Breast Lump

Differential Diagnosis

Benign Conditions

• Fibrocystic disease – often cyclically tender, with changes related to the menstrual cycle

• Fibroadenoma – typically painless, mobile, and well-defined

• Breast cyst – fluid-filled lesion that may be tender and fluctuate with the cycle

• Fat necrosis – usually follows trauma; presents as a firm, irregular lump

• Lipoma – soft, mobile benign fatty tumour

• Phyllodes tumour – rare, may be benign or malignant, usually large and fast-growing

Malignant Conditions

• Breast cancer – hard, irregular, fixed mass often accompanied by skin changes (eg, dimpling, peau d’orange), nipple retraction/discharge and lymphadenopathy

• Paget’s disease of the nipple – eczematous changes of the nipple, frequently associated with an underlying malignancy

History

• Elicit any history of trauma suggesting fat necrosis

• Note changes in lump size, consistency, or tenderness

• Ask about axillary lumps and nipple discharge

• Assess for eczematous nipple changes indicative of Paget’s disease

• Explore relationship to the menstrual cycle, with fibrocystic changes typically settling post-menses

• Inquire about systemic symptoms such as weight loss or night sweats that may indicate malignancy

Risk Factors

• Nulliparity

• Early menarche (<12 years) or late menopause (>55 years)

• Family or personal history of breast or ovarian cancer, including BRCA mutations

• Prolonged hormone replacement therapy (>5 years)

• Smoking

Examination

• Inspect breast skin for dimpling or peau d’orange suggesting lymphatic involvement

• Systematically palpate both breasts and regional lymph nodes (axillary and supraclavicular)

• Assess lump characteristics: size, consistency, mobility, and associated nipple changes

• Identify fixed, hard, irregular, non-mobile lumps as suspicious for malignancy

Investigations

Triple Test

• Clinical Assessment – Detailed history and examination

• Imaging

  • Ultrasound first-line in women under 35, pregnant or breastfeeding

  • Mammography with ultrasound for women aged 35 and above

• Biopsy – FNAC and/or core biopsy for tissue diagnosis, including immunohistochemical testing for ER/PR and HER2 if malignancy is suspected

Additional Investigations

• MRI may be considered in cases of dense breast tissue or indeterminate findings

• Genetic testing may be warranted in patients with a strong family history or early-onset cancer

Management

• Use the triple test to guide management

  • Concordant benign results: Reassure and monitor with routine follow-up

  • Concordant malignant results: Initiate multidisciplinary oncological referral

  • Discordant or indeterminate findings: Consider repeat imaging or biopsy and specialist referral

• For benign conditions, management is typically conservative with regular monitoring and symptomatic treatment

• For malignant conditions, a multidisciplinary approach involving surgery, medical oncology and radiology is essential

Notes

• Early detection and accurate diagnosis are crucial for improving outcomes in breast cancer

• Reassessment is essential; any changes in lump characteristics warrant prompt re-evaluation

• Educate patients on self-breast examination and normal breast changes

• Emphasise genetic counselling for patients with significant family histories

• Be aware of limitations in imaging, especially in younger women with dense breast tissue

• Multidisciplinary team meetings optimise management of complex cases