Breast lumps in women

Question 1

Probability diagnosis

Answer 1

Fibrocystic disease (mammary dysplasia) (32%)

Fibroadenoma (23%)

Cancer (22%)

Cysts (10%)

Breast abscess/periareolar inflammation

Lactation cyst (galactocele)

Question 2

Serious disorders not to be missed

Answer 2

Vascular:

• thrombophlebitis (Mondor disease)

Infection:

• mastitis/breast abscess
• tuberculosis

Cancer:

• carcinoma
• ductal carcinoma in situ
• Paget disease of the nipple
• sarcoma
• lymphoma
• mastitis carcinomatosa

Other:

• phyllodes tumour

Question 3

Pitfalls (often missed)

Answer 3

Duct papilloma

Lipoma

Mammary duct ectasia

Fat necrosis/fibrosis

Question 4

Is the patient trying to tell me something?

Answer 4

Anxiety or cancer phobia (esp. if family history)

Possibility of a ‘pseudo lump’ (e.g. part of normal or prominent chest wall anatomy).

If doubtful re-examine after next period or refer.

Question 5

Key history

Answer 5

FHx of breast disease

Past hx including trauma, previous breast pain

Details about pregnancies; complications of lactation such as;

• mastitis
• nipple problems
• milk retention

Note any nipple changes or discharge that may indicate carcinoma.

Question 6

Key examination

Answer 6

Both breasts; inspection looking for any asymmetry, skin discolouration, tethering, peau d’orange or visible veins.

Nipples for retraction or ulceration and variations in level.

LNs in a sitting position with the pt’s hands on hips.

Palpation using the pulps of the fingers should systematically cover the six areas of the breast:

• the four quadrants
• the axillary tail
• the region deep to the nipple and areola.

Question 7

Key investigations

Answer 7

The triple test:

1. clinical examination
2. imaging: mammography ± ultrasound

• if <35 years ultrasound
• >35 years mammogram + ultrasound

3.fine-needle aspiration ± core biopsy

Question 8

Key facts and checkpoints

Answer 8

The commonest lumps are those associated with fibrocystic breast disease (mammary dysplasia)

• is also a common cause of cysts, esp. in the premenopausal phase

Over 75% of isolated breast lumps prove to be benign

clinical identification of a malignant tumour can only definitely be made following aspiration biopsy or histological examination of the tumour

Breast cancer is the most common cancer in females (after skin cancer), affecting 1 in 8 Australian women before the age of 85

About 25% of all new cancers in women are breast neoplasms

A ‘dominant’ breast lump in an older woman should be regarded as malignant

Question 9

Diagnostic tips

Answer 9

Mammary dysplasia is the most common breast lump, and a common cause of cysts especially in the premenopausal phase.

Over 75% of isolated breast lumps prove to be benign

but clinical identification of a malignant tumour can only definitely be made following aspiration biopsy or histological examination of the tumour.

A ‘dominant’ breast lump in an older woman should be regarded as malignant.

Question 10

Red flag pointers for breast lumps

Answer 10

hard and irregular lump

skin dimpling and puckering

skin oedema (peau d’orange)

nipple discharge

nipple distortion

nipple eczema

postmenopausal women

Question 11

Breast cancer symptoms

Answer 11

lump 76%

tenderness or pain 10%

nipple changes 8%

nipple discharge 2%

breast asymmetry/dimpling 4%

periareolar inflammation—usu. due to nipple retraction or mammary duct ectasia

Paget disease of nipple = underlying malignancy

Question 12

Diagnosis

Answer 12

—the triple test

1. clinical breast examination
2. fine needle aspiration cytology ± core biopsy
3. imaging:

• <35 yrs US
• 35–50 yrs US ± mammogram (bilateral)
• >50 yrs bilateral mammogram ± US

Question 13

Investigations

Answer 13

X-ray mammography can be used as a:

• screening procedure
• diagnostic procedure.

It is currently the only effective screening tool for breast cancer.

Screening:

• established benefit for women over 50
• possible benefit for women in their 40s
• follow-up in those with breast cancer, as 6% develop in the opposite breast
• localisation of the lesion for fine needle aspiration

Breast ultrasound;

• mainly used to elucidate an area of breast density
• The best method of defining benign breast disease, esp. with cystic changes.
• It is generally most useful in women <35 yrs.

Needle aspiration techniques

1. cyst aspiration
2. fine-needle aspiration or core needle biopsy:

• very useful diagnostic test in solid lumps
• accuracy of 90–95% (better than mammography)