Makindo Medical Notes

Related Subjects: |Assesment of the Causes of Breast tenderness/pain (Mastalgia) |BRCA genes (Familial Breast Cancer) |Breast Anatomy and Examination (OSCE) |Breast Cancer |Breast Fibroadenoma |Breast Lumps: Clinical Approach and Considerations |Mastitis and breast abscess

🎗️ Breast lumps are a common finding and range from benign conditions to serious malignancies. For clinicians, evaluation requires a systematic approach: careful history, thorough examination, and appropriate investigations. Early detection is crucial, especially for breast cancer.

📖 Patient History

• 🕐 Onset & duration: Sudden vs gradual appearance, stable vs enlarging.
• 🤕 Associated symptoms: Pain, nipple discharge, skin changes, trauma.
• 🩸 Menstrual & hormonal history: Relation to cycle, pregnancy, or hormone therapy.
• 👪 Family history: Breast/ovarian cancer in close relatives (BRCA risk).
• 📋 Personal history: Prior lumps, surgery, radiotherapy.

🩺 Physical Examination

A structured breast exam is essential. Compare both breasts systematically.

• 📍 Location: Note the quadrant (upper outer quadrant most common).
• 📏 Size & shape: Round, irregular, or lobulated.
• 🪨 Consistency: Soft, firm, or hard.
• ↔️ Mobility: Mobile vs fixed (malignancy often fixed).
• 🤕 Tenderness: Painful vs painless.
• 🧷 Skin/nipple changes: Dimpling, retraction, inversion, peau d’orange.
• 🌐 Regional nodes: Palpate axillary, supraclavicular, and cervical nodes.

🩸 Causes of Breast Lumps

🔬 Diagnostic Investigations

• 📸 Mammography: Gold standard >40 yrs, calcifications, spiculated masses.
• 🧪 Ultrasound: Better in younger women (dense breasts), distinguishes solid vs cystic.
• 💉 FNA: Cytology, diagnostic for cysts.
• 🪡 Core biopsy: Histology, preferred for suspected malignancy.
• 🧲 MRI: For high-risk patients, dense breasts, or staging disease.

🩹 Management Principles

• Benign masses 🌱: Reassure, observe, excise only if symptomatic or enlarging.
• Infections 🦠: Antibiotics ± drainage.
• Malignant masses 🎗️: Multidisciplinary — surgery, radiotherapy, chemotherapy, hormone therapy as indicated.

💡 Teaching Pearl: Every breast lump in a woman >30 should be considered malignant until proven otherwise. The “triple assessment” — clinical exam, imaging, and biopsy — is the cornerstone of safe practice.

📚 Case 1: Fibroadenoma in a Young Woman

History: A 22-year-old woman presents with a painless lump in her right breast, noticed 3 months ago. No family history of breast cancer. No nipple discharge or skin changes. Lump does not change with her cycle.

Examination: 2-cm smooth, firm, mobile mass in the upper outer quadrant. No lymphadenopathy.

Investigations: Breast ultrasound shows a well-circumscribed solid lesion. Core biopsy confirms fibroadenoma.

Management: Reassure and observe. Excision only if enlarging or causing anxiety.

💡 Teaching Pearl: Fibroadenomas are called “breast mice” because they are smooth and mobile.

📚 Case 2: Breast Cyst in a Perimenopausal Woman

History: A 46-year-old presents with a tender lump in her left breast, which fluctuates in size with her menstrual cycle. No systemic symptoms.

Examination: A fluctuant, well-defined, mildly tender mass. No skin dimpling or nipple changes.

Investigations: Ultrasound confirms a fluid-filled cyst. Aspiration yields clear yellow fluid; the lump disappears.

Management: Reassure. Repeat aspiration if symptomatic recurrence.

💡 Teaching Pearl: Cyst aspiration with clear fluid and resolution is both diagnostic and therapeutic.

📚 Case 3: Breast Cancer in an Older Woman

History: A 62-year-old woman reports a hard lump in her left breast, first noticed 2 months ago. She has noticed recent nipple inversion. Her sister had breast cancer at 58.

Examination: A 3-cm hard, irregular, immobile mass with overlying skin dimpling. Palpable left axillary lymph nodes.

Investigations: Mammogram shows a spiculated lesion. Core biopsy confirms invasive ductal carcinoma.

Management: Multidisciplinary: surgery (wide local excision or mastectomy), axillary staging, plus adjuvant radiotherapy and endocrine therapy depending on receptor status.

💡 Teaching Pearl: Any hard, irregular, fixed lump in a woman >30 is malignant until proven otherwise — always do a triple assessment (exam + imaging + biopsy).