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).


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

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


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


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

Toronto Notes –gen surg section