1) The document discusses the approach to evaluating a patient presenting with a breast lump, including obtaining a thorough history, conducting a physical examination, and ordering appropriate investigations. 2) The differential diagnosis for a breast lump includes benign conditions like fibrocystic disease, cysts, and fibroadenoma, as well as breast cancer. 3) Treatment depends on the diagnosis, with benign lumps often excised for confirmation, while malignant breast cancer may require total mastectomy or lumpectomy along with further treatment and follow-up testing.

1. Approach to a
Patient with
BREAST LUMP
Presented by:
Dr. Sara Khalid Memon,
House Officer, SU 3

3. Lets Revise the
BASICS … !!

5. How to APPROACH??
By History
By Examination
By Investigation

7. What to ask in HISTORY ?
Biodata
Presenting complain with its duration
All questions of breast lump (when and how
first noticed, Pain, tenderness, change in size
over time and with menstruation.)
Associated symptoms (discharge, any other
swelling, skin changes, body aches, etc)

8. Other Important Headings like
Gynecologic History : Parous state, breast feeding, last
period, drugs (HRT)
Past Medical History : benign breast disease, breast cancer,
radiation therapy to breast
Past Surgical History: breast biopsy, lumpectomy,
mastectomy, hysterectomy, oophorectomy.
Family History : Especially in first degree relatives.
Constitutional Features : - Anorexia - weight loss -
Respiratory Symptoms - Bone Pain

9. Examination
INSPECTION
 Site
 Size
 Shape
 Extent
 Skin changes (Redness, dimpling, edema, ulceration,
Peaud orange)
 Discharge
 Nipple (everted or inverted, crusted, ulcerated)
 Prominent Veins
 Any other lump in vicinity

10. PALPATION
Size
Position
Extent
Mobility
Composition ( Fluctuant, Hard, Rubbery )
Fixation to underlying tissue or skin

11. What could
be the
cause of
this
LUMP??

12. DIFFERENTIAL DIAGNOSIS OF BERAST
LUMP
FIBROCYSTIC DISEASE
CYSTS
FIBROADENOMA
FAT NECROSIS
PAPILLOMA
BREAST CANCER

15. INVESIGATIONS
oBaseline Investigations
(CBC, RBS, Xray Chest, Ultrasound Abdomen,
HbsAg and Anti HCV, Serum urea creatinine and
electrolytes)

16. Specific Investigations
oMammography
oU/S Breast
oBiopsy of the Lump
oMagnetic Resonance Imaging
oCytology
oImaging for metastases

17. Mammography
o Indications
• screening – every 1-2 years for women ages 50-69.
• metastatic adenocarcinoma of unknown primary.
• nipple discharge without palpable mass.
o Mammogram findings indicative of malignancy
• stellate appearance and spiculated border - pathognomonic of breast cancer.
• microcalcifications, ill-defined lesion border.
• lobulation, architectural distortion
NOTE:• normal mammogram does not rule out suspicion of cancer, based on
clinical findings.

20. Ultrasonography
o Best initial test in women less than 35
years of age with breast Lump
o Performed primarily to differentiate
cystic from solid lesions.
o Not diagnostic

21. Biopsy of the Lesion
o The diagnosis of breast cancer depends upon examination of
tissue or cells removed by biopsy.
o The safest course is biopsy examination of all suspicious masses
found on physical examination and of suspicious lesions
demonstrated by mammography.
o The simplest method is needle biopsy, either by aspiration of
tumor cells ( fine – needle aspiration cytology) or by obtaining a
small core of tissue with a hollow needle.
o And by Open biopsy… ( incisional or excisional )

22. o Magnetic Resonance Imaging
• High Sensitivity for breast cancer
• Can demonstrate the extent of both invasive & non-invasive disease. • Determines
weather a mammographic lesion at the site of previous surgery is due to scar or
recurrence.
• The optimum method for imaging breast implants and detecting implant leakage or
rupture.
o Cytology
• Cytological examination of nipple discharge or cyst fluid may be helpful on rare
occasions.
• As a rule, mammography and breast biopsy are required when nipple discharge or cyst
fluid is bloody or cytologically questionable.
o Imaging for metastases
• Chest x-ray may show pulmonary metastases.
• CT scanning of liver and brain is of value only when metastases are suspected in these
areas.

23. LETS
TREAT
IT
NOW !!

24. Benign Breast Lumps !
o FIBROCYSTIC DISEASE
o FIBROADENOMA
o FAT NECROSIS
o PAPILLOMA
o FIBROADENOSIS-focal/diffuse nodularity
o GALACTOCOELE
o ABSCESS
o PERIDUCTAL MASTITIS-secondary to duct ectasia

25. Fibrocystic disease
o Benign breast condition consisting of fibrous and cystic
changes in breast.
• Age : 30-50 years
• Clinical Features - breast pain - swelling with focal areas of nodularity or
cysts - Frequently bilateral - varies with menstrual cycle
o Treatment
• If no dominant mass, observe to ensure no mass dominates. • For a
dominant mass, FNA • If > 40 years, mammography every 3 years • Avoid
xanthine-containing products (coffee, tea, chocolate, cola drinks) and
nicotine. • For severe symptoms – danozol (2- 3 months), or tamoxifen (4-
6 weeks)

26. Fibro adenoma
Most common benign breast tumour in women
under age 30.
• No malignant potential
• Clinical features – smooth, rubbery, discrete,
well circumscribed nodule, non-tender, mobile,
hormonally dependent.
• Management – usually excised to confirm
diagnosis

27. Fat Necrosis
Due to trauma (although positive history in only
50%).
• Clinical features – firm, ill-defined mass with skin
or nipple retraction, +/– tenderness.
• Management – will regress spontaneously but
complete excisional biopsy is the safest approach
to rule out carcinoma.

28. Papilloma
Solitary intraductal benign polyp.
• Most common cause of bloody nipple
discharge.
• Management – excision of involved duct

29. Breast Cancer
o Epidemiology
o Risk factors
o Pathology
o Staging (clinical & pathological)
o Metastasis
o Treatment
o Local/Regional Recurrence
o Prognosis

30. Epidemiology
• Most common cancer in women.
• Second leading cause of cancer mortality in
women.
• Most common cause of death in 5th decade.
• Lifetime risk of 1/9

31. Risk Factors
• Age - 80% > 40y.o
• Sex - 99% female
• 1st degree relative with breast cancer - Risk increases if relative was premenopausal.
• Geographic - highest national mortality in England and Wales, lowest in Japan.
• Nulliparity
• Late age at first pregnancy>30y.o
• Early menarche < 12; late menopause > 55
• Obesity
• Excessive alcohol intake, high fat diet
• Certain forms of fibrocystic change
• Prior history of breast ca
• History of low-dose irradiation
• Prior breast biopsy regardless of pathology
• OCP/estrogen replacement may increase risk

37. TREATMENT
Primary Treatment of Breast Cancer is..
• total mastectomy – removes breast tissue, nipple-
areolar complex and skin
• modified radical mastectomy (MRM) – removes
breast tissue, pectoralis fascia, nipple-areolar complex,
skin and axillary lymph nodes

39. Post Surgical Management
o Follow-up of post-mastectomy patient history
and physical every 4-6 months yearly
mammogram of remaining breast
o Follow-up of segmental mastectomy patient
history and physical every 4-6 months
mammograms every 6 months x 2 years, then
yearly thereafter
o When clinically indicated chest x-ray bone
scan LFTs CT of abdomen CT of brain

40. JAZAKALLAHU
KHAIR