One-page cheat sheet
The breast lump
Triple assessment for every lump
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Triple assessment
- Clinical examination
- Imaging: ultrasound under about 40; mammography plus ultrasound at 40 and over
- Core biopsy of the lump; ultrasound ± biopsy of abnormal axillary nodes
- All three must agree; if not, sample again
Benign lumps
- Fibroadenoma: young, smooth, very mobile
- Cyst: 40s–50s; aspirate, investigate if bloody or a lump remains
- Fat necrosis after trauma; duct ectasia; intraductal papilloma (bloody discharge)
- Lactational abscess: aspiration and antibiotics; keep breastfeeding
- Phyllodes tumour: rapid growth, wide excision
Red flags for cancer
- Hard, irregular, fixed lump
- Skin tethering, peau d’orange, new nipple retraction
- Bloody nipple discharge; axillary node
- Paget’s disease: unilateral eczema starting on the nipple
Cancer: principles
- Breast-conserving surgery (wide local excision) plus radiotherapy, or mastectomy
- Axilla: sentinel node biopsy if clinically and radiologically node-negative
- ER positive: endocrine therapy (tamoxifen before menopause, aromatase inhibitor after)
- HER2 positive: trastuzumab; chemotherapy by risk; neoadjuvant for HER2+ and triple-negative
Referral and screening
- Urgent suspected-cancer referral: 30 or over with an unexplained lump; 50 or over with nipple changes (NICE NG12)
- UK screening: mammography every 3 years, age 50 to 71
Exam pearls
- Male breast lump: gynaecomastia (drugs, liver) vs cancer
- Inflammatory cancer can look like mastitis: biopsy if it does not settle
- Always examine both breasts and both axillae