Course:PostgradFamilyPractice/ExamPrep/99 Priority Topics/Breast Lump

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Breast Lump - Key Features

1. Given a well woman with concerns about breast disease, during a clinical encounter (annual or not):
a) Identify high-risk patients by assessing modifiable and non-modifiable risk factors
b) Advise regarding screening (mammography, breast self- examination) and its limitations.
c) Advise concerning the woman’s role in preventing or detecting breast disease (breast self-examination, lifestyle changes).

2. Given a woman presenting with a breast lump (i.e., clinical features):
a) Use the history, features of the lump, and the patient’s age to determine (interpret) if aggressive work-up or watchful waiting is indicated.
b) Ensure adequate support throughout investigation of the breast lump by availability of a contact resource.
c) Use diagnostic tools (e.g., needle aspiration, imaging, core biopsy , referral) in an appropriate manner (i.e., avoid over- or under-investigation, misuse) for managing the breast lump.

3. In a woman who presents with a malignant breast lump and knows the diagnosis:
a) Recognize and manage immediate and long-term complications of breast cancer.
b) Consider and diagnose metastatic disease in the follow- up care of a breast cancer patient by appropriate history and investigation.
c) Appropriately direct (provide a link to) the patient to community resources able to provide adequate support (psychosocial support).

RF’s:

o Female
o Increases with age
o +Fhx: 1st degree relative =2x risk, 3rd degree=4x
o Personal or +FHx breast or ovarian Ca esp before age 40
o Previous breast bx
o High breast density
o Nullparity; 1st preg>30y.o
o Radiation exposure
o >5yrs HRT
o Breast cancer risk assessment calculator available at http://www.cancer.gov/bcrisktool/



Protective factors

o Pregnancy before age 30
o Fewer years menstruating
o Lactation

Note promotion of overall healthy lifestyle and women’s health promotion; obesity, alcohol

Red Flags

o Unilateral non-cyclical pain
o Unilateral nipple discharge; watery, serous, serosanguineous, single duct
o Breast mass: unilateral, hard, immobile, noncystic, skin retraction, dimpling or edema (peau d’orange)
o Hx: postmenopausal, previous hx cancer, fhx breast ca

Screening

o Genetic screening
• BRCA1/2 if +breast AND ovarian ca
• Strong fhx of br and ovarian ca (Ashkenazi Jew)
• Fhx male br ca
• <35y/o
o Mammography q1-2yrs-new guideline age 50-69 rather than 40-79
• Start 10yrs earlier of first age of Br Ca in first degree relative
o Breast self-exam no longer routinely advised

Investigation of breast cancer

o U/S→cystic vs solid
o MRI-high sensitivity poor specificity
o Galactogram/ductogram for nipple d/c – ductal lesions
o Metastatic work up as indicated – bone scan, abdo u/s, cxr, head CT (or CT chest/abdo/pelvis)
o Diagnostic mammogram always indicated even if <50y/o

Diagnosis

o Needle aspiration if palpable, cystic; send for cytology if blood or cyst doesn’t completely resolve
o U/S or mammography guided core needle bx (most common)
o Fine needle aspiration (FNA) for palpable solid masses, need experienced practioner
o Excisional bx- only as 2nd choice to core needle bx

DDx for breast mass:

o Benign
• Non proliferative: fibrocystic change, cystic mastitis, mammary dysplasia
• Proliferative - no atypia
• Fibroadenoma, intraductal papilloma, ductal hyperplasia without atypia
• Proliferative – with atypic
• Atypical hyperplasias
• Others - Fat necrosis, mammary duct ectasia, Montgomery tubercle, abscess, galactocoele, silicone implant, Granulomatous mastitis (TB, Wegners, sarcoidosis)
o Breast Cancer
• Non-invasive: ductal in-situ, lobular in-situ
• Invasive: ductal, lobular, Paget’s disease, inflammatory ca, male br ca, sarcomas, lymphomas, others (papillary, medullary, mucinous)

Complications of breast cancer

o Mets: bone>lungs>pleura>liver>brain
o Biopsychosocial
o Treatment or surgical S/E, body changes, fertility, family inheritance implications
o Bone health

Resources and support for patient
Provide contact info for patient while undergoing diagnosis and treatment
Supportive care for patient throughout experience

Study Guide

Breast Lump

Resources

http://www.cmaj.ca/content/suppl/2007/06/14/158.3.DC1#physicians
http://www.bcmj.org/sites/default/files/BCMJ_50Vol4_breastcancer.pdf
http://www.cmaj.ca/content/suppl/2005/07/15/172.10.1319.DC1/cpg9patient-final.pdf
http://www.cmaj.ca/content/183/17/1991
Toronto Notes –gen surg section