BREAST LUMPS

DR AMBREEN MUNIR
FRCS, BAPRAS Fellowship Breast, PG-D Bioethics
Associate Professor Surgery

INTRODUCTION
Of

all breast disorders, palpable

breast lump is 2nd most common
presentation, pain being the first
Generally a breast lump in
adolescents and young female is
nearly always regarded as benign
at first instance and patient may
falsely be reassured with the result
she refrain from further
consultation

INTRODUCTION
On

the other hand, all lumps are

not cancers; however the
possibility of cancer must always
be considered, as approximately
10% of all breast lumps are
finally diagnosed as cancer.

Case scenario

25 year old School teacher

came to you and she is worried
about a lump she just found in
her right breast.

Additional History
History

of trauma
Is lump painful?
Nipple Discharge
Any other lump? Axilla

Otherwise

she is healthy
Her weight is stable
She is married
She takes OCP
Her menstrual cycle is regular
No family history of cancer

Breast Examination
Inspection-

sitting position
symmetry, level of both breasts,
Contour, skin changes
Ask her to lift arms, put arms
against waist
Palpate the axilla in sitting
position
Palpate supraclavicular lymph
nodes

Palpation

of breast- supine
position with hands above head
Examine both breasts
Normal first
Examine with the flat of the hand
to avoid pinching up tissue

Four

quadrants in clockwise
direction
Nipples & areola
If you have difficulty finding a
discrete lump, ask the patient to
demonstrate it for you

About Lump
Site

- describe the location of the

lump as a position on a clockface
i.e. 'A firm mass isfelt at 2
o'clock'.
Size
Shape
Surface/ Overlyingskin
Tenderness
Consistency

Mobility

and attachment
If you are unable to move the
skin over the lump it implies
fixation or tethering
If patient mentionednipple
dischargeask her to squeeze
nipple for a sample of the
discharge

Examination Findings
Solitary

1.5 cm mass of right

breast, upper outer quadrant at
10 oclock
Mass is non-tender
Lesion is freely movable
No obvious skin changes over the
lesion
No nipple discharge
No axillary masses

Possibilities
Fibroadenoma
Fibrocystic

disease
Simple cyst
Fat necrosis
Cancer

Benign Breast diseases

ANDI
Infections
Trauma

Fibroadenoma

Benign overgrowth of one lobule

of the breast, usually isolated,
may be multiple or giant
Composed of both stromal and
epithelial elements in the breast
Well-defined, mobile, painless,
discrete
Common in younger women, and
is most common tumor in women
younger than age 30 years

Fibrocystic disease
Combination

of localized fibrosis,
inflammation, cyst formation and
hormone driven breast pain
Occurs almost exclusively
between menarche and
menopause
Causing cyclical pain and
swelling, lumpy breasts, multiple
breast cysts

Cysts

Fluid-filled, epithelium-lined cavities often

associated with FBD
Common after age 35, and rare before 25
Round symmetrical lumps, may be
discrete or multiple, occasionally painful
Three types
Simple cyst, clear or green fluid and is
benign.
Milk-filled cyst, called galactocele and is
benign.
Bloody cyst is a cause of concern for
malignancy.

Infections &
Inflammations
Lactational

Mastitis
Due to acute staphylococcal
infection of mammary ducts
Breast Abscess
When infection progress

Infections &
Inflammations

Mammary duct ectasia

Due to dilated, scarred, chronically
inflammed subareolar mammary
ducts
Recurrent yellow green nipple
discharge or recurrent breast abscess
Mondors disease
Phlebitis of the thoracoepigastric vein
Palpable, visible, tender cord along
lower quadrants

Fat Necrosis
Associated with trauma or
radiation therapy to breast
There is organization of acute
traumatic injury by fibrosis,
organized haematoma &
occasionally calcification
Can simulate cancer with mass
or skin retraction

Next step in assessment

Imaging-

choice of imaging
modality depends on specific
characteristics of the patient e.g.
age, and findings on clinical
examination
Ultrasound scan or
Mammography
MRI of breast

