Breast Lump

What If You Find a Breast Lump?

Most breast lumps will turn out to be benign but they should all be investigated. Your first step is to see your GP and ask your GP for an opinion or a referral.

Either your GP or a Breast Specialist should then perform a Clinical Breast Exam and possibly arrange for breast imaging to be performed

A new breast lump (or breast change) should be investigated with the triple test. The triple test refers to 3 diagnostic components.

• Imaging - mammogram/ultrasound- this will tell you a bit more about the lump- is it fluid filled or solid or is it normal breast tissue? does it look benign or worrying?
• Biopsy - often a biopsy is recommended to give a definitive diagnosis of your lump. This can sometimes be a fine needle aspirate where a few cells are taken but more commonly a core biopsy where a tiny piece of the lump is taken. These pieces of tissue are sent to a pathology laboratory where a pathologist can tell you what the lump is.
• Consultation - back to the GP for the results of the tests- if necessary, your GP will send you to a breast specialist- for an opinion and management of the lump. However, here at The MBU we offer a One Stop service.

Medical History and Clinical Breast Examination 

What is a Clinical Breast Exam?

A Clinical Breast Exam is a physical exam of the breasts and the underarm area by your breast surgeon.

The purpose of a Clinical Breast Exam is to look at any:

• breast lumps, 
• breast changes or 
• breast abnormalities and warning signs

Men who find a lump or a change in their breasts should also have a Clinical Breast Exam.

Benefits of Clinical Breast Exams

Clinical Breast exams are an important part of early detection. Although most lumps are discovered through breast self-exams, a Clinical Breast Exam conducted by an expert may notice a suspicious place that fails to register as a warning in the patient’s mind.

What to Expect from a Clinical Breast Exam

You are asked to remove your clothing from the waist up and while on the examination table you are covered by a sheet or gown.

Visual Breast Examination

The Clinical Breast Exam starts with your doctor looking at the breasts while you are seated, standing and then when you are lying down. 

You may be asked to raise your arms over your head, let them hang by your sides, or press your hands against your hips. These postures allow your doctor to look for differences in size or shape between your breasts.

Your doctor is looking for:

• changes or differences in the shape of the breasts
• areas of fullness or thickness in only one breast
• differences in skin colour, (redness),
• differences in the texture of the breasts or rashes,
• dimpling, visible lumps or swelling of the skin
• differences in temperature or increased skin warmth
• fluid, or discharge, leaking from the nipple
• nipple changes, such as a nipple starting to point inward  (called inverted) or scaling

Physical Breast Examination

Next, the doctor needs to feel or palpate, the breasts and the nipples. 

Breast tissue covers a large area, it goes from the middle of the chest into the armpit and up toward the collarbone and deep inside to the muscles of the chest wall. 

The Physical Breast Exam is done while you are lying down; this position enables the breast tissue over the chest wall to flatten. 

Your doctor will examine the entire area and will need to use some pressure to assess deeper tissue.

Your doctor uses firm pressure with their fingers to feel for:

• lumps, including their size, shape and whether or not they move within the tissue
• hardening or thickening in the breast tissue
• tenderness or pain

Your doctor will also feel lymph nodes in 

• the underarm area (called the axilla) and 
• in the area above and below the collarbone for any lumps or hardening.

Preparation for a Clinical Breast Exam

Whether you have breast implants or not the same technique is used

You don’t need to do anything special to prepare for a Clinical Breast Exam. 

What Happens if an Abnormality is Found

If a lump is discovered, your doctor will note its size, shape, and texture. Your doctor will also check to see if the lump moves easily. Benign lumps often feel different from cancerous ones, but any lump found will likely need to be examined with further diagnostic measures.

The doctor will talk to you about anything that is found and let you know if further diagnostic tests are required.

It may be helpful to know that lumps that appear soft, smooth, round, and movable are likely to be either benign tumours or cysts. A lump that is hard and oddly-shaped and feels firmly attached within the breast is more likely to be cancer, but further tests are needed to diagnose the problem.

Imaging 

• Under age 35: ultrasound is recommended as the first imaging modality. 
• 35 years and over: mammogram and ultrasound should both be performed. 
• In pregnancy or lactation: ultrasound is the most useful modality. 

Biopsy

• Fine needle aspiration biopsy can be used to confirm the diagnosis of a breast cyst or fibroadenoma. 
• Core biopsy is preferable for the investigation of suspicious lesions, as it can differentiate between in situ and invasive cancer. It can also provide additional information such as tumour type, tumour grade and receptor status. 

The tripe test is more accurate at detecting breast cancer than the individual components alone. When performed appropriately, the triple test will detect over 99.6% of breast cancers. A triple test negative on all components means breast cancer can be ruled out with 99% accuracy. An abnormal result (indeterminate, suspicious or malignant) on any component of the triple test requires referral to a breast surgeon. 

