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Breast lump

Surgery > Breast

Differential Diagnosis Schema 🧠

Benign Breast Conditions

  • Fibroadenoma: Common in women under 30, well-defined, mobile, non-tender.
  • Fibrocystic Changes: Cyclical breast pain, bilateral lumpy breasts, often linked to menstrual cycle.
  • Breast Cyst: Smooth, firm, and round; can be tender or painless.
  • Mastitis: Erythematous, warm, and tender; often associated with breastfeeding.
  • Fat Necrosis: Often follows trauma, firm lump, may present with skin tethering.

Malignant Breast Conditions

  • Invasive Ductal Carcinoma: Most common breast cancer, irregular, hard, immobile mass, may have associated skin changes.
  • Invasive Lobular Carcinoma: Often bilateral or multicentric, less likely to present as a distinct lump.
  • Ductal Carcinoma In Situ (DCIS): Often detected on mammography, may not form a palpable lump.
  • Paget’s Disease of the Nipple: Eczematous changes to the nipple, underlying malignancy likely.
  • Inflammatory Breast Cancer: Rapidly progressive, red, swollen, and tender breast, peau d’orange appearance.

Non-Breast Causes

  • Lipoma: Soft, mobile, benign fatty tumour; usually painless.
  • Lymphadenopathy: Enlarged lymph nodes in the axilla, often due to infection or systemic disease.
  • Costochondritis: Tenderness over the costochondral junctions, associated with chest wall pain.
  • Chest Wall Tumours: Rare, may involve ribs or intercostal muscles, often painful and firm.

Key Points in History 🥼

Symptom Characteristics

  • Onset: Sudden onset suggests trauma or infection; gradual onset may indicate malignancy.
  • Pain: Painful lumps often benign (e.g., cysts, infections); painless lumps raise concern for malignancy.
  • Size: Rapid growth may indicate malignancy; cyclical changes suggest fibrocystic condition.
  • Skin Changes: Erythema, peau d’orange, or ulceration often suggest malignancy or infection.
  • Nipple Discharge: Spontaneous, unilateral, and bloody discharge is concerning for malignancy.

Background

  • Past Medical History: History of breast cancer, radiation exposure, or hormonal therapy increases risk of malignancy.
  • Family History: Strong family history of breast or ovarian cancer may suggest genetic predisposition (e.g., BRCA mutations).
  • Drug History: Use of hormone replacement therapy (HRT) or oral contraceptives may increase risk.
  • Social History: Smoking, alcohol use, and obesity are risk factors for breast cancer.

Possible Investigations 🌡️

Imaging

  • Mammography: First-line imaging for women over 40; can detect calcifications and masses suggestive of malignancy.
  • Ultrasound: Preferred in women under 40 and for characterising cystic vs solid lesions.
  • MRI: Used for further evaluation of indeterminate lesions or high-risk patients; particularly sensitive.

Biopsy

  • Fine Needle Aspiration (FNA): Quick, minimally invasive, but may not differentiate between in situ and invasive disease.
  • Core Needle Biopsy: Provides more tissue for histopathological analysis; standard for suspicious lesions.
  • Excisional Biopsy: Indicated if core biopsy is inconclusive or if entire lesion removal is needed.

Laboratory Tests

  • Hormone Receptor Status: Determines if breast cancer is estrogen or progesterone receptor-positive, which influences treatment.
  • HER2 Testing: Assesses overexpression of HER2 protein, indicating more aggressive disease and targeted therapy.
  • BRCA1/BRCA2 Testing: Genetic testing if strong family history or early onset of breast cancer.

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Breast