Indications of U/S
To

evaluate the breast in patients

who are under the age of 35 years
To differentiate solid and cystic
lesions
Women who are pregnant and
cannot have mammography
To complement mammography
To guide fine needle aspiration and
core biopsies

Next step in this case

Solid

lesions- have internal echoes

Benign tumours have isoechoic or
hypoechoic patterns, smooth well
defined borders
Malignant tumours have hypoechoic
areas,interspersed between brighter
echoes, irregular edges
Cysts- Smooth walls, sharp anterior
and posterior borders, black
hypoechoic centres without internal
echoes

U/S report in this case is benign

solid lesion
U2

To

complete the triple

assessment, this lesion needs to
be biopsied
There are a number of different
types of biopsy( cytological or
histopathological)

Fine needle aspiration

(FNA)

Core biopsy

 FNA-Sensitivity is 80-98%, specificity

100%
False negatives are 2-10%
Core Biopsy-More tissue, however still
possibility of false negative and could
represent sampling error
Incisional biopsy- For large (>4 cm)
lesions for whom pre-op chemotherapy
or radiation will be desirable
Excisional biopsy-Removal of entire
lesion and a margin of normal breast
parenchyma

Triple

Assessment gives confident

diagnosis in 95% of cases
On other hand, Triple assessment is
not always needed to investigate
breast lumps, as it would be viable to
diagnose a breast cyst purely on
ultrasound
A solid lump will require a core
biopsy to confirm its benign or
malignant state

Treatment
Most

benign breast lumps will not

require treatment. This is especially
true of small fibroadenomas,If they are
increasing in size they may be
removed
FNA is used for simple and recurrent
cysts. In this case FNA would be used
as a treatment rather than a diagnostic
tool. Complete resolution, follow up to
ensure it does not recur,Incomplete
resolution treat as breast mass and
excise

Treatment
Mondors disease
Treatment self-limited, can use
NSAIDs if necessary
Antibiotics can be used to treat
infections of the breast and
abscesses are treated by incision &
drainage

Treatment
Mondors disease
Treatment self-limited, can use
NSAIDs if necessary
Antibiotics can be used to treat
infections of the breast and
abscesses are treated by incision
& drainage

BREAST CANCER

DR AMBREEN MUNIR
FRCS, BAPRAS Fellowship Breast, PG Diploma
Bioethics
Associate Professor Surgery

Overview
The

most common form of cancer

among women
The second most common cause
of cancer related mortality
One out of nine Pakistani women
is likely to suffer from Breast
Cancer at some point of life

Overview
Highest

incidence of Breast
cancer in the Asia
At Least 90,000 Women Suffer
From Breast Cancer In Pakistan
Every Year
40,000 Deaths Per Year, Which Is
Alarming

Risk factors
Female
Aging
First

degree Relative
Menstrual history
early onset
late menopause
Child birth
After the age of 30

Risk Factors
Hormonal

replacement
therapy(HRT)
30% increased risk with long term
use
Oral Contraceptives(OC)
risk slight
risk returns to normal once the
use of OCs has been discontinued
Radiation exposure

Risk Factors
Breast

disease
Atpyical Hyperplasia
Intraductal carcinoma in situ
Intralobular carcinoma in situ
Obesity
Diet
Fat
Alcohol

Genetic Risk Factors

BRCA-1
BRCA-2
P53
Her-2/neu

Because

of enhanced Public
awareness, number of patients
reporting with complaints of breast
diseases has increased in recent
years

Breast

diseases are common in

females because of more complex
structure of female breast, greater
volume and influence of various
hormones
Subjected to constant physiological
changes throughout reproductive
life and beyond.
These changes lead to a number of
conditions

Mostly

these conditions are benign e.g.