What Causes Benign of Breast Lumps? 

There are several types of benign breast problems, but in general, they are classified according to the predominant symptom as:

• Breast Lumps
• Breast Pain
• Nipple problems
• Infection of the Breast or Mastitis

Breast Cyst

A breast cyst is an accumulation of fluid within the breast. Breast cysts are most common in women between the ages of 30 and 50. 

It is not known what causes breast cysts. Breast cysts can be single or multiple and vary in size during the menstrual cycle. Cysts appear as lumps that are smooth, soft to firm, mobile, and sometimes tender and often of sudden onset. Breast cysts are harmless.

Breast cysts can result in a breast lump (usually smooth and mobile, sometimes tender) and nipple discharge (clear, yellow or dark brown).

Breast cysts are classified according to how they look on ultrasound, they appear as well-defined round or oval 'anechoic' (black) lesions.

• Simple cysts have smooth, thin, regularly shaped walls and are completely filled with fluid. They do not require treatment or follow-up. Cysts that are causing pain can be aspirated to reduce discomfort. Surgery (excision biopsy) is rarely recommended, only for cysts that recur after repeated aspiration or cysts that show worrying features on imaging or biopsy
• Complex cysts have irregular and thick walls and some evidence of solid areas and/or debris in the fluid.
• Complicated cysts are “in between” simple and complex. They share most of the features of simple cysts but tend to have some debris inside them. But they do not have the thick walls or obvious solid components that a complex cyst has.

Breast cysts do not progress to breast cancer and do not increase your risk of cancer. But it is important to continue to be breast aware and see your doctor if you notice any changes in your breasts, regardless of how soon these occur after your diagnosis of a breast cyst. 

Fat Necrosis

Fat necrosis occurs when an area of fatty tissue in the breast is damaged, usually after breast surgery, radiotherapy or trauma. Fat necrosis can result in a breast lump (usually firm, sometimes tender) and nipple inversion. 

Fat necrosis is harmless, and in most cases the body will break it down over a few months. It can be difficult to tell the difference between fat necrosis and breast cancer on clinical examination and on mammogram, so a biopsy may be required for diagnosis. Fat necrosis does not increase your risk of breast cancer.

Fibroadenoma

Fibroadenomas and Hamartomas are harmless lumps of glandular and fibrous tissue and often have a very specific feel to a breast surgeon together with a very particular look on ultrasound. Fibroadenomas do not increase the risk of breast cancer.

Fibroadenomas occupy 12% of all the symptomatic breast masses; most common in women aged 20 to 40 and with peak incidence in 21-25 year age group. In women over the age of 50 years, fibroadenoma occurs in less than 5% of the population.

It is not known what causes a fibroadenoma. It is thought that it probably occurs because of increased sensitivity to the hormone oestrogen.

Fibroadenomas can be single or multiple. If left alone, one third will decrease in size (or even disappear), one third will increase in size and one third will remain the same. 

Fibroadenomas can grow during pregnancy and breastfeeding or while taking hormone replacement therapy, but usually reduce in size again afterwards.

Fibroadenomas are usually present as a breast lump that is smooth and mobile, and sometimes tender. Fibroadenomas are referred to as ‘breast mice’ as their ability to move so freely gives the feeling that they are running away from the examining hand. 

Imaging for Fibroadenomas

Fibroadenomas can be detectable as a lump by

• Palpation
• Mammogram
• Breast ultrasound

Any suspected fibroadenoma either palpable or impalpable that shows atypical features on clinical or imaging assessment requires pathological diagnosis by Core Biopsy.

Surgery (excisional biopsy) is recommended for fibroadenomas that are painful, larger than 3 cm in size (or increasing in size) or show worrying features on imaging or biopsy. Fibroadenomas that are not removed are usually monitored with ultrasound for a period of time. 

Most fibroadenomas do not increase your risk of breast cancer. But it is important to continue to be breast aware and see your doctor if you notice any changes in your breasts, regardless of how soon these occur after your diagnosis of a fibroadenoma. 

Other Benign Tumours

Other benign tumours that may be found in the breast include     

• Intra-ductal Papilloma: is a benign wart-like tumour that grows inside the ducts of the breast. It is made up of glandular tissue as well as fibrous tissue and blood vessels.
• Lipoma: a tumour formed by the overgrowth of fat cells.
• Hamartoma: a tumour formed by the overgrowth of mature breast cells, and may contain fatty, fibrous and glandular tissue.       
• Hemangioma: a rare tumour made of blood vessels.
• Neurofibroma: a tumour formed by overgrowth of nerve cells.

None of these tumours increases your risk of breast cancer, but they may need to be biopsied or removed (excisional biopsy) for diagnosis and to be sure they do not contain cancerous cells.