++
This is based on following a careful history and examination.
++
The history should include a family history of breast disease and the patient’s past history, including trauma, previous breast pain, and details about pregnancies (complications of lactation such as mastitis, nipple problems and milk retention).
++
Have you had any previous problems with your breasts?
Have you noticed any breast pain or discomfort?
Do you have any problems such as increased swelling or tenderness before your periods?
Is the lump constant or changing?
Have you noticed lumpiness in your breasts before?
Has the lumpy area been red or hot?
Have you noticed any discharge from your nipple or nipples?
Has there been any change in your nipples?
Does/did your mother or sisters or any close relatives have any breast problems?
++
++
Important ‘tell-tale’ symptoms are illustrated in FIGURE 101.2.
++
++
The diagnostic strategy is outlined in TABLE 101.2.
++
++
The discharge may be intermittent, from one or both nipples. It can be induced by quadrant compression.
++
A common reason is physiological, which is usually part of a normal hormonal process.
++
+++
Periareolar inflammation
++
This presents as pain around the areola with reddening of the skin, tenderness and swelling. Causes may be inverted nipple or mammary duct ectasia.
+++
Paget disease of the nipple
++
This rare but interesting sign and condition usually occurs in middle-aged and elderly women (see FIG. 101.4). It starts as an eczematous-looking, dry scabbing red rash of the nipple and then proceeds to ulceration of the nipple and areola (see TABLE 101.3). It is always due to an underlying malignancy.
++
++
+++
Examination of the breasts
++
Identify a dominant lump (one that differs from the remainder of the breast tissue).
Identify a lump that may be malignant.
Screen the breasts for early development of cancer.
++
Time of examination: ideally, 4 days after the end of the period.
++
Red flag pointers for breast lumps
++
Inspection: sitting—patient seated upright on side of couch in good light, arms by sides, facing the doctor, undressed to waist.
Note:
asymmetry of breasts or a visible lump
localised discolouration of the skin
nipples:
– for retraction or ulceration
– for variations in the level (e.g. elevation on one side)
– or discharge (e.g. blood-stained, clear, yellow)
skin attachment or tethering → dimpling of skin (accentuate this sign by asking patient to raise her arms above her head)
appearance of small nodules of growth
visible veins (if unilateral they suggest a cancer)7
peau d’orange due to dermal oedema
Raise arms above the head (renders variations in nipple level and skin tethering more obvious). Hands are pressed on the hips to contract pectoralis major to note if there is a deep attachment of the lump.
Examination of lymph glands in sitting position: patient with hands on hips. Examine axillary and supraclavicular glands from behind and front.
Note: The draining lymphatic nodes are in the axillae, supraclavicular fossae and internal mammary chain.
Palpation:
Patient still seated: palpate breast with flat of hand and then palpate the bulk of the breast between both hands.
In supine position:
Method
Use the pulps of the fingers rather than the tips with the hand laid flat on the breast.
Move the hand in slow circular movements.
Examine up and down the breast in vertical strips beginning from the axillary tail (see FIG. 101.5).
If a suspicious lump is present, inspect liver, lungs and spine.
Note:
Most cancers occur in the upper outer quadrant (see FIG. 101.7).6
A useful diagram to record the findings is shown in FIGURE 101.8.
Lumps that are usually benign and require no immediate action are: tiny (<4 mm) nodules in subcutaneous tissue (usually in the areolar margin); elongated ridges, usually bilateral and in the lower aspects of the breasts; and rounded soft nodules (usually <6 mm) around the areolar margin.8
A hard mass is suspicious of malignancy but cancer can be soft because of fat entrapment.
The inframammary ridge, which is usually found in the heavier breast, is often nodular and firm to hard.
Lumpiness (if present) is usually most marked in the upper outer quadrant.
++
++
++
++
++
If a solitary lump is present, assess it for:
position (breast quadrant and proximity to nipple)
size and shape
consistency (firm, hard, cystic, soft)
tenderness
mobility and fixation
attachment to skin or underlying muscle
++
Mammography can be used as a screening procedure and as a diagnostic procedure. It is currently the most effective screening tool for breast cancer.9 Positive signs of malignancy include an irregular infiltrating mass with focal spotty microcalcification.
++
++
established benefit for women over 50 years
possible benefit for women in their 40s
follow-up in those with breast cancer, as 6% develop in the opposite breast
localisation of the lesion for fine-needle aspiration
++
This is mainly used to elucidate an area of breast density and is the best method of defining benign breast disease, especially with cystic changes. It is generally most useful in women less than 35 years old (as compared with X-ray mammography).
++
++
pregnant and lactating breast
differentiating between fluid-filled cysts and solid mass
palpable masses at periphery of breast tissue (not screened by mammography)
for more accurate localisation of lump during fine-needle aspiration
++
Note: CT and MRI have limited use. An age-related schemata for likely diagnosis and appropriate investigations is presented in TABLE 101.4.
