242 Breast lump
Salient features
History
• History of a palpable mass in breast and/or axilla
• Breast pain (present in 10% of breast cancer patients) and unrelated to menstrual cycle
• Nipple discharge, erosion, enlargement or itching of the nipple
• Back or bone pain, jaundice or weight loss (indicate systemic metastases)
• Family history (20% of breast cancer have family history)
• Some forms of mammary dysplasia
• History of cancer in the other breast
• History of endometrial cancer
Examination
• Breast lump that is non-tender and has poorly delineated margins. Asymmetry of the breasts and retraction or dimpling of the skin can often be accentuated by having the patient raise her arms overhead or press her hands on her hips to contract the pectoralis muscle.
• Examine axillary and supraclavicular lymph nodes
• Look for oedema of the ipsilateral arm (as a result of metastatic infiltration of regional lymphatics)
• Examine the chest (metastases, lymphangitis carcinomatosa)
• Examine for hepatomegaly (metastases); breast cancer spreads to the bones, lungs, brain and liver.
Remember: All patients should undergo ‘triple assessment’:
• Imaging: ultrasound <35 years of age, mammography and ultrasound >35 years
• Cytology and histology: ultrasound-guided core biopsy and occasionally fine needle aspiration.
Questions
How would you investigate such a patient?
• FBC and ESR (ESR is consistently raised)
• Urea and electrolytes, liver function tests (hypercalcaemia, raised alkaline phosphatase level indicates bone or liver metastases)
• Biopsy: large needle-core biopsy, fine-needle aspiration or open biopsy under local anaesthesia
• Carcinoembyronic antigen (CEA) could be a marker for recurrence
Advanced-level questions
How would you investigate a patient with a suspicious mammogram but no clinical evidence of mass?
Although a mass cannot be palpated, the patient should undergo a mammographic localization biopsy.
What are the histological types of breast cancer?
They are of two main types, which may be invasive or in situ.
• Ductal: arising from the epithelial lining of large or intermediate-sized ducts. Most arise from intermediate ducts and are invasive (e.g. invasive ductal, infiltrating ductal). When ductal carcinoma has not invaded extraductal tissue, it is intraductal or in situ ductal.
• Lobular: arising from the epithelium of the terminal ducts of the lobules.
How are patients with breast cancer managed?
Surgery
• Breast-conserving surgery (lumpectomy, axillary dissection and radiation therapy) is usually offered to patients with single tumours <4 cm in diameter because the cosmetic outcome of excising larger tumours is poor. However, in 80% of patients with large tumours and in 25% of those with locally advanced breast cancers, breast conservation is possible if the size of the tumour is reduced by a course of primary systemic treatment (such as combination chemotherapy and hormonal therapy).
• Modified radical mastectomy (total mastectomy, removal of the overlying skin, nipple as well as the underlying pectoralis fascia with axillary lymph node dissection). The major advantage is that radiation is not necessary, but many patients suffer from the psychological trauma of breast loss.
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