The referral rate for women to a breast clinic currently stands at around one in four. The vast majority of referrals from primary care are from patients who have discovered a breast lump. Many women are preconditioned to believe that breast lumps are breast cancers. This is highly due to the extensive media coverage and emphasis on health promotion. The reality is in fact that 80-90% of breast lumps are shown to be benign. When a patient presents with a breast lump, there should be a clinical focus on whether this is a discrete lump, a nodular lump, and if the features are consistent with mailgnancy. It is important to note here, that not all nodular lumps are malignant.

 

Breast Anatomy

 

To understand breast pathology, it is important to have a basic understanding of the breast and its anatomy. Its close relation to the axillary lymph nodes is a significant factor in the staging of malignant breast disease.

Breasts are present in both males and females, however, females have well developed mammary glands. Breast shape (contour) is defined by the subcutaneous fat. During pregnancy and menstruation oestrogen causes the mammary glands to enlarge. Dietary, genetic and environmental factors all affect the size of breasts. (1)

The borders of the breast span superiorly from the second rib down to the sixth rib. The axillary tail will extend along the inferolateral edge of pectoralis major, which forms the lateral border of the sternum. Two thirds of the breast lie superior to the pectoral major and minor, and the remaining third over the fascia superior to the serratus anterior muscle. The retro-mammary space allows for movement. The breast is primarily supported by suspensory ligaments. (2)

The greatest prominence of the breast is called the nipple, surrounded by the areola. The breast contains a total of 15-20 lobules of glandular tissue, each draining into a lactiferous duct, “ultimately draining into the nipple.”

 

Features of Breast Lumps

 

Discrete

  • Separate from adjoining structures 
  • Defined borders
  • Measurable

 

     

    Nodular

    • Ill-defined breast tissue
    • Bilateral
    • Fluctuates with menstrual cycle

     

      It is important when documenting breast lumps, to determine how the breast lump feels by using the following terms:

      • Firm
      • Fluctuating
      • Rubbery
      • Nodular

       

        NICE guidelines - Improving outcomes in Breast Cancer (4)

         

        Urgent referral (within two weeks):

        • Patients aged 30 or over with a discrete lump in the breast

         

          Patients with breast signs or symptoms which are highly suggestive of cancer. These include:

          • Ulceration
          • Skin nodule
          • Skin distortion
          • Nipple eczema
          • Recent nipple retraction or distortion (<3 months)
          • Unilateral nipple discharge which stains clothes

           

          Conditions that require referral, not necessarily urgent:

          Breast lumps in the following patients, or of the following types:

          • Discrete lump in a younger woman (age <30 years)
          • Asymmetrical nodularity that persists at review after menstruation
          • Abscess
          • Persistently refilling or recurrent cyst
          • Intractable pain which does not respond to simple measures such as wearing a well-fitting bra and using over-the-counter analgesics such as paracetamol

           

          Nipple discharge:

          • Bilateral discharge sufficient to stain clothes in patients aged <50 years
          • Bloodstained discharge in patients aged <50 years (urgent referral required if discharge is unilateral)
          • Any nipple discharge in patients over 50 years of age

           

          Other Symptoms for Referral

           

          Other symptoms associated with breast lumps that should be referred are as follows:

          • Any new discrete lump
          • New lump from pre-existing nodularity
          • Asymmetrical nodularity persisting at review post menstruation
          • Breast inflammation (abscess) that doesn’t settle post antibiotics
          • Recurrent cysts post aspiration
          • Lump size not associated with menstrual cycle or the contraceptive pill

           

          Red Flag Findings

           

          • Lump fixed to the skin or chest wall
          • Stony hard, irregular lump
          • Skin dimpling (peau d'orange)
          • Palpable fixed or mobile axillary nodes
          • Bloody nipple discharge
          • Skin tethering

           

            Benign Breast Lumps

             

