Breast Lump/nipple Discharge
A breast lump is a localized mass in breast tissue, and nipple discharge is fluid expressed from the nipple, both requiring evaluation to distinguish benign conditions (fibroadenoma, fibrocystic changes, duct ectasia) from malignancy.
Breast Lump / Nipple Discharge — History Taking
1. Focused Presenting Complaint — Breast Lump
The way you open matters. Begin with open questions, then funnel down.
| Question | Why it matters | Cantonese phrasing |
|---|---|---|
| "How did you first notice it?" | Self-exam vs incidental vs screening finding — affects likelihood of pathology | 你係點樣發現呢粒嘢㗎？(néih haih dím yéung faat yihn nī nāp yéh gaa?) |
| "How long has it been there?" | Chronic lumps more likely to be benign; rapidly enlarging lumps in days → abscess/expanding cyst, in weeks → carcinoma [1][2] | 呢粒嘢出咗幾耐？(nī nāp yéh chēut jó géi noih?) |
| "Was there any preceding injury or trauma?" | Fat necrosis classically follows trauma — mimics carcinoma on exam [2] | 之前有冇撞親過個胸？(jī chìhn yáuh móuh jong chān gwō go hūng?) |
| Question | Why it matters | Cantonese |
|---|---|---|
| "Is it one lump or more than one?" | Multiple bilateral lumps favour benign fibrocystic changes; a single dominant mass needs triple assessment [1][2] | 有一粒定幾粒？(yáuh yāt nāp dihng géi nāp?) |
| "Which breast? Where on the breast?" | 50% of CA breast occurs in the upper outer quadrant including the axillary tail [3] — laterality plus location needed | 邊邊胸？喺邊個位置？(bīn bīn hūng? hái bīn go wái ji?) |
| "How big is it roughly?" | Baseline size for monitoring | 大約幾大？(daaih yeuk géi daaih?) |
| "Has it been getting bigger?" | Progressive increase → malignancy or abscess [2] | 有冇越嚟越大？(yáuh móuh yuht lèih yuht daaih?) |
| "Does it change with your periods?" | Cyclical changes = more likely benign (fibrocystic changes, cysts) [1][2] | 會唔會隨住月經有變化？(wúih m̀h wúih chèuih jyuh yuht gīng yáuh bin fa?) |
| "Is it painful?" | Painful lumps more likely to be benign; carcinoma is usually painless [2] | 痛唔痛？(tung m̀h tung?) |
| "Have you had this before?" | Recurrent cysts are common; previous breast disease raises cancer risk [2] | 以前有冇試過？(yíh chìhn yáuh móuh si gwō?) |
Why pain is paradoxically reassuring
Most breast cancers present as painless lumps. Pain suggests cyst, fibrocystic change, abscess, or fat necrosis. However, inflammatory breast cancer and locally advanced disease can be painful — so pain alone never excludes malignancy.
"Is this the only lump, or have you felt any others — in the other breast, under your arms, or in your neck?"
- Contralateral lump: bilateral primary breast carcinoma is not uncommon [2]
- Axillary lump: may represent nodal metastasis
- Neck lump: supraclavicular lymphadenopathy = N3 disease
Cantonese: 除咗呢粒之外，另一邊胸、腋下或者頸有冇摸到其他嘢？(chèuih jó nī nāp jī ngoih, lìhng yāt bīn hūng, yihk hàh waahk jé géng yáuh móuh mō dóu kèih tā yéh?)
2. Focused Presenting Complaint — Nipple Discharge
Three key gateway questions — commit these to memory [2][4]:
(1) Is it truly from the nipple? (2) Is it pathological? (3) Any recent pregnancy / breastfeeding?
| Question | Why it matters | Cantonese |
|---|---|---|
| "How did you notice the discharge — staining on your bra or seeing fluid from the nipple itself?" | Some patients mistake skin exudate (eczema, Paget's disease of the nipple) for nipple discharge [2][4] | 你點樣發現有嘢流出嚟？係內衣有漬定係乳頭流出嚟？(néih dím yéung faat yihn yáuh yéh làuh chēut lèih? haih noih yī yáuh jih dihng haih yúh tàuh làuh chēut lèih?) |
Features that raise concern for pathological discharge [1][2][4][5]:
| Feature | More worrisome | Less worrisome |
|---|---|---|
| Colour | Bloody (sanguineous) or serosanguineous | Milky, green, grey |
| Laterality | Unilateral | Bilateral |
| Number of ducts | Single duct (uniductal) | Multiple ducts |
| Spontaneity | Spontaneous | Only on expression |
| Persistence | Persistent | Intermittent |
Practical phrasing:
- "What colour is the discharge?" — 啲嘢流出嚟係咩色㗎？(dī yéh làuh chēut lèih haih mē sīk gaa?)
