Curriculum · Gynecology / Women's Health / Infertility / Perinatal Care / Birth Spacing
Breast lump
What it is
A breast mass is assessed by triple assessment: clinical history and examination, imaging, and histopathology or cytology. Benign breast conditions are set out as extra or absence of breast/nipple, normal, aberrations, diseases, and others. Normal is a lumpy breast and changes in relation to the menstrual cycle; involution starts by 30y with microcyst formation, fibrosis and adenosis. Aberrations of breast development are juvenile hypertrophy and fibroadenoma (with phyllodes); aberrations in the early reproductive period are pain (mastalgia) and nodularity; aberrations of involution are cyst, sclerosis and duct ectasia. Diseases are epithelial hyperplasia and mastitis. Others are fat necrosis, intra-ductal papilloma, lipoma, gynecomastia and breast implant rupture. Most benign breast conditions and almost all breast cancers arise within the terminal duct lobular unit.
How it presents
Fibroadenoma is the second most common mass in the breast, common in women under 30 years and in the 15-30 year range. It is mobile, so much so that it is called a breast mouse, firm, non-tender, well-circumscribed and smooth, and on ultrasound well-circumscribed and homogeneous. It develops from a whole lobule, not a single cell, with epithelial and connective tissue elements, and is under the same hormonal control as the rest of the breast. Giant fibroadenoma is more than 5 cm in diameter; juvenile fibroadenoma occurs in adolescent girls. A phyllodes tumor cannot always be clinically differentiated from a fibroadenoma, and some fibroadenomas develop into phyllodes. It comes from periductal stromal cells and has cellular fibrous elements: large, fast growing, palpable, solitary, well-defined, mobile, painless, and it may have axillary lymph nodes. Fibrocystic change gives cyclical pain with lumpiness and simple or complex cysts on ultrasound. On history, the findings that point to cancer rather than a benign lump are nipple discharge or bleeding, nipple inversion, ulceration, dimpling, weight loss, lymphadenopathy and bone pain. Nipple discharge itself is divided by colour and by whether it comes from a single pore or from many. Milky discharge goes with physiological discharge, Galactorrhea and Hyperprolactinemia. Yellowish, with or without greenish, multiple pore discharge in a context of fibrocystic breast disease goes with Mammary duct ectasia and periductal mastitis. Straw-colored single pore discharge stands on its own. Bloody single pore discharge goes with Intra-ductal papilloma and carcinoma. The breast lump differential runs malignant, where invasive ductal carcinoma is the most common, and benign, where the entries are fibroadenoma, breast cyst, which may be painful, and abscess, which gives a painful, hot and swollen breast. Dimpling of the skin does not necessarily imply invasion of cancer into the underlying musculature: an intra-mammary tumour can pull on a ligament of Astley Cooper, causing dimpling of the skin, and raising the hands above the head accentuates it. In women between the ages of 20 and 50 only about 10% of palpable masses are malignant, and fibroadenomas are most commonly found in women aged 15-35, where mobile, firm, smooth and rubbery is what distinguishes the mass from a cyst, a carcinoma, a lymphoma and a phyllodes tumour.