Breast Lumps

Do not panic if you discover a breast lump, particularly if you are young (less than 40 years old) and you do not have a family history of breast or ovarian cancer. A breast lump is more likely to be benign (non-cancerous) than malignant (cancer). Only 10% of breast lumps seen by doctors in breast clinics are cancers. However, if you find a breast lump do not delay in consulting your doctor!

What Causes Breast Lumps?

Common causes of lumps in the breast are shown in the table below:

Simple cysts (benign)	Fibrocystic disease (benign)	Fibroadenoma	Breast cancer (malignant)
• Fluid-filled bag • Drained with needle	• Small cysts + hard lumps • Variation of normal breast • Caused by female hormonal activity • Common in 30–40 years	• Hard, smoothlump • Very mobile • Common in 20–30 years • Common in Afro-Caribbean women	• Hard, irregular • May be fixed to chest • With or without puckered skin • With or without nipple drawn in • With or without discharge

What Happens at the Breast Clinic?

Remember only 10% of patients referred with breast lumps turn out to have breast cancer, so if you are referred, do not panic! The breast specialist will ask you questions to help determine the likely nature of the lump.

• When did you first notice the breast lump?
• Has the lump changed in size?
• Is there any associated pain?
• Is there discharge from the nipple? If yes, what colour is it?
• Did any of your relatives have cancer of the breast or ovary?
• Do you have any children? If yes, how old were you when you had your first child and your last pregnancy?
• At what age did your menstrual periods start?
• How long ago was your last menstrual period?
• Are you taking (or have you ever taken) either the contra-ceptive pill or HRT?
• Have you had a previous breast biopsy?

The specialist will then proceed to examine your breasts and armpits. After that, the specialist will decide on whether there is any abnormality of the breast that requires further investigation. If the specialist finds a lump in the breast, he/she will arrange the following tests.

Fine-needle Biopsy

The doctor is able to obtain a small quantity of cells (biopsy) from the breast lump by inserting a thin (or fine) needle attached to a syringe. Inserting a needle in the breast causes mild discomfort, similar to that experienced when having a blood test, and occasionally causes slight bruising of the breast that fades away in a few days. This test is also called fine needle aspiration cytology and the procedure is shown in Figure 4.

The cells obtained from the biopsy are stained with special dyes and then looked at under the microscope by a specialist, called a cytologist. The cytologist will decide whether the cells have any abnormal features that may indicate that they are cancerous. In practice, the cells are assessed (or graded) from C1 to C5 (Table below).

Cytology grade	Meaning
C1 C2 C3 C4 C5	Sample inadequate for testing Normal breast cells Cells abnormal but more likely to be benign Highly suspicious of cancer Cancer cells present

The accuracy of this test depends upon the breast specialist obtaining a sample from the lump, and upon the cytologist accurately grading the cells under the microscope. If the test is positive (i.e. grade C5) then it is almost certain (99.5%) that the lump is a cancer. However, a negative test (i.e. grade C2) does not exclude the possibility of cancer but merely makes the diagnosis of cancer less likely. If the needle biopsy result is graded C1, it usually implies the sample was inadequate for analysis and the test should be repeated.

Breast Nodularity

Nodularity refers to the presence of multiple, small lumps in the breast. It can occur in one area of the breast (localised) or throughout the breast (generalised). Nodularity is one of the most frequent reasons for referring a woman to the breast clinic. In fact, pre-menstrual nodularity is normal.

Generalised Nodularity (Lumpiness)

Women with generalised nodularity are examined by the breast specialist who usually arranges a mammogram if the woman is over 35 years old. If no discrete lump is detected and the mammogram does not reveal any suspicious abnormalities, the patient can be reassured and discharged. The condition is entirely harmless and has no relationship to breast cancer.

Localised Nodularity

It can be very difficult to distinguish localised nodularity from a discrete breast lump. So in such cases, an ultrasound examination is often required to exclude a discrete lump. If no discrete lump is found by ultrasound scan or if the mammogram (for women over 35 years) does not reveal any significant abnormalities, the patient can be reassured and discharged. Any discrete lumps detected should be investigated and treated appropriately.
Localised nodularity may be related to hormones and it usually becomes less prominent with age or upon stopping HRT.