Breast presentations and diagnosis

Breast lump and cancer — triple assessment

Overview and approach

A new breast lump needs triple assessment: clinical evaluation, appropriate imaging and tissue diagnosis when indicated.

Cancer Australia's GP guide: triple test = history and clinical examination, mammography and/or ultrasound, and non-excisional biopsy (core biopsy or FNA). Any indeterminate, suspicious or malignant result needs specialist referral^1,2.
Lump causes: cysts, abscess/mastitis, fibroadenoma, intraductal papilloma, fat necrosis, lipoma, cancer; gynaecomastia in males.
Age changes the odds: only about 10% of breast masses under 40 are malignant, compared with about 60% over 50; over 70, most lumps are cancer. Cancer is very rare in teenagers^3,4.
Site: about half of cancers are in the upper outer quadrant (including the axillary tail) and about a fifth are central or subareolar, so examine all of the breast^3,4.
How cancer presents: usually a painless lump whose size does not match how long it has been noticed; sometimes an axillary lump first, skin dimpling, a retracted or destroyed nipple, or a change in breast shape. Presentation with metastases (bone pain, fracture) is uncommon, and most women feel well⁴.

Assessment and clinical features

Consent/chaperone, duration, cycle/pregnancy relation, family history, skin/nipple changes and axillary examination.

Risk factors: age; BRCA1/2 and other genes; early menarche (before 12) or late menopause (after 55); dense breasts; personal history of breast cancer, atypical hyperplasia or LCIS; family history; chest radiation before age 30; DES exposure; inactivity; postmenopausal obesity; combined HRT over 5 years, some OCPs; first pregnancy after 30, nulliparity, no breastfeeding; alcohol.
Benign lumps: cyst (smooth, rubbery, 30-50 years, may be painful); fibroadenoma (round, rubbery, smooth, painless, mainly 14-35 years); intraductal papilloma (under the nipple, clear or bloody discharge); fat necrosis (after trauma, biopsy or surgery); lipoma (soft, mobile); abscess (red, hot, fever, often lactation).
Cancer signs: lump or thickening, skin dimpling or irritation, scaly nipple skin, nipple inversion, bloody discharge, change in size or shape; often painless.
Tethering vs fixation: a tethered lump pulls on the fibrous septa (Cooper's ligaments) so the skin puckers when the lump is moved, but the lump still moves separately from the skin. A fixed lump has grown into the skin and cannot be moved apart from it. Skin fixation is almost diagnostic of cancer; the main mimic is fat necrosis⁴.
Deep fixation: recheck mobility with the pectoral muscles tensed (hands pressed on hips). If the lump becomes less mobile it is attached to the chest wall⁴.
Peau d'orange: tumour blocks the skin lymphatics, so the skin swells between the tethered hair follicle and sweat gland pits⁴.
Feel: cancers are solid with an indistinct edge and usually firm, but some are soft or smooth, so consistency alone cannot exclude cancer. Only inflammatory cancer feels warm⁴.

Typical examination findings in the three commonest lumps^3,4.

Feature	Carcinoma	Fibroadenoma	Cyst
Usual age	Rising from 30s, peak late 50s and older	Teens to 30s	40s to early 50s
Edge and surface	Irregular, indistinct	Smooth, well defined	Smooth, spherical
Consistency	Usually hard	Firm, rubbery	Soft to hard
Mobility	May be tethered or fixed	Very mobile	Less mobile, but never tethered

Axillary nodes: small soft nodes on both sides are often normal, while impalpable nodes can still contain tumour. Metastatic nodes are firm and discrete at first, then matted and fixed, especially at the axillary apex⁴.
Examine the other breast and axilla (a second primary is more likely than spread) and look for metastases: spine and long bones, pleural effusion, liver, skin nodules and neurology⁴.
If you cannot feel the lump the patient describes, ask her to show you, and if still unsure arrange imaging or review rather than dismiss it⁴.

Differentials and investigations

Ultrasound/mammography selected by age/context; biopsy suspicious or discordant findings. Benign cysts/fibroadenoma differ from carcinoma.

