Breast Lumps

5 Breast Lumps


Over their lifetimes, most women detect a lump in the breast. Approximately 80% of breast masses are discovered by the patient before mammography or physician examination. Most of these lumps are benign cysts. A woman’s estimated lifetime risk for development of breast cancer is 12%. Five-year relative survival is 98% for localized disease, 84% for regional disease, and 23% for distant-stage disease. In 2008, 40,480 breast cancer deaths occurred in the United States. Therefore, it is crucial to be able to separate benign from malignant lesions promptly. The main cause of delayed diagnosis is inappropriate reassurance that a mass is benign without the performance of a biopsy.


Benign breast disease is a continuum of entities, from fibroadenoma and cysts with atypia to cystic changes with marked atypia. The most common breast lesions are fibrocystic breasts, fibroadenomas, breast cancer, mastitis (especially in lactating women), fat necrosis, and gynecomastia, which by definition occurs only in males. Breast lumps occur in as many as 50% of premenopausal women. Most of these lumps are benign, but because breast cancer is part of the differential diagnosis, this is a problem of great concern.


Breast lumps are masses in the breast noted on physical examination and may be either benign or malignant. Benign breast disease is a pathologic diagnosis and usually applies to masses that have undergone tissue sampling. It includes fibrocystic disease; fibroadenoma; and uncommon conditions such as mastitis, lipoma, traumatic fat necrosis, and galactocele. At biopsy, 90% to 95% of all benign breast disease is found to be fibrocystic or fibroadenoma. Fibrocystic disease is a poorly defined group of pathologic breast lesions that includes cysts, fibrosis, adenosis, ductal ectasia, hyperplasia, and papilloma.



Nature of Patient


Breast masses are rare in children and are seen more often in adolescents, but malignancy is rare in both groups. Benign breast disease is common in women younger than 30 years. Of women with benign breast disease, 45% have fibrocystic disease, whereas about 45% have fibroadenomas. In those with benign breast disease after age 30 years, 85% have fibrocystic breasts, and 10% have fibroadenomas. In other words, fibroadenomas become less common with increasing age. Breast cysts are uncommon in elderly patients, but 50% of the patients in whom they occur are using estrogen supplements.


Menstrual status, previous history of breast-feeding, parity, family medical history, and drug use are also important in assessing the risk of breast cancer. Users of oral contraceptives have a lower incidence of breast cancer. Factors that increase the risk for breast cancer include a mother or sister who had breast cancer, early menarche, late menopause, and nulliparity. There is twice the risk of breast cancer in a patient whose mother or sister had breast cancer and three times the risk if both the mother and sister had breast cancer. Also, a rare genetic type of familial breast cancer appears to be inherited as an autosomal dominant trait. Other factors that increase the risk for breast cancer are age greater than 50 years, first pregnancy after age 35, obesity, and benign proliferative breast disease (ductal and lobular hyperplasia or atypia).


Gynecomastia is normal in the neonatal period, during puberty, and in older men. It also occurs in certain familial syndromes and various pathologic states (cirrhosis, prolactinoma, ulcerative colitis, prostatic and testicular carcinoma, orchitis, cryptorchidism) and among users of many drugs (angiotensin-converting enzyme [ACE] inhibitors, lansoprazole, spironolactone, H2 antagonists, and anabolic steroids). Gynecomastia in neonates is probably related to the high levels of estrogen in the placental and fetal circulation. In neonatal gynecomastia, involvement is usually bilateral, and fluid may occasionally be expressed from the nipple. Gynecomastia develops in 40% of pubertal boys (ages 13-14 years). When bilateral and mild, it may be diagnosed by the physician, but the patient and family do not recognize it unless it is marked. Unilateral gynecomastia is a more frequent patient complaint. Generally, gynecomastia can be diagnosed by physical examination. If physical findings are not certain, then men should be referred for diagnostic mammography. Breast cancer in men accounts for 1% of all breast cancers. At presentation, more than 40% of men with breast malignancy have stage III or IV disease; therefore, any mass suspicious for malignancy in men should be referred directly for tissue sampling.


Prevalence of breast cancer in pregnancy is approximately 3 in 10,000 pregnancies, accounting for approximately 3% of all breast cancers. Therefore, imaging of a breast lump should not be postponed in pregnancy.



Nature of Symptoms


The most common breast complaints are nipple discharge, breast pain, and a lump in the breast. Nipple discharge, usually bilateral, can be caused by drugs such as oral contraceptives and phenothiazines. Discharges that are unilateral, pink or bloody, nonmilky, or associated with a mass are suggestive of cancer.


Fibroadenoma is the most common breast lump that occurs during adolescence, but because it is asymptomatic, it is usually detected on physical examination by the patient or physician. These lumps are usually single, unilateral, and located in the upper outer quadrant, although they may be multiple or bilateral in 25% of patients. Fibroadenomas do not vary in size with the menstrual cycle, whereas the lumps of fibrocystic breast disease often enlarge premenstrually.



Associated Symptoms


Pain in the breast (mastodynia) in young women suggests fibrocystic disease, especially if the pain is bilateral and increases premenstrually. Pain in one breast in postmenopausal women is highly suggestive of a malignant process. Cyclic breast pain that increases premenstrually suggests a benign condition, especially fibrocystic breast disease. Mastodynia may also be caused by papillomas, sclerosing adenosis, ductal ectasia, sporadic puerperal mastitis, breast lipomas, traumatic fat necrosis, and galactoceles. Other causes of chest wall pain include pectoral or intercostal muscle sprain, mastitis, costochondral separation, and costochondritis.


If the lump is fixed to the skin or if nipple discharge or axillary adenopathy is present, cancer is probable. Although nipple discharge, particularly if it is bloody, suggests cancer, it occasionally occurs with fibrocystic disease and in males with adrenogenital syndrome.


If lactation is associated with a breast lump, prolactinoma or pregnancy should be suspected.

Related posts:

  1. Constipation
  2. Chest Pain
  3. Facial Pain
  4. Vaginal Discharge and Itching

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 21, 2018 | Posted by in BIOCHEMISTRY | Comments Off on Breast Lumps

Full access? Get Clinical Tree
Get Clinical Tree app for offline access