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Probability diagnosis

Fibrocystic disease (mammary dysplasia) (32%)

Fibroadenoma (23%)

Cancer (22%)

Cysts (10%)

Breast abscess/periareolar inflammation

Lactation cyst (galactocele)

Serious disorders not to be missed

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

Pitfalls (often missed)

Duct papilloma

Lipoma

Mammary duct ectasia

Fat necrosis/fibrosis

Is the patient trying to tell me something?

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.

Key history

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).

   Note any nipple changes or discharge that may indicate carcinoma.

Key examination

  • 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.

Key investigations

  • 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

Diagnostic tips

  • 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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