5 s Breast lump

Breast lump is the most common presenting

Breast abscess
feature of breast cancer. All breast lumps must
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be referred to a specialist breast service for The lump usually develops rapidly and is tender.
There is often overlying erythema; there may be

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evaluation by triple assessment, comprising
fever and evidence of a systemic inflammatory
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clinical, radiological and pathological evaluation.

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The majority of referrals to breast services are response

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In lactating women, breast abscesses occur
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benign. Results of malignant lumps should be
managed in a multidisciplinary team setting. most frequently in the first 12 weeks post-partum;
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USS is the imaging modality of choice in painful, cracked nipples are common. It may be

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women <35 years due to the high density difficult to distinguish an abscess if breast tissue
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of breast tissue. MRI scanning is suitable for is grossly indurated due to mastitis; in these cases
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referral should be made for further assessment
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selected patients. Older women should have

mammography ± USS. Pathological assess- and ultrasound imaging.
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ment is undertaken by ultrasound-guided core In non-lactating women, abscesses are

biopsy, fine needle aspiration (for cystic lesions) uncommon and an underlying inflamma-
or occasionally excision biopsy. tory cancer should be excluded. Subareolar
abscesses are the most common form, typically
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Breast cancer associated with a periductal mastitis; there is a

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The breast is the most common site of cancer in strong association with smoking.
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women; 1 in 9 women in the UK are affected by

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Fibroadenoma
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breast cancer in their lifetime. The risk increases

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with age and the mean age at diagnosis is 60 Fibroadenoma is a common benign neoplasm
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that occurs after puberty in younger women

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years. Risk factors are shown in Box 5.1. Features

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of a breast lump that suggest cancer are shown usually <30 years. It typically presents as a
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discrete, mobile, non-tender mass with a rubbery

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in Box 5.2. However, it is not possible to exclude

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cancer by clinical examination alone and all palpable consistency. The diagnosis should be confirmed
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masses should be regarded as potentially malignant by triple assessment.

until proven otherwise. Fibrocystic change
Fibrocystic change is a benign condition associated
with tender, lumpy breasts that may affect up to
50% of women between 20 and 50 years but is
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Box 5.1 Risk factors for breast cancer

• Previous breast cancer
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• Increasing age Box 5.2 Suspicious features of breast lump

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• Family history
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• Oral contraceptive pill • Hardness

• Hormone replacement therapy • Immobility
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• Ea ly menarche • Skin tethering/puckering

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• Late menopause • Skin changes (peau d’orange, eczema)

• Nulliparity • Nipple retraction
• First pregnancy >35 years • Lymphadenopathy
• Current smoker • Bloody nipple discharge

rare after menopause. Features often vary over
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the course of the menstrual cycle due to hormone
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fluctuations. Areas of firm, lumpy breast tissue
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without a discrete mass are often termed nodular
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breast tissue; if this is localized or asymmetrical and
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persists throughout the cycle, referral should be
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made to exclude underlying cancer. Breast cysts
are firm, smooth, well-defined lumps which may
cause discomfort if enlarging. USS confirms their
cystic nature. If needle aspiration yields bloody fluid,
this should be sent for cytological examination.
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Fat necrosis
Fat necrosis is a benign condition that arises
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after trauma or surgery. It may present as a firm,
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irregular mass with tethering to overlying skin,
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making it difficult to distinguish from malignancy.
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Irrespective of recent trauma, all lumps with
suspicious features should be regarded as
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potentially malignant and evaluated urgently by
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triple assessment.
Other causes
Skin and subcutaneous lesions, such as epi-
dermoid cysts and lipomata, may occur on the
breast. Phylloides tumours are rare and share
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many clinical features with fibroadenomas but
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are typically more aggressive; metastasis is
rare but can occur. Superficial thrombophlebitis
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(spontaneous thrombosis of superficial breast
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veins) presents with palpable, erythematous linear
Breast lump
47
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Differential diagnosis
nodules, and resolves over weeks. Galactocoele
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is a rare cystic lesion of the breast. It contains
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milk and most commonly occurs in lactating
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women; occurrence in non-lactating women
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requires further endocrine investigation.
Nipple lesions
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These must be investigated (triple assessment)
to rule out an underlying cancer. Causes include
Paget’s disease of the nipple (95% association
with cancer), nipple adenoma, eczema of the
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nipple, basal cell carcinoma, melanoma and
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Bowen’s disease.
Male breast disease
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Breast lumps in men are rare. Gynaecomastia
most commonly presents as a rubbery button
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of tissue, concentric to the areola. It occurs
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frequently at puberty and necessitates careful
testicular examination and assessment of sexual
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development. Around 25% are idiopathic. Other
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causes include drugs (~20%), e.g. spironolac-
tone, anabolic steroids, liver cirrhosis (decreased
metabolism of oestrogen, <10%), gonadal failure
(decreased androgens, <10%) and testicular
tumours (increased oestrogen production,
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~3%). Male breast cancer (1% of all breast
cancers) typically presents as a hard, fixed lesion,
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sometimes with overlying skin involvement, and
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is usually eccentric to the areola.
 Breast lump
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Overview