- "Is it from one spot on the nipple or from several?" — 係由乳頭一個位流出嚟定係幾個位？
- "Does it come out by itself or only when you squeeze?" — 係自己流出嚟定係㩒先至有？(haih jih géi làuh chēut lèih dihng haih gam sīn jì yáuh?)
| Colour | Think of… |
|---|---|
| Milky (bilateral, multiductal) | Galactorrhoea → hyperprolactinaemia (prolactinoma, drugs, hypothyroidism, CKD) [3][6] |
| Straw-coloured / serous | Intraductal papilloma (classical), physiological, DCIS [3] |
| Bloody / serosanguineous | Intraductal papilloma (most common cause of bloody discharge), DCIS, invasive ductal carcinoma, duct ectasia [3][5] |
| Greenish / black / multicoloured / cheesy | Duct ectasia [3] |
| Purulent / foul-smelling | Mastitis / breast abscess [2] |
- Normal lactation may persist up to 6 months (up to 2 years) after cessation of breastfeeding [3]
- Bloody nipple discharge can be seen in 20% of women during 2nd or 3rd trimester and during lactation — usually benign [3]
- Discharge present >1 year after stopping breastfeeding is worrisome and warrants investigation [2]
Cantonese: 你最近有冇懷孕或者餵母乳？幾時停㗎？(néih jeui gahn yáuh móuh wàaih yahn waahk jé wai móuh yúh? géi sìh tìhng gaa?)
3. Associated Breast Symptoms
Always systematically screen for these:
| Feature | Significance | Cantonese |
|---|---|---|
| Deviation / Displacement | Underlying mass pulling the nipple | 乳頭有冇歪咗？ |
| Discolouration | Paget's disease | 乳頭有冇變色？ |
| Dermatitis (eczema-like) | Paget's disease of the nipple — almost always associated with underlying breast cancer (HER2+ve) [3] | 乳頭有冇出疹、痕或者甩皮？ |
| Depression (retraction/inversion) | New-onset retraction suggests underlying carcinoma; congenital inversion is benign [3] | 乳頭有冇凹咗入去？ |
| Discharge | As above | 乳頭有冇嘢流出嚟？ |
Paget's Disease Trap
A common OSCE pitfall: unilateral nipple eczema that does not respond to topical steroids should be biopsied to rule out Paget's disease. It is almost ALWAYS associated with underlying breast cancer [3]. Don't dismiss it as dermatitis!
- Dimpling / puckering → underlying cancer infiltrating fibrous septa
- Peau d'orange → tumour blocking lymphatics, causing oedema with pitting at hair follicles/sweat glands [3]
- Ulceration → locally advanced disease
- Erythema / warmth → inflammatory breast cancer (T4d) or abscess
Cantonese: 個胸皮膚有冇凹凸唔平、紅、損或者好似橙皮噉？(go hūng pèih fū yáuh móuh nāp daht m̀h pìhng, hùhng, syún waahk jé hóu chíh cháang pèih gám?)
4. Targeted Systems Review
- Loss of weight (LOW), loss of appetite (LOA), fatigue
- Systemic symptoms (LOW, LOA) rarely occur in early breast cancer — their presence suggests advanced disease [2]
- Fever → think infection (mastitis / abscess)
Cantonese: 有冇瘦咗、冇胃口或者成日覺得好攰？(yáuh móuh sau jó, móuh waih háu waahk jé sìhng yaht gok dāk hóu guih?)
Metastatic symptoms generally come earlier than constitutional symptoms [2]:
| Site | Symptoms | Cantonese |
|---|---|---|
| Bone (most common) | Back pain, bone pain, pathological fractures | 有冇骨痛或者腰骨痛？ |
| Lung / Pleura | Dyspnoea, cough | 有冇氣促或者咳？ |
| Liver | Jaundice, nausea, abdominal pain | 有冇眼黃、肚痛？ |
| Brain | Headache, neurological deficits | 有冇頭痛或者手腳冇力？ |
5. Risk Factors for Breast Cancer
This is the crux of the OSCE history — examiners will expect you to systematically cover oestrogen exposure, previous breast pathology, family history, and lifestyle factors [1][2][5][7].
