11. Breast Lump

Question 1

List the four most common causes of breast lump.

Answer 1

Benign cystic change
Fibroadenoma
Breast cyst
Carcinoma

Question 2

List some other causes of breast lump.

Answer 2

Fat necrosis 
Abscess 
Mastitis 
Galactocoele 
Sarcoma 
Duct papilloma
Non-breast lumps (e.g. lipoma, sebaceous cysts)

Question 3

Which causes of breast lump are most likely in <30yrs

Answer 3

Fibroadenoma
Physiological lumpy breast
Benign cystic change

Question 4

Which causes of breast lump are most likely in 30-40yrs

Answer 4

Benign cystic change
Breast cyst
Abscess
Carcinoma

Question 5

Which causes of breast lump are most likely in <45-60yrs

Answer 5

Breast cyst
Abscess
Carcinoma

Question 6

Which causes of breast lump are most likely in >60yrs

Answer 6

Carcinoma

Question 7

List two causes of breast lump that are exclusive to breast-feeding women.

Answer 7

Galactocoele
- Occurs shortly after cessation of lactation
- Caused by blockage of lactiferous ducts
- May get infected
Mastitis
- More common in breast-feeding women

Question 8

Which organisms are usually responsible for mastitis?

Answer 8

Staphylococcus aureus

Staphylococcus epidermidis

Question 9

List the major risk factors for breast cancer.

Answer 9

Previous breast cancer
Family history of breast cancer 
Chest wall irradiation
Previous cancer (in particular: ovarian, endometrial, bowel)
Increased exposure to oestrogen

Question 10

List some examples of increased exposure to oestrogen that can be elicited from a history.

Answer 10

Early menarche
Late menopause 
Nulliparity
Late first child (> 30 yrs)
HRT 
COCP
Not breast-feeding
Obesity

Question 11

List some important questions that should be asked regarding the history of presenting complaint.

Answer 11

How long has the lump been there for?
Has there been any trauma to the breast?
Is the lump painful?
Has it changed in size? Is the change in size related to your menstrual cycle?
Have you noticed any changes in the skin on the breast?
Have you noticed any discharge?
Are you otherwise fit and well?

Question 12

Which causes of breast lump appear quite rapidly?

Answer 12

Cysts

Abscesses

Question 13

Which causes of breast lump appear more gradually?

Answer 13

Fibroadenoma

Carcinoma

Question 14

Why is it important to ask about breast trauma?

Answer 14

Increases the risk of fat necrosis and infective causes of breast lump (e.g. abscess, mastitis)

Question 15

Why is it important to ask about the relationship between the changing size of the breast lump and the patient’s menstrual cycle?

Answer 15

The lumps in benign cystic change undergo cyclical changes in size and character

Question 16

Which causes of breast lump are classically associated with being painful?

Answer 16

Benign cystic change
Abscess
Mastitis

Question 17

What would warm, erythematous skin overlying the lump suggest?

Answer 17

Infective/inflammatory cause (e.g. mastitis, abscess)

Question 18

What does tethering of the skin over the lump suggest?

Answer 18

Carcinoma until proven otherwise

Question 19

Describe the character of the discharge in Breast Carcinoma

Answer 19

Bloody

Question 20

Describe the character of the discharge in Intraductal Papilloma

Answer 20

Serous or seranguinous

Question 21

Describe the character of the discharge in Periductal Mastitis

Answer 21

Yellow, green, brown

Question 22

Describe the character of the discharge in Galactocoele

Answer 22

Milky

Question 23

Define duct ectasia.

Answer 23

A condition in which the lactiferous ducts become blocked or clogged

Question 24

Why is it important to check whether the patient is otherwise fit and well?

Answer 24

Most patients with breast lumps don’t have an other symptoms
Patients with infective/inflammatory causes of breast lump (e.g. mastitis, abscess) may experience fever
NOTE: breast cancer rarely leads to systemic signs of malignancy

Question 25

List some key features of inspection of the breasts.

Answer 25

Asymmetry Contours Skin changes Nipple discharge

Question 26

List some skin changes of the breast that you should look out for.

Answer 26

``` Erythema Ulceration Peau d’orange Tethering Radiotherapy tattoos ```

Question 27

Describe what a solitary cyst feels like on palpation

Answer 27

Smooth surface + distinct border + firm to lax | NOTE: feels similar to fibroadenoma

Question 28

Describe what benign cystic change feels like on palpation

Answer 28

Irregular surface + indistinct borders + mixed consistency

Question 29

Describe what a fibroadenoma feels like on palpation

Answer 29

Smooth surface + distinct borders + rubbery + mobile

Question 30

Describe what a carcinoma feels like on palpation

Answer 30

Irregular surface + indistinct borders + hard Tethering? Lymphadenopathy?

Question 31

What are the components of triple assessment?

Answer 31

Clinical examination Radiological examination FNA and core biopsy

Question 32

Which types of radiological assessment of the breast lump are offered to patients?

Answer 32

< 35 years = ultrasound 35+ years = two-view mammogram NOTE: younger women do not get mammograms because their breast tissue is more dense and it is difficult to identify masses

Question 33

What is the difference between an FNA and a core biopsy?

Answer 33

FNA – samples cells for cytology | Core biopsy – samples tissue for histology

Question 34

Describe the management of fibroadenomas.

Answer 34

Benign condition that will resolve over several years | Can be removed by excisional biopsy

Question 35

What are the four most common sites of metastasis of breast cancer?

Answer 35

Liver Bone Lungs Brain

Question 36

Describe the treatment options for breast cancer.

Answer 36

Local Treatments: Radiotherapy + Surgery | Systemic Treatments: Chemotherapy + Hormonal Therapy + Monoclonal Antibodies

Question 37

Describe the typical presentation of a patient with a breast abscess.

Answer 37

Sudden appearance of a painful lump Usually in middle-aged smokers Fever, skin erythema and tethering may also be found

Question 38

What important risk factor is strongly associated with breast abscess and non-lactational mastitis?

Answer 38

Smoking

Question 39

How are breast abscesses treated?

Answer 39

Incision and drainage | Antibiotics

Question 40

Describe the typical presentation of breast cysts.

Answer 40

Well-circumcribed lump with a smooth surface and firm texture (may be painful)

Question 41

How can cysts and fibroadenomas be distinguished?

Answer 41

Ultrasound Cysts will be hypoechoic Fibroadenomas will be hyperechoic NOTE: when cysts are drained, the fluid will be green, brown or yellow

Question 42

What is gynaecomastia?

Answer 42

Enlargement of the breasts in males, either due to hormone imbalance or drug therapy

Question 43

List some pathological causes of gynaecomastia.

Answer 43

Liver disease Drugs (e.g. spironolactone, cimetidine, finasteride) Primary testicular failure (e.g. bilateral cryptorchidism) Acquired testicular failure Secondary testicular failure (e.g. panhypopituitarism) Endocrine tumours (e.g. testicular, adrenal, pituitary)