Breast Lumps

INTRODUCTION

Key facts and checkpoints

• The commonest lumps are those associated with fibrocystic breast disease (mammary dysplasia)

• Fibrocystic disease is also a common cause of cysts, esp. 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

• Breast cancer is the most common cancer in females (after skin cancer), affecting 1 in 8 Australian women before the age of 85

• About 25% of all new cancers in women are breast neoplasms

• A ‘dominant’ breast lump in an older woman should be regarded as malignant

THE CLINICAL APPROACH

Breast cancer symptoms

• Lump 76%

• Tenderness or pain 10%

• Nipple changes 8%

• Nipple discharge 2%

• Breast asymmetry/dimpling 4%

• Periareolar inflammation—usu. due to nipple retraction or mammary duct ectasia

• Paget disease of nipple = underlying malignancy

Nipple discharge This may be intermittent from one or both nipples. A common reason is physiological, and is usu. part of a normal hormonal process. Discharge can be induced by quadrant compression.

• Bloodstained

  • – intraduct papilloma (commonest)

  • – intraduct carcinoma

  • – fibrocystic disease

• Green-grey

  • – fibrocystic disease

  • – mammary duct ectasia

• Yellow

  • – mammary dysplasia (serous)

  • – breast abscess (pus)

• Milky white (galactorrhoea)

  • – lactation cysts

  • – lactation

  • – hyperprolactinaemia

  • – drugs (e.g. chlorpromazine)

DIAGNOSIS—THE TRIPLE TEST

1. Clinical breast examination

2. Fine-needle aspiration cytology ± core biopsy

3. Imaging: <35 yrs US; 35–50 yrs mammogram (bilateral) ± US ± MRI; >50 yrs bilateral mammogram ± US

INVESTIGATIONS

X-ray mammography Mammography can be used as a screening procedure and as a diagnostic procedure. It is currently the only effective screening tool for breast cancer. Screening:

• established benefit for women over 50

• 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

Breast ultrasound This is mainly used to elucidate an area of breast density and is the best method of defining benign breast disease, esp. with cystic changes. It is generally most useful in women less than 35 yrs.

Breast MRI Not routinely performed but may be requested by specialists for high-risk groups, if there is diagnostic uncertainty or to determine extent of disease.

Needle aspiration techniques

• Cyst aspiration

• Fine-needle aspiration or core-needle biopsy: very useful diagnostic test in solid lumps with an accuracy of 90–95% (better than mammography)

CARCINOMA OF THE BREAST

Breast carcinoma is uncommon <30 yrs but steadily increases to a max. at ~60 yrs. About ⅓ of women are premenopausal and ⅔ postmenopausal.

Clinical features...