A brief approach for a patient with breast Lump, presented by Dr. Sara Khalid Memon, LUMHS!

1. Approach to a
Patient with
BREAST LUMP
Presented by:
Dr. Sara Khalid Memon,
House Officer, SU 3

3. Lets Revise the
BASICS … !!

5. How to APPROACH??
By History
By Examination
By Investigation

7. What to ask in HISTORY ?
Biodata
Presenting complain with its duration
All questions of breast lump (when and how
first noticed, Pain, tenderness, change in size
over time and with menstruation.)
Associated symptoms (discharge, any other
swelling, skin changes, body aches, etc)

8. Other Important Headings like
Gynecologic History : Parous state, breast feeding, last
period, drugs (HRT)
Past Medical History : benign breast disease, breast cancer,
radiation therapy to breast
Past Surgical History: breast biopsy, lumpectomy,
mastectomy, hysterectomy, oophorectomy.
Family History : Especially in first degree relatives.
Constitutional Features : - Anorexia - weight loss -
Respiratory Symptoms - Bone Pain

9. Examination
INSPECTION
 Site
 Size
 Shape
 Extent
 Skin changes (Redness, dimpling, edema, ulceration,
Peaud orange)
 Discharge
 Nipple (everted or inverted, crusted, ulcerated)
 Prominent Veins
 Any other lump in vicinity

10. PALPATION
Size
Position
Extent
Mobility
Composition ( Fluctuant, Hard, Rubbery )
Fixation to underlying tissue or skin

11. What could
be the
cause of
this
LUMP??

12. DIFFERENTIAL DIAGNOSIS OF BERAST
LUMP
FIBROCYSTIC DISEASE
CYSTS
FIBROADENOMA
FAT NECROSIS
PAPILLOMA
BREAST CANCER

15. INVESIGATIONS
oBaseline Investigations
(CBC, RBS, Xray Chest, Ultrasound Abdomen,
HbsAg and Anti HCV, Serum urea creatinine and
electrolytes)

16. Specific Investigations
oMammography
oU/S Breast
oBiopsy of the Lump
oMagnetic Resonance Imaging
oCytology
oImaging for metastases

17. Mammography
o Indications
• screening – every 1-2 years for women ages 50-69.
• metastatic adenocarcinoma of unknown primary.
• nipple discharge without palpable mass.
o Mammogram findings indicative of malignancy
• stellate appearance and spiculated border - pathognomonic of breast cancer.
• microcalcifications, ill-defined lesion border.
• lobulation, architectural distortion
NOTE:• normal mammogram does not rule out suspicion of cancer, based on
clinical findings.

20. Ultrasonography
o Best initial test in women less than 35
years of age with breast Lump
o Performed primarily to differentiate
cystic from solid lesions.
o Not diagnostic

21. Biopsy of the Lesion
o The diagnosis of breast cancer depends upon examination of
tissue or cells removed by biopsy.
o The safest course is biopsy examination of all suspicious masses
found on physical examination and of suspicious lesions
demonstrated by mammography.
o The simplest method is needle biopsy, either by aspiration of
tumor cells ( fine – needle aspiration cytology) or by obtaining a
small core of tissue with a hollow needle.
o And by Open biopsy… ( incisional or excisional )

22. o Magnetic Resonance Imaging
• High Sensitivity for breast cancer
• Can demonstrate the extent of both invasive & non-invasive disease. • Determines
weather a mammographic lesion at the site of previous surgery is due to scar or
recurrence.
• The optimum method for imaging breast implants and detecting implant leakage or
rupture.
o Cytology
• Cytological examination of nipple discharge or cyst fluid may be helpful on rare
occasions.
• As a rule, mammography and breast biopsy are required when nipple discharge or cyst
fluid is bloody or cytologically questionable.
o Imaging for metastases
• Chest x-ray may show pulmonary metastases.
• CT scanning of liver and brain is of value only when metastases are suspected in these
areas.

23. LETS
TREAT
IT
NOW !!

24. Benign Breast Lumps !
o FIBROCYSTIC DISEASE
o FIBROADENOMA
o FAT NECROSIS
o PAPILLOMA
o FIBROADENOSIS-focal/diffuse nodularity
o GALACTOCOELE
o ABSCESS
o PERIDUCTAL MASTITIS-secondary to duct ectasia

25. Fibrocystic disease
o Benign breast condition consisting of fibrous and cystic
changes in breast.
• Age : 30-50 years
• Clinical Features - breast pain - swelling with focal areas of nodularity or
cysts - Frequently bilateral - varies with menstrual cycle
o Treatment
• If no dominant mass, observe to ensure no mass dominates. • For a
dominant mass, FNA • If > 40 years, mammography every 3 years • Avoid
xanthine-containing products (coffee, tea, chocolate, cola drinks) and
nicotine. • For severe symptoms – danozol (2- 3 months), or tamoxifen (4-
6 weeks)

26. Fibro adenoma
Most common benign breast tumour in women
under age 30.
• No malignant potential
• Clinical features – smooth, rubbery, discrete,
well circumscribed nodule, non-tender, mobile,
hormonally dependent.
• Management – usually excised to confirm
diagnosis

27. Fat Necrosis
Due to trauma (although positive history in only
50%).
• Clinical features – firm, ill-defined mass with skin
or nipple retraction, +/– tenderness.
• Management – will regress spontaneously but
complete excisional biopsy is the safest approach
to rule out carcinoma.

28. Papilloma
Solitary intraductal benign polyp.
• Most common cause of bloody nipple
discharge.
• Management – excision of involved duct

29. Breast Cancer
o Epidemiology
o Risk factors
o Pathology
o Staging (clinical & pathological)
o Metastasis
o Treatment
o Local/Regional Recurrence
o Prognosis

30. Epidemiology
• Most common cancer in women.
• Second leading cause of cancer mortality in
women.
• Most common cause of death in 5th decade.
• Lifetime risk of 1/9

31. Risk Factors
• Age - 80% > 40y.o
• Sex - 99% female
• 1st degree relative with breast cancer - Risk increases if relative was premenopausal.
• Geographic - highest national mortality in England and Wales, lowest in Japan.
• Nulliparity
• Late age at first pregnancy>30y.o
• Early menarche < 12; late menopause > 55
• Obesity
• Excessive alcohol intake, high fat diet
• Certain forms of fibrocystic change
• Prior history of breast ca
• History of low-dose irradiation
• Prior breast biopsy regardless of pathology
• OCP/estrogen replacement may increase risk

37. TREATMENT
Primary Treatment of Breast Cancer is..
• total mastectomy – removes breast tissue, nipple-
areolar complex and skin
• modified radical mastectomy (MRM) – removes
breast tissue, pectoralis fascia, nipple-areolar complex,
skin and axillary lymph nodes

39. Post Surgical Management
o Follow-up of post-mastectomy patient history
and physical every 4-6 months yearly
mammogram of remaining breast
o Follow-up of segmental mastectomy patient
history and physical every 4-6 months
mammograms every 6 months x 2 years, then
yearly thereafter
o When clinically indicated chest x-ray bone
scan LFTs CT of abdomen CT of brain

40. JAZAKALLAHU
KHAIR