Breast Cancer/Breast Lump

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QUESTION: Dear Dr Nordquist,

I wondered if I could please ask your advice.

I am 25 years of age and around 3 weeks ago I discovered a small lump in my right breast, just beneath the nipple.  The lump is about the size of the end of a cotton bud / cotton swab.  I wouldnít describe it as very hard, but itís not soft either.

When I discovered the lump, I thought there was a possibility it could be connected to my period.  As a result, I thought it would be best to see if it shrunk / disappeared after my next period before going to the doctors.

I came to the end of my period a few days ago and the lump is still there.  It is no smaller or bigger Ė just exactly the same as it was 3 weeks ago.  The lump is not at all painful.

I do not know if this is connected, but the skin on my nipple area (both left and right) is very itchy (and has been like this on and off for over a year).  It is also a little flaky.  I assumed that this itchiness was just being caused by dry skin and nothing to worry about, but since discovering the lump, Iím now worried that there may be a connection.

I am planning on booking an appointment to see my Doctor in the next few days to have it checked out, but I am worried about going.

Will the doctor know just by examination what is causing the lump or do you think I will have to be referred for testing?

If the lump was just a cyst / connected to my period, do you think that it would have disappeared by now?

I have Endometriosis, could this be in any way connected to the breast lump?

Thank you very much for your time

Ruby

ANSWER: You should definitely let your doctor check this. It may be nothing important or dangerous but we do NOT know that at present so it SHOULD be investigated. There is no certain connection with the state of your nipples and certainly not with your endometriosis. It is quite possible that further tests must be done after your visit to your doctor. That is part of the game and may be necessary to be sure.That is all that can be said at present. Good luck!

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---------- FOLLOW-UP ----------

Diagram showing location of breast lump
Diagram showing locati  
QUESTION: Dear Dr Nordquist,
I hope that you donít mind me asking you a follow-up question.  I e-mailed you for advice a number of weeks ago regarding a firm, painless lump in my right breast and you advised that I have this checked out by my GP.

I have since been to my GP and saw the nurse practitioner there.  Before examining me the nurse said that because of my age (26) and because I have a slim frame, she thought it was probably a rib I was feeling and mistaking it for a breast lump.

The nurse examined my breast and told me: ďThere is nothing untoward thereĒ and said there was no lump and it was probably just my rib I was feeling.  I felt 100% certain that it was not my rib I was feeling, so asked if I could please lie down on the bed (as itís much easier to feel the lump when Iím lying flat) and see if she could feel it that way.  The nurse felt again and said ďOh yes, there is a lump there, but itís so small!Ē  She then told me it was up to me what I wanted to do and that she could refer me to a breast clinic if I wanted to.

I asked if she could please refer me as the lump had been there for around a month (at the time of the appointment) and hadnít gone away or changed with my period.  As I was leaving the consultation room, the nurse said that the lump was ďprobably just a cystĒ.

Two weeks after my appointment with the nurse practitioner, I attended a breast clinic at my local hospital.  The doctor I saw examined by breasts and underarms and said that he wanted me to have an ultrasound of the lump.  He said that because the lump was small (about the size of the tip of a cotton bud) it may not show up on the ultrasound.  

When I went for the ultrasound, the lady carrying out the procedure said that she could certainly feel the lump, but could not pick it up on the ultrasound.  She said something to the effect of: ďIt might be a milk duct youíre feeling side on.  I canít see anything on the ultrasound so Iím going to write down ĎnormalíĒ.

I always thought that the milk ducts were actually inside the nipple Ė if Iím right in thinking this I canít understand how the lump can be a milk duct Iím feeling because my breast lump is not within the areola / it is not on or behind my nipple Ė itís about 1.5cms BENEATH the edge of the nipple (please see diagram attached).  

The lady did not say that she thought the milk ducts were swollen or anything Ė she seemed to be saying that the milk ducts were normal, but I might just feeling one of them side on.  I remember thinking that surely if the lump was just a milk duct, it would ALWAYS have been there and I would be able to feel the same in my other breast too?  The fact that the lump is new is something else which makes me feel certain that this canít be a milk duct Iím feeling?

After the ultrasound, I went back into the Doctorís office and he told me that my results were ďnormalĒ.  He did not mention anything about the lump being related to my milk ducts (as the lady who had carried out the ultrasound did).  I asked if there was any possibility that the lump could be a cyst and the doctor told me no because a cyst would have showed up on the ultrasound.  