++
++
Breast imaging for palpable lumps—summary
<35 years: bilateral ultrasound; bilateral mammography if ultrasound suspicious
35–50 years: bilateral mammography + bilateral ultrasound
>50 years: bilateral mammography ± bilateral ultrasound
+++
Needle aspiration and biopsy techniques
++
Cyst aspiration
Fine-needle aspiration biopsy: this is a very useful diagnostic test in solid lumps, and has an accuracy of 90–95% (better than mammography)6
Large needle (core needle) biopsy
Incision biopsy
++
Oestrogen receptors are uncommon in normal breasts but are found in two-thirds of breast cancers, although the incidence varies with age. They are good prognostic indicators. Progesterone receptors can also be estimated.
+++
Fine-needle aspiration of breast lump
++
This simple technique is very useful, especially if the lump is a cyst, and will have no adverse effects if the lump is not malignant. If it is, the needle biopsy will help with the preoperative cytological diagnosis.
++
Follow-up: the plan for aspiration is outlined in FIGURE 101.9.
++
+++
Summary: investigation of a breast lump
++
If the patient presenting with a breast lump is younger than 35, perform an ultrasound;10 if older than 35 perform a mammogram and an ultrasound. If the lump is cystic—aspirate; if solid—perform a fine-needle biopsy and then manage according to outcomes. If it is suspicious, an excisional biopsy is the preferred option.
++
More than 99% of breast cancers will be detected if any component of an appropriately performed triple test is positive.11
++
Indications for biopsy or excision of lump
The cyst fluid is bloodstained.
The lump does not disappear completely with aspiration.
The swelling recurs within 1 month.
++
Breast cancer is uncommon under the age of 30 but it then steadily increases to a maximum at the age of about 60 years.6 About one-third of women who develop breast cancer are premenopausal and two-thirds postmenopausal. Ninety per cent of breast cancers are invasive ductal carcinomas, the remainder being lobular carcinoma, papillary carcinomas, medullary carcinomas and colloid or mucoid carcinomas.1
++
++
increasing age (>40 years)
living in a Western population
pre-existing benign breast lumps
alcohol intake >2 SDs/day
use of menopause hormonal therapy (MHT) (combined oestrogen and progestogen) >5 years
personal history of breast cancer
family history in a first-degree relative (raises risk about threefold)
known genetic mutations BRCA1 or BRCA2
nulliparity
late menopause (after 53)
obesity
childless until after 30 years of age
early menarche9
ionising radiation exposure
Ashkenazi Jewish ancestry
+++
Familial breast cancer
++
Up to 5% of cases are familial, with most being autosomal dominant. Refer to CHAPTER 18.
++
The majority of patients with breast cancer present with a lump (76%).6
The lump is usually painless (10% associated with pain).
Usually the lump is hard and irregular.
Nipple changes, discharge, retraction or distortion.
Rarely cancer can present with Paget disease of breast (nipple eczema) or inflammatory breast cancer (see CHAPTER 100).
Rarely it can present with bony secondaries (e.g. back pain, dyspnoea, weight loss, headache).
++
Note: There are basically three presentations of the disease:
++
++
Of those who present with local disease, approximately 50% will develop metastatic disease.
++
++
Immediate referral to an expert surgeon on suspicion or proof of breast cancer is essential.
++
Guidelines for referral include:11
++
any positive component of the triple test
incomplete cyst aspiration
spontaneous unilateral bloody or serious discharge from a single duct (especially in women aged 60 years and over)
persistent eczematoid changes of nipple that do not respond to topical treatment
unresolving inflammatory mastitis
++
The treatment has to be individualised according to the nature of the lump, age of the patient and staging. Accurate staging requires knowledge of whether the draining lymph nodes are involved with the tumour, as this is the single most powerful predictor of subsequent metastases and death. Staging for systemic disease also requires full blood examination and liver function tests (including alkaline phosphatase). A bone scan may be used as a valuable baseline. Size and histological grading of tumour plus nodal status and receptor status are the most important prognostic factors.
++
Optimal management of locally advanced breast cancer is a combined approach that uses chemotherapy, radiotherapy, surgery and/or endocrine therapy if applicable (level IV evidence).
++
++
++
Most relapses12 after surgery occur in the first 3 years.
+++
Ductal carcinoma in situ
++
DCIS is a non-invasive abnormal proliferation of milk duct epithelial cells within the ductal–lobular system and is a precursor lesion for invasive breast cancer. Since mammography screening it is readily detected and now comprises about 20% of breast cancer. It may present clinically with a palpable mass or nipple discharge or Paget disease of the nipple with or without a mass.
++
Management decisions are challenging, with options being total mastectomy or breast-conserving therapy with or without radiotherapy. Patients usually have an excellent outcome with low local recurrence rates and a survival of at least 98%.13
+++
Adjuvant therapy for breast cancer
++
The consultant will choose the most appropriate surgical and adjuvant treatments (which are designed to treat and destroy micrometastatic disease) for the individual patient.
++
The National Breast Cancer Consensus report emphasised that ‘continuing care should be coordinated through the patient’s GP as the impact of treatment may last longer than therapy and support must continue’. The report made the following recommendations:14
++
Tumour excision followed by whole breast irradiation was the most preferred local therapy for most women with stage I or II cancer.
Total mastectomy and breast-conservation surgery had an equivalent effect on survival.
