Approach To

Breast Lump
Done by :Dr. Maha Alharbi –R4
Supervised by :Dr.Azza Abdulmajeed
:Objectives

• Approach & clinical presentation (Hx and Ex).

• Differential diagnosis.
• Diagnosis and investigation.
• Management.
• Indications for referral.
• Breast masses are very common complain in women.

• Breast masses are associated with an increased risk of breast cancer.

• Evaluation of a palpable breast mass requires a systematic approach to the history,

physical examination, and radiographic imaging studies .

• A delayed or missed breast cancer diagnosis can severely affect patient outcome.
• A breast mass may be benign or malignant.

• A benign mass may be solid or cystic, whereas a malignant mass is typically solid.

• A cystic mass with solid components (complex cyst) can also be malignant.
 :Clinical presentation
• The clinical presentation is variable, may detected on a patient's self-breast
examination while others are found on a routine clinical breast examination by
physician.

• It is frequently found after a breast examination prompted by other symptoms (e.g

pain, nipple discharge) or trauma.
:Important tips in history
• Age (70%of breast cancer occur in women older than age 50 years ).

• Precipitating factors( such as :truma).

• Breast lump in details(site , size , number , change in breast appearance , skin

changes , nipple change or discharge, pain?).

• Relationship to menstrual cycle and lactation.

• Associated symptoms(fever , night sweat, weight loss ,fatigue).

• Obstetric & gynecological history(early menarche<12 years, late menopause >55
years and nulliparity or first live birth after the age of 30 years all are considering
risk factor of breast cancer )

• Medical &surgical history (Prior biopsy history of atypical hyperplasia, history of

lobular carcinoma in situ ,Patients diagnosed with an invasive cancer )

• Medication/allergy (contraception, hormonal replacement treatment )

• Family history , are at increased risk of breast cancer if :
✔ There is FHx of a first-degree relative(her mother, sister or daughter ) had breast cancer at an early
age
(premenopausal breast cancer ),or ovarian cancer at any age .
✔ If women in her family has had both breast and ovarian cancer.
✔ If women in her family has had breast cancer in both breasts .
✔ If Men in her family has had breast cancer.

• Social history ,lifestyle :physical activity ?alcohol, smoking?

• ICEE
:Examination
• A carful examination of both breasts should be performed.

• Complete clinical breast examination include:

• visual inspection while the patient is seated with her hands on her hips.

Look for:

nipple discharge(color, presence of blood).

asymmetry.

skin changes or nipple change (retraction, bulging, edema, erythema ,

dimpling , or skin thickening).
• palpation of the axillary, supraclavicular, and cervical lymph nodes.

• palpation of the breasts should be performed with the both lying and sitting
position ,with her hands on her hips and then above her head.

• Comment on (size, consistency , location , tenderness ,mobility ,firmness ,

well-defined or nondiscrete margins , fixed to the chest wall or skin, distinction of
the mass from the surrounding tissue).
• The characteristics of the mass and the age of women will provide initial clues
toward likely diagnosis .
:Differential diagnosis
• Benign breast lesions , has three categories according to histopathology:

.non-proliferative .1

.proliferative without atypia .2

.atypical hyperplasia .3
Non-PROLIFERATIVE LESIONS:
• Benign breast condition characterized by fibrous and cystic changes in the
breast.
• most common: breast cysts.
• no increased risk of breast cancer.
• Clinical features:
breast pain, focal areas of nodularity or cysts often in the upper outer
quadrant, frequently bilateral, mobile, varies with menstrual cycle.
Cyst:
• A benign fluid-filled mass.
• Can be palpated as a component of fibrocystic changes of the breast or as a discrete,
compressible, or ballotable solitary mass.
• Commonly found in premenopausal, perimenopausal, and occasionally
postmenopausal women.

Simple cyst .Benign lesion, well circumscribed, may be aspirated if pt in server pain

Complicated Homogenous low-level echoes due to debris ,biopsy is needed to confirm that it is benign ,repeat
cyst .imaging in 6 months to document stability

complex
cyst .Mass with thick walls &septa ,cystic and solid component ,biopsy confirmation is needed
Fibrocystic changes:

• Common, particularly in premenopausal women.

• Most patients present with breast pain that may be cyclical or constant and
may be bilateral, unilateral, or focal.

• The breast tissue, particularly in the upper outer quadrant, may increase in
size prior to the onset of menses then return to baseline after the onset of the
menstrual flow.

Physical finding :

• breast tissue tends to be more diffuse and tender bilaterally .

• Mass not discrete or well-defined.

Treatment for Non-PROLIFERATIVE LESIONS:
• Evaluation of breast mass (U/S, mammography as indicated) and
reassurance.

• Analgesia (ibuprofen).
Proliferative lesions – without atypia
Atypical hyperplasia:
• Can involve ducts (atypical ductal hyperplasia) or lobules (atypical lobular
hyperplasia).

• Increased risk of breast cancer.

• Diagnosis : core or excisional biopsy.

