Approach to a Breast Lump

1. History

• Age (critical - guides differential)
• Age at menarche and menopause
• Number of pregnancies and age at first birth
• Use of oral contraceptives or hormone replacement therapy
• Family history of breast, ovarian, or other cancers (especially first-degree relatives, age of onset, bilateral disease)
• History of previous breast biopsies and their histologic diagnosis
• History of prior thoracic radiation

• Onset and duration
• Change in size - progressive growth vs. fluctuation with menstrual cycle
• Relationship to menstrual cycle (cyclic tenderness = more likely benign)
• Associated pain, nipple discharge, skin changes
• Whether patient or a clinician first detected it

Note: From a purely surgical standpoint, "the history is largely irrelevant, for whether a lump is discovered or not depends on the physical examination" - Pye's Surgical Handicraft, 22nd ed. - but risk stratification and cancer screening decisions rely heavily on it.

2. Clinical Examination

Inspection (patient seated, arms at sides)

1. Visible lump or asymmetry
2. Tethering - of skin or nipple (malignant tethering usually involves the areola and is eccentric)
3. Skin changes - dimpling, peau d'orange (edema), erythema
4. Nipple changes - inversion (new vs. longstanding), eczematous change (Paget disease), discharge

Benign nipple inversion is often a midline fold or inpulling of a few ducts, correctable by flattening. Malignant inversion involves the areola and is eccentric. - Pye's Surgical Handicraft

Palpation

• Patient lies supine, upper body at ~30°, ipsilateral arm raised above head
• Use the flat of the fingers (not tips), with gentle pressure
• Systematically cover all four quadrants, the areola, and the axillary tail
• Repeat with arms above head and then sitting up

Lymph Node Examination

• Axillary nodes (support the ipsilateral arm to relax the pectoral muscle)
• Supraclavicular and infraclavicular nodes
• Note size, consistency (soft vs. firm), mobility (mobile vs. matted), and tenderness

After examination, the clinician makes one of three decisions (Pye's Surgical Handicraft):

1. A definite lump is present → proceed to investigation
2. No abnormality → discharge
3. No definite lump but breast not entirely normal → re-examine at a different cycle phase in 6 weeks, or mammogram and discharge

3. Triple Assessment

Component 1 - Clinical Examination (as above)

Component 2 - Imaging

• Primary modality in women ≥35-40 years
• Two standard views: mediolateral oblique (MLO) and craniocaudal (CC)
• Important: 15-20% of palpable breast cancers are NOT visible on mammography - a normal mammogram does NOT rule out malignancy; palpation remains paramount
• Never view the mammogram before palpating the breast - it biases the examiner
• Results reported using the BI-RADS (Breast Imaging Reporting and Data System) classification:

• Preferred in women <35 years (dense breast tissue limits mammography)
• Can differentiate cystic from solid masses
• Characterizes shape, margins, orientation, echogenicity, and attenuation
• Can detect lesions occult on mammography
• Guides needle biopsy

• Not routine for initial diagnosis
• Used when disease extent is difficult to define on mammography/US
• Recommended for high-risk screening (≥20% lifetime risk, BRCA carriers, prior chest radiation aged 10-30)

Component 3 - Tissue Diagnosis (Biopsy)

• First step for any palpable lump
• If fluid aspirates freely → cyst → empty it; if lump resolves completely, no further follow-up needed
• If lump remains after aspiration → investigate as solid lump

• Same 23G needle used to pass through the lump 10-15 times under suction
• Requires trained cytopathologist - must achieve 100% specificity (no false positives for cancer)
• Benign fibroadenoma cells can mimic malignancy
• Limitation: cannot distinguish in situ from invasive disease

• Provides histological (not just cytological) diagnosis
• Distinguishes invasive from in situ cancer
• Provides hormone receptor status (ER, PR, HER2) and histologic grade - all needed for treatment planning
• A positive Trucut for cancer = proceed to definitive surgery; a negative result is usually disregarded (small fibroadenomas can be pushed away)
• Now preferred over FNAC in most centers as the standard tissue diagnosis method

• If needle techniques fail to establish a diagnosis
• Day-case surgery, usually under general anaesthesia
• In women <25 years with a clinically typical fibroadenoma - conservative management (with FNAC confirmation) is appropriate, as cancer is very rare

4. Age-Related Differential Diagnosis

5. Red Flag Features Indicating Malignancy

• Hard, irregular, fixed mass
• Skin dimpling or peau d'orange
• Nipple retraction (new onset, eccentric, with areolar involvement)
• Nipple discharge (unilateral, bloodstained)
• Palpable axillary lymphadenopathy (hard, matted nodes)
• Age >40 with a new lump
• Progressive growth not related to menstrual cycle
• First-degree family history of breast cancer

6. Staging and Further Workup (if malignancy confirmed)

• Axillary ultrasound - evaluate for nodal involvement
• Staging CT (chest/abdomen/pelvis) + bone scan - reserved for clinical stage III or with symptoms suggesting metastases
• PET/CT - not indicated in clinical stage I or II disease (NCCN guidelines)
• Tissue biopsy must establish: histologic type (ductal/lobular), grade, ER/PR/HER2 status