Breast Lumps Flashcards
What are the other differentials for a breast lump?
Fat necrosis Periductal mastitis Abscess Galactocele Phyllodes tumour Sarcoma Duct papilloma 'Non breast' lumps eg lipoma, sebaceous cyst
What is the most common diagnosis for a breast lump in women
Physiologically normal lumpy breasts Benign cystic change Fibroadenoma Abscess (if breast feeding) Galactocele
What is the most common diagnosis for a breast lump in women aged 30-45?
Benign cystic change
Cyst
Abscess (smokers)
Carcinoma
What is the most common diagnosis for a breast lump in women aged 45-60?
Cyst
Abscess (smokers)
Carcinoma
What is the most common diagnosis for a breast lump in women aged >60?
Carcinoma
What breast lump diagnoses would you only come across in breast feeding women?
Galactoceles
Lactating women are also more prone to mastitis
What is are galactoceles and what is there cause?
Firm mass (often subareolar) and are caused by the obstruction of a laciferous duct
What are the main risk factors for breast cancer?
Previous breast cancer
Family history of breast cancer
Previous ovarian, endometrial or bowel cancer
Irradiation to the chest wall
Increased exposure to oestrogens
- Early menarche
- Late menopause
- Nulliparity
- Having first child after 30
- Non breast feeding
- HRT
- COCP
- Obesity
What are the relevant pieces of information you want to obtain from a woman with a breast lump?
How long has the lump been there for? Why was it first noticed?
Breast trauma?
Size changes? Relation to menses?
Is it painful?
Any skin changes to the breast?
Discharge from the nipple?
Otherwise fit and well?
Why would you ask about breast trauma in a patient with a breast lump?
Predispose to fat necrosis and infective sequel we such as an abscess
Why do you ask about change in breast lump size when taking a history from a patient with a breast lump?
Abscess or cysts can appear overnight and undergo rapid increases in size
Lumps that undergo cyclical change in size/character are more likely to be benign cystic breast disease
What kind of breast lumps are painful?
Benign cystic change, acute mastitis and abscesses classically cause breast pain and tenderness
Carcinoma can be painful but are more often non-tender
What are the most common causes of a breast lump?
Benign cystic change (AKA fibrocystic change)
Fibroadenoma
Cyst
Carcinoma
Why do you ask about changes to the skin of the breast when taking a breast lump history?
Warm erythematous skin should raise your suspicion of an infective or inflammatory process such as mastitis or an abscess
Or perhaps inflammatory breast carcinoma
Puckering of the skin over a lump suggests carcinoma until proven otherwise
Why do you ask about changes to the nipple when taking a history form a patient with a breast lump?
Recent distortion of the nipple hint at carcinoma
What kinds of nipple discharge might a patient with a breast mass experience and what are their likely causes?
Bloody discharge - Carcinoma
Serous or serosanguinous discharge - Intraductal papilloma
Green, brown or yellow discharge - Periductal mastitis arising from duct ectasia
Milky discharge - Galactocele
Why do you ask about the patients general wellbeing when taking a history about a breast lump?
Patients with mastitis or an abscess may be febrile
Breast carcinoma rarely causes generalised systemic symptoms - such as weight loss, night sweats and fevers
Also back pain may occur in breast cancers with spinal metastases
What do you look for on examination of the breasts?
Asymmetry
Contours
Skin changes
Nipple changes
What will a solitary breast cyst feel like on examination?
Smooth
Distinct borders
Firm to lax consistency
Non mobile
No fixity
No lymphadenopathy
What will a fibroadenoma feel like on examination?
Smooth
Distinct edges
Rubbery consistency
Mobile
No fixity
No lymphadenopathy
What will benign cystic change feel like on examination?
Irregular surface
Indistinct border
Mixed consistency
No fixity
No mobility
No lymphadenopathy
What will breast carcinoma feel like on examination?
Irregular
Indistinct edges
Hard consistency
No mobility
May have fixity
May have lymphadenopathy
How are all solid lumps investigated at the breast clinic?
Clinical examination
Radiological examination
Fine needle aspiration or core biopsy
What are the two treatment options for fibroadenoma?
Reassure the patient
- Most will resolve over several years and pose no increased risk of malignancy
Excisional biopsy
- Indication include patient preference, lump of increasing size or a lump that is causing discomfort
What are the most likely sites of metastasis for a breast carcinoma and how are the identify?
Lungs - CXR
Liver - Abdominal palpation, liver enzymes, liver ultrasound
Bone - Palpation for sites of bony tenderness, serum calcium and phosphate, isotope bone scan
Brain - CT head (only if symptoms such as fitting or early morning headache and nausea)
What is peau d’orange and what causes it?
Peau d’orange refers to the skin change that may occur with an infiltrating carcinoma of the breast
The skin has a dimpled appearance
What it the difference between skin fixity and skin tethering?
If a lesion is fixed to the skin, it cannot be moved independently of the overlying skin
If a lesion is tethered to the skin then it can be moved independently of the skin to some extent (as if tethered by a string)
What are the advantages of FNA in breast lump sampling?
Quick
Minimally invasive
Low risk of bruising or local complications
Adequate for assessing the hormone receptor status of the cancerous cells
What are the disadvantages of FNA in breast lump sampling?
May have poor sensitivity
In situ and invasive disease cannot be differentiated as local architecture is lost
What are the advantages of core biopsy in breast lump sampling?
In situ and invasive disease can be differentiated as local architecture is preserved during the biopsy
What are the disadvantages of core biopsy in breast lump sampling?
Higher risk of complication and bruising than FNA
Results are not immediate
Requires local anaesthesia
More invasive and time consuming than FNA
What methods exist for axillary staging of breast cancer?
Axillary clearance
Axillary sampling
Sentinel lymph node biopsy
Axillary clearance
Removal of all local lymph nodes. Three levels of clearance (I, II and III) refer to removal of increasing numbers of lymph nodes lateral, posterior and medial to pectoralis minor
Axillary sampling
A minimal dissection of axilla is undertaken and a selection of at least four nodes is removed from the low axilla for histological analysis
Sentinel lymph node biopsy
Aim is to identify the first node which drains the breast
Blue dye and/or radio-isotope is injected into the peri-areolar tissure in the same breast quadrant as the cancerous tissue - taken up by node
Single node can be removed and sent for histology
What is the scoring system used to describe breast cancer staging?
Eg P4R4C4B5
P = Physical examination R = Radiological examination C = Cytology (FNA) B = Biopsy (core)
1 = normal, 2 = benign, 3 = probably benign, 4 = probably benign, 5 = malignant
What is ANDI?
Aberrations of Normal Development and Involution