• Treatment: complete resection, risk modification (avoid exogenous hormones),

close follow-up.
:Other lesions

• Fat necrosis: uncommon, result of trauma ,after breast surgery.

clinical presentation :Firm , ill-defined mass with skin or nipple retraction ,-

.±tenderness

prognosis : Regress spontaneously ,but for complete imaging ±biopsy to rule out-
.carcinoma
• Abscess: localized, painful inflammation of the breast associated with fever
and malaise, along with a fluctuant, tender, palpable mass.

The diagnosis is established via ultrasonography demonstrating a fluid-

.collection

• Mammary duct ectasia: obstruction of a subareolar duct.

:Malignant masses
• The differential diagnosis of a malignant breast mass includes:

-invasive and noninvasive cancers.

• The most common breast cancer is an infiltrating ductal breast carcinoma

,approximately 70 to 80 percent of invasive breast cancers.

• Other invasive breast cancers include infiltrating lobular carcinoma and

mixed ductal/lobular carcinoma.
Diagnosis and investigation for
breast
• Definitivelump:
diagnosis in nearly all cases by a triple test of:

✔ Clinical breast examination.

✔ Imaging (e.g., mammography and ultrasonography).

✔ Biopsy.
• A highly suspicious breast mass found on clinical breast examination (CBE)
should be biopsied regardless of imaging findings.

• suspicious masses on imaging should be biopsied even if the CBE suggested

benign findings.
• The diagnosis of a benign or malignant breast mass is confirmed by a breast biopsy.

• imaging should be performed before biopsy because post biopsy changes in the
breast tissue may distort imaging findings.

• In most cases, a core needle biopsy should be performed for evaluation of a

suspicious mass.

• Compared with fine-needle aspiration, core needle biopsy has superior sensitivity,
specificity, and ability to detect possible malignant invasion.
• Diagnostic mammography is the most appropriate initial imaging modality for
women 40 years and older who present with a breast mass.

• Ultrasonography is recommended for women younger than 30 years.

• There is no clear evidence to support one imaging modality over the other in
women 30 to 39 years of age, although many guidelines recommend
evaluating these patients according to algorithms for women older than 40
years.
• U/S: can be used to differentiate between solid and cystic breast lump.

it is the first line of imaging in a woman who is pregnant and/or lactating.

• MRI: not recommended as a routine component of the diagnostic

evaluation of breast cancer for most women.

:Indications for referral patient with breast lump

Patients presenting with the following require urgent referral:

▪ A new, discrete lump (at any age).

▪ Bloodstained, persistent or troublesome nipple discharge.

▪ Recent nipple retraction or distortion.

▪ Altered breast contour or dimpling.

▪ Any skin changes that suggest breast cancer .

MCQs Questions
A 52-year-old woman presents to her family physician with a palpable
breast
lump. An attempt at FNA does not result in aspiration of fluid. Her
mammogram
.is normal. Her mother was diagnosed with breast cancer at age 45
She does not smoke. She currently takes low-dose.estrogen contraception
pills and takes 1200 mg of calcium daily. She began
her menstrual periods at age 10 and she had her first child at age 24. Which
of
?the following is the appropriate next step in evaluation of this patient
.A. Repeat clinical examination in 4 to 6 weeks
.B. Repeat mammogram routinely in 1 year
.C. Referral for biopsy
.D. Discontinuation of her hormone replacement therapy
C. A biopsy is the next most appropriate step in this setting. A negative
mammogram
is not diagnostic of a benign process and does not rule out the possibility
of having breast cancer. A tissue diagnosis is needed in this setting
especially with a known first-degree relative with breast cancer and early age
.of menarche to evaluate for potential malignancy
A 33-year-old woman presents with the complaint of a palpable, firm,
,mobile
cm mass in the 12 o'clock position on her right breast. She states that-2.5
it
has been present for almost 6 months, enlarges with her menstrual cycle,
and
becomes most painful with the onset of her menses. She has no family
.history of breast cancer
Which of the following is the most appropriate initial evaluation of this
?mass
A. Surgical excision
B. Mammogram
C. Ultrasound
D. FNA
,C. Ultrasound is the most appropriate first step in evaluation of this lesion
which is likely a fibroadenoma. This modality can characterize whether or
not the lesion is cystic or solid. If it is cystic, then FNA is the next step. If
.solid, then mammography is the next step
 :Summery
• The initial workup includes a detailed clinical history and physical examination.

• Diagnostic mammography is usually preferred, but ultrasonography is more

sensitive in women younger than 30 years.

• Any suspicious mass detected on physical examination, mammography, or

ultrasonography should undergo biopsy.

• A triple test of clinical breast examination, imaging (e.g., mammography and

ultrasonography), and needle biopsy can lead to a definitive diagnosis in nearly
all cases.
:REFERENCES

• Uptodate .

• AAFP.

• toronto note.

• NICE guideline.

• Case files family medicine.

ANY QUESTION
THANK YOU ALL