Breast Lump

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Introduction

 

 

The Case of...

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Differential Diagnosis

 

Fibrocystic changes

Ages 30 until menopause

Symptoms often include pain and swelling, with focal nodularity and cysts. Symptoms often begin with ovulation and progress until menstruation.

The mass is usually symmetric and in the upper, outer quadrant.

The texture is similar to a thickened plaque, and it blends into the normal breast tissue.

 

Simple cysts

Age 35-50

Cysts are round or oval, fluid-filled masses. They can be hard or soft, depending on amount of fluid

Severe, localized pain may occur with acute enlargement.

 

 

Fibroadenoma

Most common ages 15-35

This benign tumour can be unilateral or bilateral, and may increase in size over several months in response to hormones.

Masses are firm and mobile, and may be lobular and multiple.

There may be an increased risk of cancer if complex, of there is adjacent proliferative disease, or if there is a positive family history.

Diagnosis needs to be confirmed with biopsy, but does not need to be excised unless biopsy is suspicious, or for cosmetic reasons. Serial observation is recommended.

 

 

Fat Necrosis

Fat necrosis is a harmless lesion that occurs following surgery or trauma. It can be difficult to distinguish from cancer, both clinically (firm, ill-defined mass with skin or nipple changes and occasional tenderness) and on mammogram. Biopsy is often therefore carried out.

 

 

Intraductal Papilloma

This solitary, intraductal benign lesion is the most common cause of unilateral, bloody discharge.

It is a true polyp, usually near areola and <1cm in size. Atypical cells or ductal carcinoma can be associated with papilloma, and thse lesions should therefore be removed.

 

 

Lipoma

Lipoma is a benign, solitary fat cell tumour. They are soft, non-tender, and well-circumscribed.

If there is diagnostic uncertainty, or if there is rapid growth, they should be removed.

 

 

Galactocele

These soft, non-tender cystic masses are usually caused by an obstructed milk duct. Aspiration reveals a milky liquid. They are harmless.

 

 

Hamartoma

A hamartoma is a benign lesion that presents with a solitary, painless, encapsulated mass. Excision is recommended, as FNA can be insufficient to rule out malignancy.

 

 

Abscess

Breast abscess is a unilateral, painful, erythematous infection, usually by S. aureus. Oral antiobiotics and incision and drainage are normally required. If the abscess is non-lactational and not resolving, biopsy should be carried out to rule out malignancy.

 

 

Sclerosing adenosis: has been misdoagnosed as cancer, both grossly and histologically. They may also have calcifications. They are benign and do not need to be excised.

 

 

Phylloides (leaflike) tumour are very similar to fibroadenoma clincially and by radiology. Can grow very rapidly. Can be benign and malignant, indistinguishable on core biopsy, and therefore should be removed.

Ductal hyperplasia: most common hyperplastic lesion of the breast. Defined as presence of more than two cell layers. Spaces within the duct lumen that are irregular and slit-like. Mild, moderate, and florid are subjective terms.

Atypical ductal hyperplasia: resembles carcinoma in situ, but lacking sufficient size. Numerous genetic mutations. 4-5x increased relative risk of cancer.

Ductal carcinoma in situ: malignancy, contained by basement membrane. Myoepithelial cells are maintained. All of these need to be excised, as low-grade DCIS has a chance of developing malignant potential at a rate of 1%/year. Treatment is with excision with negative margins, (partial or total mastectomy) followed by radiation.

Atypical lobular hyperplasia: found incidentally in less than 5% of biopsies. 5-8x risk of breast cancer, with increased risk of both breasts.

Lobular cacrinoma in situ: dyscohesive cells with oval of round nuclei. Risk of malignant potential is 1%/year for both breasts. Treatment can range from close observation (examination vs routine mammography) versus bilateral mastectomy. This is the most difficult situations to discuss with patients, given the uncertainty and the extremes of treatments.

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History and Physical Exam

  • history
  • physical exam

History

 

the lump:

  • when it was first felt
  • changes in appearance of breast
  • skin changes
  • new nipple inversion
  • nipple discharge (one/both sides? timing, colour, spontaneity)
  • relation to menstrual cycle
  • tenderness? (not helpful)

risk factors:

  • age
  • family history (maternal and paternal)
  • reproductive history: menarche, LMP, regularity of period, pregnancies, age at menopause)
  • estrogen supplementation
  • alcohol
  • prior breast biopsies
  • radiation exposure

general medical conditions

Physical Exam

A well-done breast exam is critical.

  • soft vs firm
  • well-circumscribed?
  • mobile vs non
  • skin changes

lymph nodes: axillary and supraclavicular

respiratory exam: pleural effusion

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Investigations

  • lab investigations
  • diagnostic imaging

Lab Investigations

Fine needle aspiration (FNA) can determine cystic vs solid. Cells can be sent for cytology. A positive FNA suggests cancer, while a negative FNA is less helpful, given a high false negative rate.

If the FNA is negative, a core or excisional biopsy is recommended.

Diagnostic Imaging

Ultrasound is useful to determine whether a lump is cystic or solid.

Mammography can be used to identify worrying features. It has little role in excluding cancer if suspected clinically.

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Management

 

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Pathophysiology

 

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Resources and References

Barton MB, Harris R, Fletcher SW. 1999. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA 282(13):1270-80.

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