Breast lumps are one of the most common presenting complaints amongst female patients in general practice. Understandably, the concept of malignancy causes great concern among women. Anyone who presents with a breast lump should have a full history taken, followed by a thorough examination. It is essential to include a family history, as well as a focus on the patients' lifetime exposure to oestrogen- in the form of the oral contraceptive pill (OCP) and pregnancies. Fortunately, in most women presenting with a breast lump, the outcome is most commonly a benign condition such as a cyst or a fibroadenoma.
The first step in breast examination is to distinguish between benign and malignant masses, which can be done using the following criteria:
Breast cancer is the most common malignancy to affect women, and a lump that is suspicious should be urgently referred under the two week rule.
There are also a number of breast changes that warrant a referral but are unlikely to be malignancies, and so a non-urgent referral system can be used instead.
For the majority of women presenting with a breast lump, benign lumps such as cysts and fibroadenomas form the mainstay of diagnosis.
The benign causes of a breast lump are listed below, along with details about what to explore in a history and the common findings on examination that will help lead to a diagnosis.
These are the most common of benign breast tumours, and are thought to be caused by an increased sensitivity to oestrogen.
Presentation: It is common in those under 40 years of age and the median age of presentation is 25. It is a lump of an average size of 3cm, and is non-tender.
Examination: On examination, a smooth, rounded, mobile mass will be felt. It is sometimes called a breast mouse, as it characteristically darts around under the fingers when being examined.
Management: If you are confident in your diagnoses, then no action is necessary. However, it is important to advise the patient to regularly check the lump and return if it enlarges. To image a lump in this age group, ultrasound is used. This is due to the fact that mammograms are difficult to interpret in < 50 year olds. The reason for this being the high density of the breast tissue present in younger patients. If imaging fails to give a definitive diagnosis, then progression to a biopsy or excision is made.
Presentation: Breast cysts are caused by proliferation of the terminal ducts. They can be microscopic in nature or can present as ‘gross cysts’ which can be several centimetres large.
Investigation: Cysts are completely fluid filled masses with a thin outer lining. Ultrasound is used to distinguish between a cyst and a fibroadenoma. Using ultrasound, fibroadenomas appear as solid masses in contrast to liquid filled cysts.
Management: Cysts are almost always benign and can be aspirated if the patient prefers to have them removed.
Up to 60% of females experience breast changes that occur in concurrence with their menstrual cycle.
Presentation: Patients present with pre-menstrual swelling and tenderness that will rapidly resolve once menstruation begins. Patients tend to be between 30-50 years old. Women taking the OCP are found to experience this condition less frequently than their counterparts. It is rare to find physiological swelling and tenderness in post menopausal women.
Management: Re-assure patients and advise a good, well-supporting bra. Avoidance of caffeine has also been found to be useful.
Presentation: In women who are breast feeding, breast ducts can become blocked with milk. Bacteria invades the region, causing infection and abscess formation in the outer tissue. Patients will present with erythema that is classically in a streaking pattern, directed away from the nipple, in combination with breast tenderness. Commonly patients will also have axillary lymphadenopathy and can sometimes have systemic features of fever and malaise.
Management: A 10 day course of antibiotics, such as flucloxacillin is advised. Any abscesses that have formed will require incision and drainage, and swabs should be taken and sent for culture. It is important to encourage breast feeding with the un-affected breast.
Presentation: Mastitis is less common in non-breast feeding women. When it does present, it can be associated with diabetes mellitus or a state of immuno-compression. Bacterial route of entry is through the skin and this results in inflammation and abscess formation within the ducts. Any patient who is treated for mastitis, but is still experiencing symptoms one month after treatment with antibiotics, should be referred to exclude an inflammatory breast cancer.
Presentation: A wart like lump is found behind the areolar in women of all ages. Women > 40 years are likely to present with one lesion, whilst younger women may have several.
Examination: A small lump may be felt, and in some cases a sticky discharge is also present.
Management: Fine needle aspiration or a biopsy may be carried out.
Presentation: Those with a family history of breast cancer are at risk of developing atypical hyperplasia. This is a hyperplasia of the cells in the ducts and lobes of the breast and there is a chance that lobular carcinoma may develop.
Management: Annual mammograms are recommended to observe the progression of this type of lump.
Presentation: A painless lump occurs post trauma and is more likely in women with larger breasts or those who are obese.
Examination: This lump can be surrounded by skin that is red, bruised and dimpled.
Management: A biopsy may be taken, but if the diagnosis is confirmed then there is no need for further investigation.
In duct ectasia, ducts behind the nipple are found to be dilated and so they can become occluded with fluid. The epithelium becomes ulcerated and resultant breast pain and infection can develop.
Periductal mastitis affects younger women more than duct ectasia. The symptoms and management of both diseases, however, are similar.
Presentation: Most patients are > 50 years old. They will complain of retro-areolar pain, nipple retraction and a creamy thick nipple discharge. If the patient describes a bloody discharge, this may be associated with ductal carcinoma. Duct ectasia usually affects women approaching the menopause and is more common in patients who smoke.
Examination: A tender retro-areolar area is found, erythaema is also present with nipple retraction and creamy thick discharge that can sometimes be bloody.
Management: The presenting symptoms are sometimes similar to those seen in malignancy and so a referral to the breast clinic is needed. Definitive diagnosis can only be made by excision of the duct.
When presented with a breast lump there are a number of differential diagnoses to consider. The first priority is to exclude a malignancy. Once this has been done the classical features and characteristics of the lump should help steer towards a diagnosis. Clinically, cysts and fibroadenomas are the most common presenting breast lumps, but if there is any cause for suspicion, then further investigations are vital.
Fastbleep © 2019.