Breast Lump

Question 1

A 60 year old woman presents with a breast lump she has found herself. You are unable to palpate the lump. How would you manage this situation?

Answer 1

Impression - MANAGEMENT QUESTION
Despite non-palpable breast lump, am concerned about the possibility of malignancy particularly given the patients advanced age.

Provisionally want to rule out malignancies including DCIS and LCIS, or invasive ductal/lobular carcinoma.
Differentials to consider include fibrocystic change, fibroadenoma, and breast abscess.

Question 2

Breast Lump - History

Answer 2

History

• sx: pt to describe lump, time course, natural history, pain, result of last mammogram and breast screening
• REDFLAG: fevers, night sweats, weight loss, etc, other sx of metastasis
• RISK: age, fam hx, past hx of breast cancer, BRCA1/2 mutations, hyperestrogenism, obesity, smoking
• PMHx, medications, SNAP
• social history: ECOG status, home supports, etc

Question 3

Breast Lump - Examination

Answer 3

Examination

• general appearance + vitals
• breast assessment: nipple changes/discharge/retraction, skin changes (peak d’orange, nipple tethering, 4 quadrants - structured approach
• examine both breasts, checking for bilateral lesions
• lymph nodes palpation
• systems review (evidence of bony, lung, brain mets)

Question 4

Breast Lump - Investigations

Answer 4

Investigations
- Triple assessment is gold standard; breast exam, imaging (US/mammography, tissue biopsy (FNA, CNB, excisions)

• Bedside: vitals
• Bloods: FBC, LFTs + UEC/CMP for mets, tumor markers (CEA)
• Histopathology on biopsy: receptor testing (ER/PR)
• Imaging: staging imaging if distant mets (CT CAP, PET)

Question 5

Breast Lump - Management

Answer 5

Mangement
Essential/initial components
- arrange MDT (oncology, gen surg, nursing, plastics etc)
- patient education

Supportive/if negative on investigation

• analgesia
• counselling, psychology referral
• ongoing review, reinforce need for ongoing screening
• reinforce breast self-examination

Definitive Mx options;
- hormone therapy for sensitive cancers (Herceptin, SERMs e.g. Tamoxifen)
- breast sparing (lumpectomy + radiation)
- mastectomy +/- reconstruction
- sentinel lymph node evaluation
- axillary lymph node dissection
+/- adjuvant chemo/radiation for each modality