Total mastectomy is preferred for a large tumour, multifocal disease, previous irradiation and extensive tumour on mammography.
Recommendations for radiotherapy after mastectomy are:15
– tumours >4 cm in diameter
– axillary node involvement of >3 nodes
– the presence of positive or close tumour margins
Intraoperative radiotherapy following tumour excision is one of several techniques for partial breast irradiation.16
Cytotoxic chemotherapy has an important place in management, especially in young, healthy women who are E receptor negative and have visceral spread.17
Adjuvant hormonal therapy by the anti-oestrogen agent tamoxifen 20 mg (o) daily if E receptor +ve, which is a specific modulating agent, is widely used and is most suitable in postmenopausal women. The usual course is 5 years.
Adjunct agents available for treatment include:18,19
anti-oestrogens (E receptor blockers or SERMS): tamoxifen, toremifene
aromatase inhibitors (for hormone receptor +ve cancer in postmenopausal women): anastrozole, letrozole, exemestane
monoclonal antibodies: trastuzumab (Herceptin) or pertuzumab (Perjeta)
bisphosphonates: recommended for women with bony metastases since evidence indicates reversal of bone density loss and cancer recurrence17,18
progesterones (e.g. medroxyprogesterone acetate)
the OCP (if taken) should be ceased, and pregnancy is inadvisable
++
Guidelines for adjuvant treatments can be accessed at <guidelines.nbocc.org.au/guidelines/guideline_2.pdf>.
++
Synonyms: fibroadenosis, chronic mastitis, mammary dysplasia, cystic hyperplasia, fibrocystic disease.
++
Most common in women between 30 and 50 years
Hormone-related (between menarche and menopause)
Pain and tenderness and swelling
Premenstrual discomfort or pain and increased swelling
Fluctuation in the size of the mass
Usually settles after the period
Unilateral or bilateral
Nodularity ± a discrete mass
Ache may extend down inner aspect of upper arm
Nipple discharge may occur (various colours, mainly green–grey)
Most cysts are premenopausal (final 5 years before menopause)
++
Examination. Look for lumpiness in one or both breasts, usually upper outer quadrant.
++
Consider mammography if diffuse lumpiness is present in patient >40 years.
Perform needle biopsy if a discrete lump is present and aspirate palpable cysts.
Reassure patient that there is no cancer.
Give advice to alleviate mastalgia (see treatment for cyclical mastalgia in CHAPTER 100).
Use analgesics as necessary.
Surgically remove undiagnosed mass lesions.
++
Common in women aged 40–50 years (perimenopausal)
Rare under 30 years
Associated with mammary dysplasia
Tends to regress after the menopause
Pain and tenderness variable, most asymptomatic
Has a 1 in 1000 incidence of cancer
Usually lined by duct epithelium
++
Examination. Look for a discrete mass, firm, relatively mobile, that is rarely fluctuant.
++
++
++
++
in upper outer quadrant of breast
a physiological change to breast
managed with clinical surveillance
investigate with imaging in older women if asymmetric or perceived change
+++
Lactation cysts (galactoceles)
++
These milk-containing cysts arise during pregnancy and present postpartum with similar signs to perimenopausal cysts.
They vary from 1–5 cm in diameter.
Treat by aspiration: fluid may be clear or milky.
++
A discrete, asymptomatic lump
Usually in 20s (range: second to sixth decade, commonly 15–35 years)
Firm, smooth and mobile (the ‘breast mouse’)
Usually rounded
Usually in upper outer quadrant
May double in size every 12 months7
++
Ultrasound and fine-needle aspiration or core biopsy with cytology are recommended plus mammography in older women. If needle aspiration or core biopsy is negative, the patient can be reassured and followed up until the fibroadenoma is deemed stable. A repeat ultrasound and examination within 6–12 months is ideal. Excision biopsy if large (>3–4 cm), continues to enlarge, suspicious biopsy or woman >40 years.
++
These are giant fibroadenoma-like tumours that are usually benign but 25% are malignant and metastasise. They are completely excised with a rim of normal breast tissue.
++
Fat necrosis is usually the end result of a large bruise or trauma that may be subtle, such as protracted breastfeeding. The mass that results is often accompanied by skin or nipple retraction and thus closely resembles cancer. If untreated it usually disappears but the diagnosis can only be made on excision biopsy.
++
The full triple test is required.
++
These are benign hyperplastic lesions within large mammary ducts and are not premalignant (nor usually palpable). They present with nipple bleeding or a bloodstained discharge and must be differentiated from infiltrating carcinoma. Mammography and ductography are usually of limited value. The involved duct and affected breast segment should be excised.20
++
Synonyms: plasma cell mastitis, periductal mastitis.
++
In this benign condition a whole breast quadrant may be indurated and tender. The larger breast ducts are dilated. The lump is usually located near the margin of the areola and is a firm or hard, tender, poorly defined swelling. There may be a toothpaste-like nipple discharge. It is a troublesome condition with a tendency to repeated episodes of periareolar inflammation with recurrent abscesses and fistula formation. Many cases settle but sometimes surgical intervention is necessary to make the diagnosis. The condition is most common in the decade around the menopause.