            Localised Benign Breast Lumps

            • Ductal papillomas: may be single or multiple and are very common aberrations of involution. They are wart like masses that grow within the duct, usually close to the nipple. Sometimes the papilloma may ooze clear or bloody discharge expressed from the nipple. They are usually 1-2cm in size but can be larger. It may be easier to remove one large area if multiple masses are present. The key point to note is that these lumps are non-cancerous.
            • Lipoma: “soft lobulated radiolucent lesions”. They are encapsulated nodules of adipose tissue, presenting as a breast lump.
            • Haematomas: Commonly form following trauma, such as an RTA or after a FNA. A large, red, bruised area arises on the breast and may spread towards the abdomen. It is seen as an ill-defined and hyper-echoic mass on ultrasound. Note that it is extremely rare for a breast cancer to present with a spontaneous haematoma.
            • Fat Necrosis: Commonly following direct trauma to the breast causing thickening and scarring of the breast tissue which appears as a lump. Similar to that of fibrocystic change. This can occur at any age, with the patient unaware of the traumatic event.
            • Sarcoidosis: Sarcoid can present with single or multiple breast masses. It may be a primary site for the sarcoid or as a secondary site from sarcoidosis elsewhere in the body. Diagnosis is confirmed by a core biopsy.

             

             

            Cysts

            7% of women in the western world will present with palpable breast cysts (macrocysts) at some stage in their life. It is a discrete entity consisting of a palpable fluid sac, a distended and involuted lobule within the breast tissue. Cysts typically present in perimenopausal women and can be painful, visible, and of varying size. It has been documented in post-menopausal women receiving hormone replacement therapy due to exxcessive circulating oestrogen. Cysts are thought to originate from the terminal duct and is regulated by the hormonal balance within the body. Menstruation causes the ducts to dilate. A blockage results in the failure of the duct to shrink after menstruation, and is the possible mechanism for development of a cyst. Stroma surrounding the cyst can often become fibrotic and histologically show clusters of chronic inflammatory cells.

            Cysts have a characteristic halo on mammograms and can be easily diagnosed by ultrasonography and a FNA. If any residual mass is present following aspiration, a mammogram is required.  Only 1-3% of patients with cysts coincidentally have a carcinoma, with very few having a direct association between the two. The risk of developing breast cancer in the future is only slightly increased for patients who have a history of cysts (RR x 2-3). However, it is debatable whether this is of any clinical significance. Clinically, a low pressure cyst will appear soft and fluctuant. The firm characteristics of a deep or tense cyst may resemble a tumour. Generally cysts can develop at a rapid rate, as quickly as an overnight presentation. Resolution can also take a similar course.

             

            *Galactocele: a simple milk-filled cyst formed by overdistention of a lactiferous duct. A firm, non-tender mass is felt. Commonly in the upper outer quadrants and can almost always be cured by diagnostic aspiration.

             

             

            Fibroadenoma

            Fibroadenomas are one of the most common benign solid tumours of breast tissue. They present anytime after the start of puberty but appear to have a high incidence in the third decade, and under the age of 25. They are seen more commonly in African-American women. They develop from an entire lobule rather than a single cell. Fibroadenomas are classified into four different types:

            • Giant adenoma - >5cm.
            • Juvenile adenoma - in adolescent females. They undergo rapid growth.
            • Phyllodes tumours - distinct pathological entireties, not always easily differentiated from common fibroadenomas.
            • Common fibroadenoma

             

            These breast lumps are responsive to the bodies’ hormones and have a characteristic course of increasing size towards the end of each menstrual cycle. Hence during pregnancy, the cyst remains enlarged. Clinically, fibroadenomas are well-circumscribed, freely moveable tumours with a configuration seen as rounded, lobulated or even discoid. They are rarely painful.  On ultrasound you should expect to see uniform internal echoes with sharp borders. If a distinct diagnosis can be made from ultrasound then the patient is followed up with regular examinations, as it may not be necessary to carry out FNA biopsy. Treatment of fibroadenomas >4cm in size is by excision. If the patient is under 40 years of age, then excision will not usually be carried out, unless specifically requested by the patient.

