A breast lump/mass is defined as a three dimensional discrete mass that is distinct from the surrounding breast tissue and is not present symmetrically in the other breast. It may represent a benign or malignant growth.
Presentation[]
Oftentimes, the mass will be palpated by the patient, or on a general checkup. It may be associated with symptoms such as overlying skin changes, breast dimpling, nipple changes, nipple discharge, breast pain, or it may be otherwise asymptomatic. As such, risk stratification and thorough examination is required.
History should include questions regarding skin changes, nipple discharge, breast pain, and changes with the menstrual cycle. Family history of cancer should be elicited, as well as reproductive and obstetrical/gynecological history. Furthermore, constitutional symptoms should be elicited (fever, night sweats, weight loss).
Differential[]
Not a lump[]
- Prominent rib
- Costochondral junction
- Firm margin at edge of breast
- Defect/scar from previous biopsy
Actually a lump[]
- Normal glandular tissue
- Macrocyst
- Fibroadenoma
- Present generally in the younger population (<age 30)
- Rubbery on palpation, non-tender, mobile
- Placement is usually upper outer quadrant, symmetrical
- Usually associated with the menstrual cycle, and can be painful
- No overlying skin changes
- Can investigate with mammogram+U/S+FNA
- Excision if >5cm/rapid growth/patient preference
- Watchful waiting otherwise - if growing, consider excision
- Fibrocystic changes
- Breast pain on history
- Present between ages 30-50
- Focal nodularity, bilateral
- Plaques
- Brown/green discharge
- Varies with menses
- Investigate with mammogram and FNA
- Manage with OCPs, NSAIDs
- Watchful waiting
- Fat necrosis
- Cystic breast mass
- usually >40 years old, uncommon after menopause
- Fluctuates with cycle
- Well demarcated, mobile, firm
- Tender
- Diagnose with needle aspiration of clear fluid (with subsequent cyst resolution)
- Abscess
- Unilacteral, localized pain and erythema
- Fluctuant or loculated
- Nipple discharge
- Systemic symptoms
- Investigate with U/S
- Tx with I&D, oral antibiotics
- Intraductal papilloma
- Blood nipple discharge
- Solitary intraductal polyp
- Investigate with mammogram+U/S
- Will require surgical excision
- Cancer
- Red flag symptoms include scaling, eczema-like lesion (PAget's), p'eau d'orange, skin edema/erythema/induration
- Often arises in >50 years of age
- DCIS (ductal carcinoma in situ)
- 80% non-palpable, usually detected by screening
- LCIS (lobular carcinoma in situ)
- nonpalpable, not usually found on screen, usually diagnosed on biopsy
- Infiltrative ductal carcinoma
- Most common cancer - 80%
- Hard scirrhous infiltrating tentacles, gritty on cross section
- Invasive lobular carcinoma
- 8-15% of breast cancers
- 20% of these present bilaterally
- Difficult to detect
- Paget's disease of the breast (1-3%)
- Ductal carcinoma that invades the nipple with scaling+eczema
- Inflammatory carcinoma (1-4%)
- Ductal carcinoma that invades dermal lymphatics
- Most aggressive form of cancer - erythema, warm, tender, edema
- P'eau d'orange indicates advanced disease
- Metastases - bone, lungs, liver, brain
Risk Factors for Cancer[]
- Increased age
- Female sex
- History of breast biopsy with atypical hyperplasia
- Lobular carcinoma in situ
- Ductal carcinoma in situ
- History of breast cancer
- History of mantle radiation for Hodgkin's disease in childhood
- Strong family history of breast cancer, BRCA positive family
- Radiation
- Alcohol >1/d, obesity
- Unopposed estrogen
- Menarche < age 12, late menopause>age 55, 1st pregnancy >age 30, >5 years of HRT
- Nulliparity
Screening and workup[]
No evidence for self-exam of breasts by patients.
Physical exam of the breast should include examination and palpation of both breasts, surrounding tissue, cervical and axillary lymph nodes.
Mammography is the screening method of choice. It, however, does fail to detect around 10-15% of breast cancers, and has fairly poor sensitivity for cancer (36%). Screening for breast cancer by mammography is recommended for:
- Women between the ages of 50-74 years, mammography q2 years
- Screening in patients who have a 1st degree relative with breast cancer should start 10 years prior to the youngest age of their relative's presentation.
Ultrasound can be used to differentiate between cystic and solid masses. For cystic lesions that are palpable, needle aspiration should be attempted. For solid masses, fine needle aspiration can be done for sampling. For suspicious lesions, core needle biopsies can be done by a surgeon, or excisional biopsies.
Genetic screening for the BRCA1/2 gene should be done if:
- Patient is diagnosed with breast and ovarian cancer
- Patient is diagnosed with a second breast cancer under the age of 50
- Strong family history
- >2 1st degree relatives with breast or ovarian cancer
- Family history of male breast cancer, or the BRCA1/2 gene
Follow-up[]
For cancer patients, visits q3-6 months x 2 years
Annual mammography.