Assessing a Breast Lump

Introduction

A breast lump is one of the commonest presentations in general practice and in a surgical clinic, and the great majority are benign. The purpose of a bedside assessment is therefore not to make the diagnosis - no combination of history and examination is accurate enough for that, which is precisely why triple assessment exists - but to answer two narrower questions: does this person need an urgent cancer referral, and what exactly am I feeling?

The second question matters more than students expect. A lump described as a 2 cm smooth, mobile, non-tender mass in the upper outer quadrant of the left breast, 4 cm from the nipple, with no skin or nipple change and no palpable axillary nodes allows the next clinician to know whether anything has changed. A lump described as a lump does not.

This article covers the clinical method. The specific conditions are dealt with in the articles on breast cancer, on fibroadenoma and breast cysts, and on mastitis and breast abscess.

The differential diagnosis by age

Age is the single most useful piece of information before you touch the patient, because the prior probability of each diagnosis changes so sharply across the decades.

History

The lump itself

• When and how it was noticed - found incidentally, on self-examination, or after trauma
• Has it changed in size since it was noticed, and does it change with the menstrual cycle - cyclical change favours a benign cause
• Is it painful, and is the pain cyclical, constant or related to anything. Pain is not a useful discriminator: most cancers are painless, but so are most benign lumps.
• Are there other lumps, in the same or the other breast
• Any previous breast lumps, biopsies or operations, and what the results were

Associated breast symptoms

• Nipple discharge - ask about colour, whether it is from one duct or several, whether it is spontaneous or only on expression, and whether it is blood-stained. Spontaneous, single-duct, blood-stained discharge is the pattern that concerns.
• Nipple changes - new inversion, retraction, deviation, or an eczematous change suggesting Paget disease
• Skin changes - dimpling, tethering, peau d'orange, erythema or ulceration
• Axillary lumps or swelling of the arm

Risk factors and background

• Reproductive history - age at menarche and menopause, parity, age at first pregnancy, and duration of breastfeeding
• Hormonal exposure - current or previous HRT and combined oral contraception, and how long for
• Family history - ask specifically about breast, ovarian and prostate cancer, the ages at diagnosis, whether disease was bilateral, whether any male relative was affected, and about known BRCA mutations in the family. Draw a pedigree if the history is significant.
• Previous chest irradiation, particularly for lymphoma in adolescence
• Smoking, alcohol and body mass index
• Whether she is in the screening programme, when her last mammogram was and what it showed
• Symptoms of metastatic disease - weight loss, bone pain, breathlessness, jaundice, headache or new neurological symptoms
• Ideas, concerns and expectations. Almost every patient is afraid of cancer, and naming that explicitly changes the tone of the consultation and makes the rest of the history easier to take.

Examination

Breast examination is an intimate examination. Offer a chaperone, document that one was offered and whether it was accepted, and record the chaperone's name. Explain what you are going to do, obtain consent, ensure privacy and warmth, and expose the patient from the waist up only for as long as necessary.

Inspection

Sit the patient at about 45 degrees or upright, and inspect in four positions. Each one is looking for a different thing.

1. Arms by the sides - baseline symmetry, size, contour, scars, visible masses, skin changes, nipple position and any obvious erythema or ulceration
2. Arms raised above the head - stretches the skin and reveals tethering and dimpling that is invisible at rest, and shows the inframammary folds and the axillary tails
3. Hands pressed firmly on the hips - contracts pectoralis major and demonstrates fixation to the chest wall, in which the lump becomes less mobile or the skin puckers
4. Leaning forward - allows the breasts to fall free, showing asymmetry, tethering and any mass that is otherwise concealed, and is particularly useful in larger breasts

Palpation

1. Lie the patient at 45 degrees with the hand behind the head on the side being examined, which flattens the breast against the chest wall
2. Examine the normal breast first, then the symptomatic one
3. Use the flat of the fingers in a systematic pattern covering all four quadrants, the axillary tail of Spence, the areola and the nipple, with no area left out. Concentric circles, radial spokes or vertical strips are all acceptable as long as the method is consistent.
4. When a lump is found, characterise it fully - site (quadrant and distance from the nipple), size in centimetres, shape, surface, consistency, edge definition, tenderness, fluctuance, and temperature
5. Assess mobility: whether it moves freely within the breast, whether it is tethered to the skin (skin dimples when the lump is moved), and whether it is fixed to pectoralis major (mobility reduces when the patient presses on their hips)
6. Gently express the nipple if discharge is reported, noting colour and whether it comes from a single duct
7. Examine the axilla - support the patient's arm with your own so the muscles relax, and palpate the anterior, posterior, medial, lateral and apical groups. Then examine the supraclavicular fossae.
8. Complete the examination - chest for effusion, abdomen for hepatomegaly and ascites, spine for tenderness, and a brief neurological assessment if metastatic disease is a possibility

Investigation: triple assessment

Patients referred with a breast lump are seen in a one-stop clinic where all three components are performed at the same visit, and the results discussed the same day where possible. Each component is scored independently on a five-point scale prefixed by the modality.

