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Probability diagnosis

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Fibrocystic disease (mammary dysplasia) (32%)

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Fibroadenoma (23%)

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Cancer (22%)

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Cysts (10%)

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Breast abscess/periareolar inflammation

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Lactation cyst (galactocele)

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Serious disorders not to be missed

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Vascular:

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  • thrombophlebitis (Mondor disease)

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Infection:

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  • mastitis/breast abscess

  • tuberculosis

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Cancer:

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  • carcinoma

  • ductal carcinoma in situ

  • Paget disease of the nipple

  • sarcoma

  • lymphoma

  • mastitis carcinomatosa

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Other:

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  • phyllodes tumour

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Pitfalls (often missed)

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Duct papilloma

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Lipoma

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Mammary duct ectasia

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Fat necrosis/fibrosis

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Is the patient trying to tell me something?

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Consider anxiety or cancer phobia (esp. if family history) and possibility of a ‘pseudo lump’ (e.g. part of normal or prominent chest wall anatomy). If doubtful re-examine after next period or refer.

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Key history

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Family history of breast disease and past history including trauma, previous breast pain and details about pregnancies (complications of lactation such as mastitis, nipple problems and milk retention).

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   Note any nipple changes or discharge that may indicate carcinoma.

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Key examination

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  • Careful examination of both breasts with inspection looking for any asymmetry, skin discolouration, tethering, peau d’orange or visible veins.

  • Examine the nipples for retraction or ulceration and variations in level.

  • Examine lymph nodes in a sitting position with the patient’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 and the region deep to the nipple and areola.

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Key investigations

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  • The basis of investigation of a new breast lump is the triple test, which is:

    • clinical examination (above)

    • imaging: mammography ± ultrasound

    • working rule for imaging: <35 years ultrasound; >35 years mammogram + ultrasound

    • fine needle aspiration ± core biopsy

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Diagnostic tips

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  • Mammary dysplasia, which is the most common breast lump, is 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.

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