2 yearly mammogram, or based on patient’s individual risk factors (fam history)