Imaging and biopsy results must be concordant with the clinical findings; discordance needs specialist review¹.
Mammography: accuracy improves with age as dense glandular tissue is replaced by fat. Cancer shows as an irregular density or small, irregular, clustered calcifications; round densities are usually cysts or fibroadenomas. About 10% of invasive cancers are not seen, so a palpable lump with a normal mammogram still needs work-up³.
Ultrasound separates solid from cystic lesions and outlines the edge of a solid lump³.
Needle tests: FNA gives cells for cytology; core biopsy gives tissue for histology and is often image guided⁴.
Mimics: fat necrosis (scarring and skin tethering after an injury the patient may not recall) and Mondor's disease (thrombophlebitis of a superficial chest wall vein causing a cord-like groove in the skin)⁴.
Staging for confirmed cancer (MRI, CT) is a specialist decision.

Management and follow-up

Refer through the breast pathway; MDT treatment depends on stage, receptor status, fitness and preferences.

Cyst or fibrous lump: monitoring or aspiration; abscess: drainage (needle or incision) plus antibiotics; cancer: surgery, chemotherapy, radiotherapy and hormonal therapy in combination.
A solid component or recurrent cyst after aspiration needs further assessment for cancer.

Red flags and clinical pearls

A clinically suspicious lump requires follow-up even if initial imaging is reassuring; skin tethering, new inversion or pathological discharge needs prompt review.

A non-breastfeeding breast abscess needs tests to exclude cancer.
Inflammatory carcinoma: tumour emboli block the dermal lymphatics, giving a red, swollen, warm breast that mimics infection. Consider it in any red swollen breast, especially if not lactating³.
Recent, one-sided nipple inversion that will not evert is more worrying than long-standing, bilateral or easily everted inversion⁴.

References

Cancer Australia: Investigation of a new breast symptom, a guide for GPs (PDF)
Cancer Australia: Breast cancer diagnosis
Kumar V, Abbas AK, Aster JC, editors. Robbins and Cotran Pathologic Basis of Disease. 9th ed. Philadelphia: Elsevier Saunders; 2015. Chapter 23, The breast.
Burnand KG, Black J, Corbett SA, Thomas WEG, editors. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 5th ed. Boca Raton: CRC Press; 2015. Chapter 13, The breast.

Additional notes and images

Breast Lump

Approach

A breast lump is a localized swelling, protuberance, bulge, or bump in the breast that feels different from the breast tissue around it or the breast tissue in the same area of the other breast.

Epidemiology / Causes

Breast lumps may develop in both males and females but are more common in females. Some lumps are cancerous, but most are not.

cysts
abscesses, which can indicate an infection, such as mastitis
fibroadenoma
intraductal papillomas
fat necrosis
lipoma
breast cancer
gynecomastia, in males, when there is swelling in breast tissue

Risk Factors

Risk Factors You Cannot Change

Getting older. The risk for breast cancer increases with age. Most breast cancers are diagnosed after age 50.
Genetic mutations. Women who have inherited changes (mutations) to certain genes, such as BRCA1 and BRCA2, are at higher risk of breast and ovarian cancer.
Reproductive history. Starting menstrual periods before age 12 and starting menopause after age 55 expose women to hormones longer, raising their risk of getting breast cancer.
Having dense breasts. Dense breasts have more connective tissue than fatty tissue, which can sometimes make it hard to see tumors on a mammogram. Women with dense breasts are more likely to get breast cancer.
Personal history of breast cancer or certain non-cancerous breast diseases. Women who have had breast cancer are more likely to get breast cancer a second time. Some non-cancerous breast diseases such as atypical hyperplasia or lobular carcinoma in situ are associated with a higher risk of getting breast cancer.
Family history of breast or ovarian cancer. A woman’s risk for breast cancer is higher if she has a mother, sister, or daughter (first-degree relative) or multiple family members on either her mother’s or father’s side of the family who have had breast or ovarian cancer. Having a first-degree male relative with breast cancer also raises a woman’s risk.
Previous treatment using radiation therapy. Women who had radiation therapy to the chest or breasts (for instance, treatment of Hodgkin’s lymphoma) before age 30 have a higher risk of getting breast cancer later in life.
**Exposure to the drug **diethylstilbestrol (DES). DES was given to some pregnant women in the United States between 1940 and 1971 to prevent miscarriage. Women who took DES, or whose mothers took DES while pregnant with them, have a higher risk of getting breast cancer.

Risk Factors You Can Change

Being physically active can help lower your risk of getting breast cancer.

