Breast tissue is normally lumpy and women commonly have premenstrual breast changes including generalised tenderness, lumpiness and nodularity, which recedes after menstruation. Nodularity may be generalised or localised and it may be difficult to differentiate a localised area of nodularity from a discrete breast lump. It should however be noted that particularly in younger women, breast cancer may present as an area of localised nodularity. Further assessment is required for any new discrete lump, a new lump within pre-existing nodularity or asymmetrical nodularity that persists after menstruation.
Many women develop one or more breast lumps during their lifetime. Whilst the finding of a lump is very distressing, the majority are due to benign breast disorders and only a minority are due to carcinoma of the breast. A lump larger than 1 cm in size is usually palpable, although some are missed until they are much larger.
The clinical approach to breast lump assessment uses a triple approach combining clinical examination, imaging and fine needle aspiration cytology (FNAC) and/or needle core biopsy. This combined approach gives a diagnostic accuracy exceeding 99%.
The history should include when and how the lump was discovered, whether it has grown and whether there have been any previous lumps. Other important aspects include a family history of breast cancer (including the number of first- and second-degree relatives affected and their age at diagnosis), history of oestrogen usage, including the combined oral contraceptive pill or hormone replacement therapy, pregnancy history and history of breast feeding. A menstrual history including the date of last menstrual period should also be documented.
Inspection of the breasts starts with the woman sitting upright with her arms to the side and then raised above her head. The symmetry of the breasts and evidence of any skin changes (see Table 10.1) should be noted. The breasts should be palpated (normal breast first) examining each quadrant in turn. Both axillae should be palpated for lymph nodes.
· A firm discrete lump with no associated skin features in a younger woman is most likely to be a fibroadenoma.
· A cyst may be soft, firm or tense and hard. It is generally spherical.
· Signs suggestive of a malignant lump include hard texture, poorly defined edges and fixation to skin or underlying tissues. There may be associated lymphadenopathy or bloody nipple discharge. Skin changes suggestive of malignancy are given in Table 10.1.