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Full clinical assessment + breast examination

1 Discrete lump palpable?

Yes No

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Asymmetrical or localised No
Re-examine and consider breast imaging.
nodularity?

Yes
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Refer for triple assessment if

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patient >35 years or lump persists

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after menstruation

Yes

Yes
2 Evidence of abscess? Refer to on-call breast specialist

Features of/risk factors for Yes

3 breast cancer?
Refer urgently for triple assessment

No
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Refer for triple assessment

A B C

Fig. 5.1 Positions for inspecting the breast. A Hands pressed into hips. B Hands above head. C Leaning forward.
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(From Ford MJ, Hennessey I, Japp A. Introduction to Clinical Examination, 8th edn. Edinburgh: Churchill Livingstone, 2005.)
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 Breast lump
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Step-by-step assessment

1 Discrete lump palpable? breast/surgical team. Refer to a breast specialist

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to exclude an abscess in any breast-feeding
If you are unable to locate a lump, ask the patient

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woman with gross mastitis and induration
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to attempt to find it and examine in different
positions, e.g. supine and upright. In the absence
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Features of/risk factors for

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of a discrete lump, assess carefully for nodularity.
3 breast cancer?

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Refer any patient >35 years old with a localized
area of nodularity or discrete lump for urgent triple 5
Refer any patient with a palpable breast lump

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assessment. If the patient is <35 years, refer for specialist triple assessment to exclude breast
for triple assessment if the localized nodularity cancer.
persists at review after menstruation. Request urgent review if:
If no lump or nodularity is detected, consider
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• patient has risk factors for breast cancer
ultrasound or mammography as appropriate to
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(Box 5.1)
exclude underlying impalpable pathology.
• lump is rapidly enlarging

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• lump has features of breast cancer (Box
2 Evidence of abscess?
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5.2)
Suspect breast infection if there is an acute, • patient ≥30 years with a new discrete lump
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painful swelling with overlying erythema, fever or • patient <30 years with a major risk factor,
a systemic inflammatory response; start antibiotic e.g. personal or family history of breast
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treatment and refer as an emergency to the cancer.

Clinical tool
Breast examination
• Obtain consent and offer a chaperone; ensure privacy against the chest wall using the palmar surface of the
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and a warm room. fingers held flat on the surface of the breast. Palpate
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• Enquire whether the patient has noticed any breast clockwise to cover all of the breast tissue, including
lumps and ask her to point them out. under the nipple.
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• With the patient sitting comfortably, hands resting on • Record the size, position, attachments, mobility,
the thighs, inspect for asymmetry, local swelling, skin su face, edge and consistency of any lumps and look
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changes, e.g. dimpling, redness and nipple inversion or for associated signs of inflammation (tenderness,
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discharge. warmth, redness).

• Repeat the inspection (Fig. 5.1) with the patient’s • Palpate for axillary lymph nodes. Ask the patient to sit
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hands pressed against her hips (contracting the facing you and support the full weight of her arm at the
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pectoral muscles), raised above her head (stretching wrist with your opposite hand. After warning of possible
the pectoral muscles) and sitting forward with the discomfort, use your other hand to palpate all around
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breasts dependent. the axilla, compressing its contents against the chest
• With the patient supine, and hands under the head, wall. Repeat on the other side.
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palpate each breast: compress the breast tissue