             

             

            Periductal Mastitis

            Periductal mastitis occurs in perimenopausal and postmenopausal women and is characterized by the unilateral dilatation of subareolar ducts. Presentation is usually a painful or tender mass, and may often be accompanied by skin retraction, which can lead to difficulties in diagnosing a benign or malignant mass. Nipple inversion results from traction on the nipple by fibrotic and shortening ducts. This is common in 30-40% of cases. There may also be serous or bloody discharge expressed from the nipple. Evidence shows that periductal inflammation is followed by duct ectasia.

             

             

            Infection

            Lumps caused by infection are more commonly seen in women who are breast-feeding. The lactiferous ducts become blocked. Bacteria enters through cracks in the nipple to form an abscess. The abscess can present as a breast lump. A warm compress, paracetamol and sometimes antibiotics are necessary.

             

            Malignant Breast Lumps

             

            Breast cancer is a collection of abnormal breast tissue cells, growing in an uncontrolled and undifferentiated manner. The lump is formed by irregular borders and a nodular surface. The lump will feel hard, and be fixed to the surrounding tissue. In some cases there may be some ambiguity whether the lump is mobile or whether it is the tissues around the fixed mass that are moving. Mammogram and ultrasound guided core biopsy allow for a confirmatory diagnosis. Subsequently, the biopsy is evaluated for histological staging. Unlike some common benign breast lumps, breast cancer can be located almost anywhere within the breast. It can be found superficially, deep inside the breast tissue or close to the chest wall. Nodules palpable within the axillary lymph nodes are indicative of metastasis and needs further investigation.

            Breast cancer lumps can present in women of any age but are 70% more common in those over the age of 50. The National Screening Programme run by the NHS, addresses this population group. Currently women from the age of 50 are invited for a screening mammogram routinely every 3 years. The year 2012 will introduce screening in those from 47-73.

             

            Risk Factors for Future Breast Cancer

             

            A history of fibrocystic change which has required a biopsy is an indication for a slight increased risk of developing breast cancer in the future. Women with a history of multiple breast lumps which show no high risk pattern histologically, are generally considered low risk. As a general rule, an increase in breast density, which can be viewed on mammogram, is associated with an increased risk of breast cancer. The following masses have the potential of developing into invasive breast cancer:

            • Complex fibroadenoma
            • Moderate to florid hyperplasia
            • Sclerosing adenosis
            • Papilloma

             

            Investigations

            Breast lumps can present alone or in association with other symptoms. Almost always, there are a number of symptoms that present with a breast lump that is suspicious of malignancy. Most breast lumps present in the community. However, a number are picked up on screening mammography allowing for early stage diagnosis and prompt treatment. The triple assessment is used within the NHS to diagnose breast cancer, and gives a 95% confident diagnosis.

            Triple assessment is not always needed to investigate breast lumps, as it would be viable to diagnose a breast cyst purely on ultrasound. In this case FNA would be used as a treatment rather than a diagnostic tool. Ultrasound is preferred in those under the age of 35 as these patients have dense breast tissue and other imaging techniques are not sensitive enough. For malignant breast lumps, the triple assessment allows for a confident diagnosis and subsequently the most appropriate treatment to be initiated.

             

            Treatment of Breast Lumps

             

            Most benign breast lumps will not require treatment. This is especially true of small fibroadenomas, haematomas and lipomas. If they are increasing in size they may be removed. Phyllodes lumps and papillomas will always be removed, as there is some potential for them to become cancerous. FNA is used for simple and recurrent cysts with no follow-up necessary. A solid lump will require a core biopsy to confirm its benign or malignant state. Antibiotics can be used to treat infections of the breast and abscesses, which can also be drained if pus has accumulated inside.

            Malignant breast lumps are treated in an aggressive manner with the intention to remove all abnormal cancerous cells. The size and pathology of the lump determines the therapy used; including surgery, chemotherapy, radiation and hormone suppression therapy. The treatment option will be discussed by a MDT to allow for the best possible prognosis.

             

            References

            1, 2. Keith L. Moore, A. M. R. Agur. (2007). Thorax. Essential clinical anatomy (pp. 50) Lippincott Williams & Wilkins)

            3. http://www.green-beauty.info/ENGLISH/Tips/Tips/anatomy-big.jpg.

            4.http://www.nice.org.uk/nicemedia/live/10887/28763/28763.pdf

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