Breast lumps

Introduction

A breast lump is any localized swelling, bump, or mass felt within the breast tissue. Lumps may be benign (non-cancerous) or malignant (cancerous).

• Benign breast disease is common, especially in young women.

• Malignant breast disease is more common in women over 40 but can occur at any age, and in men as well.

Because of the possible link to breast cancer, every breast lump must be taken seriously and evaluated by a healthcare professional.

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Causes of Breast Lumps

1. Benign Conditions

• Fibroadenoma

  • Commonest benign breast tumor, usually in young women (15–35 years).

  • Smooth, firm, mobile (“breast mouse”).

• Breast cysts

  • Fluid-filled sacs, common in women aged 35–50.

  • Can be tender, fluctuate with cycle.

• Fibrocystic changes

  • Nodular, “lumpy” breast tissue, related to hormones.

  • Painful before menstruation.

• Lipoma

  • Benign fatty tumor, soft and mobile.

• Intraductal papilloma

  • Small benign growth in duct, may cause nipple discharge.

• Abscess / mastitis

  • Infection, common in lactating women.

  • Presents with painful lump, redness, fever.

• Traumatic fat necrosis

  • After trauma or surgery. Firm, irregular lump that can mimic cancer.

2. Malignant Conditions

• Breast carcinoma

  • Hard, irregular, immobile lump.

  • Associated with skin dimpling, nipple retraction, lymph node involvement.

  • Risk increases with age, family history, BRCA mutations, obesity, HRT.

• Phyllodes tumor

  • Rare fibroepithelial tumor, can be benign or malignant.

• Metastases to breast (rare).

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Clinical Features

• Benign lumps: Smooth, well-defined, mobile, may be painful.

• Malignant lumps: Hard, irregular borders, fixed to skin/chest wall, usually painless, associated with skin/nipple changes.

• Associated signs:

  • Nipple discharge (bloody, purulent, serous).

  • Skin dimpling, redness, ulceration.

  • Enlarged axillary lymph nodes.

  • Systemic symptoms (weight loss, bone pain, fatigue in advanced cancer).

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Diagnostic Approach

1. History

• Age, menstrual/menopausal status.

• Duration, change in size.

• Cyclical variation.

• Family history of breast/ovarian cancer.

• Medication use (OCP, HRT).

• Associated pain, discharge, systemic symptoms.

2. Examination

• Inspection: asymmetry, skin/nipple changes.

• Palpation: lump size, shape, mobility, tenderness.

• Axillary and supraclavicular lymph nodes.

3. Investigations

• Triple assessment (gold standard):

  1. Clinical examination.

  2. Imaging:

     • Ultrasound (best for <35 years).

     • Mammography (best for >40 years).

     • MRI (complex cases).

  3. Pathology:

     • Fine-needle aspiration cytology (FNAC).

     • Core needle biopsy (preferred, gives tissue architecture).

• Blood tests: CBC, liver function, tumor markers (CA 15-3, CEA not reliable for diagnosis).

• Genetic testing: BRCA1/2 if strong family history.

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Management and Treatment

A. Benign Lumps

1. Fibroadenoma

   • Small, asymptomatic: observation.

   • Large/painful: surgical excision (lumpectomy).

2. Breast Cysts

   • Aspiration (needle drainage).

   • If recurrent: excision.

3. Fibrocystic Changes

   • Reassurance, supportive bra.

   • NSAIDs (Ibuprofen 400 mg orally every 8 h).

   • Hormonal: Tamoxifen 10 mg orally daily for 3–6 months in severe cases.

4. Mastitis / Abscess

   • Antibiotics:

     • Flucloxacillin 500 mg orally every 6 h × 7–10 days.

     • Clindamycin 300 mg orally every 6 h (if penicillin allergy).

   • Drainage if abscess.

5. Lipoma / Fat necrosis

   • Usually observation.

   • Excision if symptomatic or suspicious.

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B. Malignant Lumps (Breast Cancer)

Treatment depends on stage, type, hormone receptor status (ER/PR/HER2), and patient factors.

1. Surgery

• Lumpectomy (breast-conserving surgery) with sentinel lymph node biopsy.

• Mastectomy if large/multifocal or patient preference.

2. Radiotherapy

• Usually after lumpectomy to reduce recurrence.

3. Chemotherapy

• For node-positive or high-risk tumors.

• Common regimens:

  • Cyclophosphamide + Doxorubicin + Fluorouracil (CAF).

  • Docetaxel + Cyclophosphamide.

4. Hormonal Therapy

• For ER/PR-positive cancers:

  • Tamoxifen 20 mg orally daily (premenopausal).

  • Anastrozole 1 mg orally daily (postmenopausal).

5. Targeted Therapy

• HER2-positive tumors:

  • Trastuzumab (Herceptin) 8 mg/kg IV loading, then 6 mg/kg IV every 3 weeks.

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Complications

• Benign lumps: Recurrence, infection, anxiety.

• Malignant lumps: Metastasis (bone, lung, liver, brain), recurrence.

• Post-treatment: lymphedema, cosmetic deformity, chemotherapy side effects.

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Prognosis

• Benign breast disease: Excellent prognosis.

• Breast cancer: Prognosis depends on stage:

  • Stage I: >90% 5-year survival.

  • Stage IV: <30% 5-year survival.

• Early detection is key to survival.

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Patient Education

• Most breast lumps are benign, but evaluation is essential.

• Perform monthly breast self-examination.

• Get mammography screening as recommended (from age 40–50 depending on guidelines).

• Maintain healthy lifestyle (exercise, diet, limit alcohol, avoid smoking).

• Adhere to treatment and follow-up if diagnosed with breast disease.