• LUMP

A breast lump is the most common symptom of breast cancer. On clinical examination, It is described as having a defined border, as though someone has placed a “marble” within the breast, which in principle means that one could get a pen and draw a border around it. If one is able to conceive this impression, then there is a high likelihood that you are feeling a true lump, that is clearly defined. This is quite distinct from a nodular firmness where breast duct tissue undulates under the skin and feels irregular, but is continuous over a large area, which is part of normal breast tissue. 

Some people have firmer or more nodular feeling breasts based on one’s breast tissue density, or the amounts of firm breast ductal tissue compared to more fatty breasts, that feel softer. It is important to be breast aware, and to perform breast self examination. 

Breast examination can be performed in the shower using the flat of the hand as though one is feeling from the skin downwards, comparing this to pressing down onto a mattress, that varies in consistency. A firmer nodular breast feels like the “cobbles in a street”, and is mostly in the upper central and outer breast areas. The softer fatty breast areas are in the lower central breast where there is much less ductal tissue. 

A lump can be found in the breast, close to the armpit area, or in the armpit.

Most perceived lumps are not cancerous. Normal benign lumps may comprise a benign fibroadenoma, that often occurs in puberty and is a benign developmental lump. Breast cysts are common and relate to the sudden awareness of a new lump, that arises based on normal age-associated changes that occur in the breast ducts such as duct dilatation, with intraductal secretions that produce inflammation with debris that blocks microscopic ducts to produce a fluid filled cavity or cyst.

Other benign or normal lumps vary from a fatty lipoma (benign fatty lump with a border), injury related fat necrosis, a developmental hamartoma (encapsulated “breast within a breast”), a milk filled cyst or galactocele that occurs during pregnancy, or an infected cyst or abscess that is associated with inflammation.  

All perceived lumps however, need to be clinically checked to rule out cancer.

• NIPPLE CHANGE

Nipple changes that are indicative of a cancer:

Inverted or permanent indrawing of the nipple and/or the surrounding areola is clinically concerning. If this change is accentuated when one raises your arms, this increases concern.

A cancer produces an inflammatory reaction (part of one’s immune defence), that increases tissue scarring, and pulls in adjacent tissues with it, to permanently dimple or indent the nipple. This may be visible as a nipple depression or distortion of the breast.

Nipple Eczema must be differentiated from eczema of the areola.

Nipple Eczema that is indicative of a cancer:

Eczema that starts on the nipple is concerning, and should be distinguished from eczema of the areola, where areolar eczema is part of a skin condition, and merits a referral to a Consultant Dermatologist.

Persistent and erosive eczema of the nipple only, of which the signs are itching, scaling, red or raised plaques and discharge from the nipple, may indicate Paget’s disease of the nipple. Paget’s disease of the nipple is rare, and usually occurs in older women. It may be isolated to the nipple, presenting as a clinical stage 0 breast cancer, or Ductal Carcinoma in Situ (DCIS).

Any nipple changes as described above, should be checked by a Doctor or a Consultant Breast Specialist.

• NIPPLE DISCHARGE

Nipple Discharge that may be normal :

Normal nipple discharge can be intermittent, spontaneous, and straw coloured, with discharge that varies in its volume. Breast ducts open microscopically onto the skin of the nipple.

Breast ducts are channels that are lined by breast duct epithelial cells, and are responsive to hormonal stimulation by oestrogen, progesterone, and prolactin (milk producing hormone). Normal factors that raise these hormones are the: contraceptive pill, pregnancy, breast feeding, HRT, IVF, and antidepressants that (secondarily) raise prolactin levels. These factors can lead to normal or physiological nipple discharge.

Breast ducts age after pregnancy, and breastfeeding, with contributions by individual genetic factors. This results in breast duct wall thinning, with duct dilatation, leading to stagnation of secretions within ducts. These changes are called ductal ectasia or prominent ductal dilation, that can produce normal nipple discharge. 

It is important that women are not alarmed by this change, but should still seek the expert advice at a One-Stop breast clinic. 

Nipple Discharge that maybe abnormal:

Excess milky nipple discharge is called galactorrhea, and is defined as an increased volume and frequency of milky nipple discharge in the non-lactational breast. It is important to exclude commonly occurring contributors such as drug induced galactorrhea, that is secondary to  antidepressants or selective serotonin uptake inhibitors (SSUIs), that increase serotonin in the brain, and also increase blood prolactin levels. A number of sedatives and antipsychotics may also produce this effect.

Excess breast stimulation is another factor that emulates the milk duct reflex (eg. similar to when the baby breast feeds), and produces increases in the milk producing hormone, called prolactin.

Other conditions of the pituitary gland called a benign adenoma (or growth), may produce significant increases in prolactin levels. A suspected prolactinoma is diagnosed on a CT scan or an MRI of the brain.

       Excess milky nipple discharge in the non-breastfeeding breast should be assessed by a breast specialist in a one stop clinic 

Nipple discharge bloody

(not breast milk) / (other than breast milk)

This presentation is clinically concerning and should always be reviewed by a breast specialist in a one stop triple assessment clinic. However, bloody nipple discharge is frequently benign. Often there is no clear lump or change on mammograms.

It is important to exclude abnormal breast cancer cells within a microscopic duct called ductal cancer in situ (DCIS). This may present with breast calcifications on the mammogram, or is challenging to see in the area directly behind the nipple, where abnormal cellular changes are often mammographically occult (not seen on imaging). Breast ultrasound of the ducts under the nipple is key in demonstrating a focal lesion that can be biopsied, such as a papilloma or polyp like lesion within a breast duct. Any focal area of abnormality will undergo an image guided biopsy.

The positive predictive value for detecting malignancy for an abnormality found on mammography was 53.5%, and for ultrasonography, it was 65.2%. The role of cytology (cellular analysis of the fluid) in detecting malignancy was inconclusive, and is generally unreliable.

Breast MRI is important to complement a mammogram and ultrasound findings, and is indicated before any surgical excision. Clinicians must endeavour to diagnose the cause of the bloody nipple discharge before any surgery intervention such as benign inflammatory changes may also produce a bloody nipple discharge secondary to secretions and inflammatory debris that collects within dilated ducts called ductal ectasia. MRI guided vacuum biopsy is important where there is a specific type of enhancement.

In some cases, the cause for galactorrhea may not be found, and is called idiopathic.  

It is important to identify potential causes, and to measure blood prolactin levels, where high prolactin levels can be treated with a drug called Cabergoline.

   Bloody nipple discharge is mostly benign, but requires triple assessment with examination, mammogram, ultrasound and breast                                                                                                         MRI guided biopsy of any lesion.

• BREAST SKIN INDENTATION  

A cancer produces an immune response by the body that results in inflammation and causes a secondary fibrosis or tissue scarring. This scarring pulls in or distorts surrounding tissues. This can be subtle and may appear as a temporary skin indentation or shadow, when you compress the skin between two fingers, or elevate the arm.

In principle, one may miss this symptom, therefore if you think you can feel a lump, try and assess whether you think there may be a skin shadow or indentation, when performing the above steps.

Skin indentation remains an important sign even in the absence of a lump. You should always seek a Specialist Breast Cancer Consultant’s advice at a symptomatic One-Stop clinic, undergoing a thorough clinical examination and comprehensive breast imaging.