I asked what he thought had caused the lump.  He told me that it would just be ďnodularityĒ caused by my periods.  But during my first meeting with him (before the ultrasound) I had specifically explained that I had had 2 periods since discovering the lump and the lump had stayed the same before during and after my period. (e.g. it did not appear to be hormone related).  

Before I left, the Doctor told me that if the lump grows I can arrange another appointment.

I thought I would be able to breathe a sigh of relief after being told my results were ďnormalĒ but I just feel so full of doubt Ė mainly because different medical staff are telling me very different things.  Iíve been told that the lump:

*isnít there (that itís my rib Iím feeling)

*is there but itís probably a cyst

*is not a cyst

*might be a milk duct Iím feeling side-on

*would just be nodularity being caused by my periods (even though the lump has remained the same before, during and after my period)

Since I havenít received a definitive diagnosis of the cause of the lump, Iím still quite worried Ė especially after reading all sorts on the internet about breast lumps not showing up on ultrasound but turning out to be cancer.

In your opinion, do you think that I should still be concerned about the lump?

If my lump is just down to nodularity, is it normal for a nodule to last 6+ weeks?

Do you feel that this could be a milk duct issue (the lump is around 1.5cms beneath the edge of my nipple)?

If the lump does not go away, how long should I leave it before returning to my GP?

Thank you very much in advance and apologies for such a lengthy question

Answer
You live in the UK and that complicates matters. In the NHS system of the UK you MUST seek help via your GP and your case is an illustration of the possible bad effects of that. All your questions are valid but unfortunately I can not answer them well since I have not examined you myself and can not do so for geographical reasons. You are 26 years old. At that age your risk of breast cancer is small but it is not 0. At your age breast tissues are usually rather dense which makes it difficult to use mammography as an examination method. Even so in my opinion once you have decided to do a thorough breast examination mammography should be included too! However due to the probable tissue density it is not enough. Ultrasound breast scans should also be used and if necessary also other methods. In your case we do have a palpable breast mass and its nature should be determined. Since ultrasound has not been of help (and mammography not done) we have to do other things! Mammography should be done as well as MRI breast scans! Since your mass is palpable a transcutaneous needle biopsy (fine/thin needle aspiration biopsy) guided by touch should also be attempted. If your mass can be seen on mammography a stereotactic needle biopsy could also be done guided by your mammograms. It is also possible to guide such biopsies by ultrasound (if anything is seen) or by MRI scans. Milk ducts are present in the whole glandular tissue volume of a breast. Not just in the nipple & areola area. Otherwis not all the milk would be able to come out. Breast milk glands are actually transformed sweat glands and sex hormone dependent. However how to get all the above done within the framework of NHS in the UK is beyond me. There you have to rely on your own ingenuity and cleverness. For your information. When I still worked - before I retired - and was running my own private practice here in Stockholm, Sweden, I routinely used all the diagnostic modalities described above (mmammography, ultrasound, MRI, needle biopsies). My fee for the whole procedure was roughly 55 £ of which the patient paid somewhat less than half and the rest was paid directly to me by the Swedish National Health Insurance. That Insurance also paid directly for the costs of mammography, ultrasound, MRI & needle biopsies. The patients could make their appointments with me directly. They did not need to go through their GP-s. In my opinion that was easier, simpler & more convenient especially for the patients. Right?

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Claes-Gustaf Nordquist, M.D.

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I`m a doctor of medicine and a specialist in radiation therapy and medical oncology. I have long experience in diagnostics and treatment of breast tumours.

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I'm a Doctor of Medicine and specialist in Medical Oncology and Radiation Therapy educated & trained in Sweden. Now retired. Background in Radiation Therapy, Medical Oncology, Radiation Protection, Nuclear Medicine, Diagnostic Radiology, Gynecological Oncology, Clinical Pathology, Clinical Cytology,Hematology and Internal Medicine. M.D. from the faculty of medicine, Royal Karolinska Institute, Stockholm, Sweden. Have also been an exchange student at the Hebrew University, Hadassah Medical School, Jerusalem Israel. Former medical consultant, Swedish National Board of Radiation Protection. Former Police Surgeon and Medical Examiner, Stockholm Police Department. Former Chief Medical Officer, The Royal Guards, The Royal Horse Guards and the Royal Household Brigade, Royal Swedish Army Medical Corps.You can also reach me on: http://www.lifestylerescue.com/expert/health-fitness-advice/dr-claes-gustaf/128 I have no restrictions on the number of questions there.

I also answer questions about Oncology (General Cancer), General History, Military History, Brain Tumors, Colon Cancer

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I'm a medical doctor and specialist in medical oncology and radiation therapy.

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