• Imaging - ultrasound alone under 40, because dense glandular tissue makes mammography insensitive and the radiation dose is best avoided; mammography plus ultrasound at 40 and over. MRI is added for lobular cancers, implants, very dense breasts and when planning breast-conserving surgery.
• Pathology - core biopsy is preferred because it distinguishes invasive from in situ disease and provides tissue for oestrogen, progesterone and HER2 receptor testing. Fine needle aspiration cytology cannot do either, and is now mainly used to aspirate cysts and sample lymph nodes.
• A B3 result - a lesion of uncertain malignant potential such as a radial scar, atypical hyperplasia or a papillary lesion - is not a benign result. It requires multidisciplinary discussion and usually vacuum-assisted excision or open excision.
• Discordance is an abnormal result. A B2 biopsy of a P5, M5 lesion means the biopsy missed the lesion, not that the lesion is benign. It must be re-sampled.

Particular situations

A breast lump in a man

The distinction to make is between gynaecomastia - proliferation of glandular tissue producing a concentric, rubbery, often tender swelling centred on the nipple, frequently bilateral - and carcinoma, which is typically a hard, eccentric, painless mass away from the areola, sometimes with skin or nipple change and axillary nodes. Pseudogynaecomastia is fat alone in an obese man, without a palpable disc of glandular tissue.

• Physiological gynaecomastia occurs in neonates, in puberty and in older men, and usually resolves without treatment
• Drug causes are a long and frequently examined list - spironolactone, digoxin, cimetidine, ketoconazole, finasteride, anti-androgens, calcium channel blockers, antipsychotics, anabolic steroids, cannabis and alcohol
• Pathological causes - chronic liver disease, hyperthyroidism, chronic kidney disease, hypogonadism, Klinefelter syndrome, and hCG-secreting tumours of the testis, lung or liver. Examine the testes in every man with gynaecomastia.
• Investigate with LFTs, U&Es, TFTs, testosterone, LH, FSH, oestradiol, prolactin and hCG where a pathological cause is suspected
• Refer a man aged 50 or over with a unilateral firm subareolar mass with or without nipple change on a two-week wait pathway¹

Pregnancy and lactation

The physiological changes of pregnancy make examination and imaging harder, and this contributes to the later stage at which pregnancy-associated breast cancer is often diagnosed. Do not attribute a persistent discrete lump to pregnancy. Ultrasound is safe and is the first-line investigation; mammography with abdominal shielding is also acceptable where needed. Refer through the same pathway as anyone else.

Breast implants

Implants obscure breast tissue on mammography, so specific views and often MRI are needed. New swelling or a seroma around an implant years after insertion should prompt referral to exclude breast implant-associated anaplastic large cell lymphoma, a rare entity associated with textured implants.

Referral and communication

How the referral is framed matters. Patients should be told that the two-week pathway is used to investigate symptoms quickly and that most people referred do not turn out to have cancer, but they should not be told there is nothing to worry about, which is both untrue and undermines their trust when a diagnosis follows. Give a clear explanation of what will happen at the clinic: examination, imaging and probably a biopsy, all on the same day, with results often available at the same visit.

Where a diagnosis of cancer is given, it is done in a face-to-face consultation with a breast care nurse present, with time set aside, and with written information and a point of contact provided. The nurse is not an optional extra; continuity through a breast care nurse specialist is one of the most consistently valued parts of the pathway.²

Outcomes

Around 90% of lumps referred to a one-stop breast clinic turn out to be benign, and the majority of patients are reassured and discharged at the first visit. That figure is worth knowing because it is what makes the two-week wait pathway tolerable: the system is designed to accept a very large number of benign referrals in order to catch the cancers early.

For the minority who do have cancer, the assessment described here is the first step of a pathway whose outcome is largely determined by stage at diagnosis, and stage at diagnosis is largely determined by how quickly the patient reached the clinic. The chain runs from the patient noticing a change, through a clinician taking it seriously, to a referral being made on the right pathway - and the weakest links are usually the first two.

The practical conclusion is that the value of a good breast examination lies less in what it excludes than in what it documents and what it triggers. Describe the lump precisely, apply the referral criteria as written, do not let a benign impression override them, and tell the patient honestly what happens next.