bilateral nodularity, tender lumpy
breasts

Our

aim should be to exclude cancer

That

aim is achieved through proper

assessment

Triple Assessment
Clinical

History
Examination

Imaging

Ultrasound
Mammography

Histopathology

FNAC
Trucut Biopsy

History
Age
Family

history of breast and other

cancers with emphasis on
gynaecological cancers

History
Reproductive

history
age at menarche
age at first delivery
number of pregnancies, children
and
miscarriages
age at onset of menopause
history of hormonal use including:
contraceptive pills (type and
duration)
hormonal replacement
therapy (type
and duration)

Signs/Symptoms
Any

new discrete breast lump

Any new lump in a pre-existing
nodularity
Recurrent breast cysts
Unilateral axillary lump
Unusual increase in the size of
one breast

Signs/Symptoms

Persistent

or unilateral breast

pain
Pain associated with a lump

Signs/Symptoms
Nipple

discharge other than breast

milk
Blood stained
Single duct
Bilateral troublesome discharge
in more than 50 years
New nipple retraction
Nipple eczema if not elsewhere or
unresponsive to steroids

Signs/Symptoms
A

puckering of skin of breast

Skin irritation or dimpling
Redness, scaling or thickening of
skin of breast
Swelling of arm

Clinical Examination
Annually

for women over 40

At least every 3 years for women
between 20 and 40
More frequent examination for
high risk patients

Clinical examination
Breast

Sitting
Supine
Both Axillae & Supraclavicular
fossae
Local examination of possible
metastatic sites

Mammography
Not

recommended under the age

of 35 unless there is a strong
clinical suspicion of cancer
Mammography allows for efficient
diagnosis of breast cancers at an
earlier stage
Normal mammogram does not
rule out possibility of cancer
completely

Mammogram
Two of the most important
mammographic indicators of breast
cancers
Masses
Microcalcifications: Tiny flecks
of calcium like grains of salt in
the soft tissue of the breast that
can sometimes indicate an early
cancer.

Malignant

masses have a more

spiculated appearance

Calcifications

show up as white
spots on a mammogram

Round

well-defined, larger
calcifications are more likely
benign

Tight

cluster of tiny, irregularly

shaped calcifications may
indicate cancer

Breast Ultrasound
To

see whether the lump is solid

or cystic
Margins, complexity
For aspiration or biopsy

Histopathology
Fine

needle aspiration cytology

performed with 5 cc disposable
needle as outpatient procedure
Trucut biopsy
performed with core cut needle
under local anaesthesia

Treatment
Based

on many factors
Varies from reassurance to radical
Surgery

TNM Staging
TX:

primary tumor cannot be

assessed
T0:
no evidence of tumor
Tis:
carcinoma in situ
T1:
tumor <2 cm
T2:
tumor 2-5 cm
T3:
tumor >5 cm
T4:
direct extension to chest
wall or skin

TNM staging
NX:regional

nodes cannot be assessed

N0: negative lymph nodes
N1: metastases to moveable
ipsilateral
axillary lymph nodes
N2: metastases to fixed ipsilateral
axillary lymph nodes
N3:
metastases to ipsilateral
internal
mammary nodes

TNM staging
MX: distant sites cannot be
assessed
M0: no distant metastases
M1: distant metastases

Breast cancer treatment

Breast

Conserving surgery
Mastectomy
Axillary sampling( Sentinel node
biopsy)
Axillary clearance
Chemotherapy
Radiotherapy
Hormone Therapy

Oncoplastic Surgery
The

combination of reconstructive
surgery in cancer surgery.
Immediate breast reconstruction
following partial or total
Mastectomy

Oncoplastic
Tumours

smaller than 3 cm
Nodal status-N0, N1
Peripheral tumors
Large breasts

Conclusion
The

diagnosis of breast cancer is

devastating for most women and
is compounded by mental
anguish associated with the
anticipated changes in their
appearance

Conclusion
As clinical breast examination
(CBE) may play a positive role in
detecting cancer earlier, especially
in reducing tumour size from 5 cm
to 2 cm at presentation in
developing countries without a
mammography screening
programme, the practice of CBE by
doctors and trained nurses should
be encouraged.

Conclusion
If

breast cancer patients are

offered breast oncoplasty
procedures, more women are
likely to come forward for
treatment at an early stage.