Not being physically active. Women who are not physically active have a higher risk of getting breast cancer.
Being overweight or having obesity after menopause. Older women who are overweight or have obesity have a higher risk of getting breast cancer than those at a healthy weight.
Taking hormones. Some forms of hormone replacement therapy (those that include both estrogen and progesterone) taken during menopause can raise risk for breast cancer when taken for more than five years. Certain oral contraceptives (birth control pills) also have been found to raise breast cancer risk.
Reproductive history. Having the first pregnancy after age 30, not breastfeeding, and never having a full-term pregnancy can raise breast cancer risk.
Drinking alcohol. Studies show that a woman’s risk for breast cancer increases with the more alcohol she drinks.

Clinical features

**Non-cancerous **

Breast cysts

A breast cyst is a benign or noncancerous fluid-filled sac in the breast. They commonly affect females aged 30–50 yearsTrusted Source and are rare after menopause.

It may cause no symptoms, or a person may notice:

a smooth and rubbery lump under the skin
pain
nipple discharge

It is not clear what causes breast cysts, but they may develop in response to hormones related to menstruation.

Cysts can be simple or complex. In both cases, a doctor may suggest removing it by aspiration, a type of surgery.

Very rarely, a cyst with solid components that returns after aspiration is linked to underlying breast cancer.

Abscesses

Abscesses sometimes develop in the breast, especially during breastfeeding. They are noncancerous and usually result from a bacterial infection, such as mastitis.

A person may noticeTrusted Source:

a lump or mass
pain and swelling
redness in nearby skin if the skin is pale, or a darkening of darker skin
heat in the area around the abscess
discharge from the nipple
nausea and vomiting
fever
swollen lymph glands

Treatment will usually involve:

draining the abscess
taking antibiotics
using nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, to manage pain and inflammation

If a breast abscess occurs when a person is not breastfeeding, a doctor may do tests to rule out breast cancer.

Fibroadenoma

A breast fibroadenoma is an unusual growth of glandular tissue in the breast.

It is a benign tumor with the following features:

a round, rubbery solid, lump
smooth borders
painless
most commonly appears in females aged 14–35Trusted Source years but can occur at any age

Fibroadenomas often shrink and disappear over time. However, a person with a large fibroadenoma may wish to have it removed through surgery.

Intraductal papillomas

Intraductal papillomas are a type of benign tumor. They are wart-like growths that develop in the ducts of the breast.

They oftenTrusted Source:

form a round or oval mass
develop under the nipple
involve a clear or bloody discharge

A surgeon can remove an intraductal papilloma. They will likely test the tissue to rule out unusual growth that could indicate cancer, a Phyllodes tumor, or other lesions.

Fat necrosis

Fat necrosis happensTrusted Source when fatty tissue in the breast does not receive enough oxygen. It becomes damaged and breaks down. It can happen after breast reconstruction surgery, trauma, a biopsy, and some medical treatments.

There may be:

lumps due to oil cysts, which have a solid shell and fat or oil in the center
a change in breast shape
pain in some cases

Lipoma

A lipoma is a benign, fatty tumor.

It will likelyTrusted Source be:

soft
movable
painless

Lipomas can occur anywhere on the body, including the breast. They do not usually need treatment.

Cancerous

A breast cancer lump or tumor can appear in the breast or underarm.

Warning signs include:

a lump, thickening, or swelling of the breast
skin irritation or dimpling
flaky skin on the breast or around the nipple that may be red or darker than the surrounding skin
nipple pain
nipple inversion, or pulling inward of the nipple
discharge, which may contain blood
changes in the size or shape of the breast
pain anywhere in the breast, although there is often no pain

Some people do not notice any symptoms but following a doctor’s recommendations about screening can help identify breast cancer if it arises.

The symptoms of breast cancer can resemble those of other breast lumps. It is a good idea to seek medical advice if any breast changes occur.

Management

Diagnosis

a physical examination
a mammogram
a breast ultrasound scan
a breast biopsy to rule out cancer
an MRI or CT scan to see if changes have occurred elsewhere in the body

Treatment

For a cyst or a fibrous lump, a doctor may recommend monitoring the lump but not taking any further action.

If there is an abscess, the doctor may lance and drain it with a fine needle and prescribe antibiotics.

If cancer is present, treatment usually involves a combination of:

surgery
chemotherapy
radiation therapy
hormonal drug treatment

Benign Breast Lesions

Definition

Breast Cancer

Retained linked reference