| Question | Risk factor | Cantonese |
|---|---|---|
| "How old were you when your periods started?" | Early menarche (< 12 years) [2][7] | 你幾歲開始嚟月經？ |
| "Have your periods stopped? If so, when?" | Late menopause (>55 years) [2][7] | 你收咗經未？幾歲收㗎？ |
| "When was your last menstrual period?" | Determines pre- vs post-menopausal status (affects management and obesity-related risk) [3] | 你最後一次月經係幾時？ |
| "Have you been pregnant? How many times? What age was your first pregnancy?" | Nulliparity or late first pregnancy (>30–35 years) → 2× risk [2][7] | 你有冇生過BB？第一胎幾歲？ |
| "Did you breastfeed? For how long?" | No breastfeeding increases risk [2][7] | 你有冇餵母乳？餵咗幾耐？ |
| "Are you taking or have you taken the contraceptive pill or hormone replacement?" | Oestrogen-based OCP, HRT (effect of HRT disappears ~5 years after stopping) [2][7] | 你有冇食避孕藥或者荷爾蒙補充劑？ |
- History of breast cancer (↑ risk in contralateral breast) [3]
- Atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH) — substantial increase in subsequent cancer risk [3]
- Previous breast biopsy results and diagnoses
- Previous irradiation to the chest (e.g. mantle radiation for Hodgkin lymphoma) [2][7]
- Previous breast checkup: clinical examination, mammogram, ultrasound [2]
- Smoking (1.1× risk) [7]
- Alcohol (increased risk even at very low doses, especially if intake before 30 years) [2][7]
- Obesity — risk depends on menopausal status: ↓ risk in premenopausal, ↑ risk in postmenopausal women (peripheral aromatase in adipose tissue) [3]
- Lack of physical activity, night shift work [7]
Specifically ask about previous breast augmentation by injection/surgery — breast symptoms may be sequelae of augmentation (e.g. reaction to injection) [2]
Cantonese: 你有冇做過隆胸手術或者打過針？(néih yáuh móuh jou gwō lùhng hūng sáu seut waahk jé dá gwō jām?)
This is where you screen for hereditary breast cancer syndromes:
| Question | Why | Cantonese |
|---|---|---|
| "Does anyone in your family have breast cancer? At what age? Which side of the family?" | 1st-degree relative with CA breast → risk doubled; early onset (< 40 years) or bilateral disease suggests BRCA1/2 [2][7] | 你屋企人有冇人生過乳癌？幾歲嗰陣？ |
| "Any ovarian, prostate, pancreatic, or colon cancer in the family?" | BRCA-associated cancers include ovary, prostate, pancreas, melanoma (BRCA2) [1][7] | 屋企人有冇卵巢癌、前列腺癌、胰臟癌？ |
| "Any family member who had cancer at a very young age or multiple cancers?" | Li-Fraumeni syndrome (TP53) — breast cancer, sarcoma, brain tumours, adrenocortical cancer, leukaemia [3] | 有冇家人好後生就生癌或者生過幾種唔同嘅癌？ |
7. Past Medical History, Surgical History, Medications & Allergies
- Drug allergies (document agent and reaction type)
| Domain | Details |
|---|---|
| Smoking | Pack-years; current or ex-smoker |
| Alcohol | Units per week; ↑ alcoholic intake before 30 years raises risk [2] |
| Occupation | Night shift work [7]; exposure to radiation |
| Psychosocial | Coping, anxiety about diagnosis; impact on daily life, body image |
| Activities of Daily Living | Baseline functional status (relevant if surgery being considered) |
Cantonese: 你飲唔飲酒？食唔食煙？(néih yám m̀h yám jáu? sihk m̀h sihk yīn?)
| If considering… | Key differentiating questions |
|---|---|
| Fibroadenoma (< 30 y) | Very mobile "breast mouse"? Painless? Slow growth? |
| Breast cyst (30–55 y) | Sudden appearance? Tense, fluctuant? Tender? Cyclical? |
| Fibrocystic changes | Bilateral lumpiness? Worse before menses, better after? |
| Fat necrosis | History of trauma or surgery? Bruising? |
| Breast abscess | Lactating? Fever? Rapid onset? Red, hot, swollen? Failed antibiotics? |
| Duct ectasia | Older woman? Multicoloured cheesy discharge? Nipple inversion? Not associated with increased risk of CA breast [3] |
| Intraductal papilloma | Bloody or serous uniductal discharge? No palpable mass? [3] |
| Paget's disease | Unilateral nipple eczema not responding to treatment? [3] |
| Inflammatory breast CA (T4d) | Painful swollen breast, peau d'orange involving ≥1/3 of breast, erythema? [1] |
| Galactorrhoea | Bilateral, milky, multiductal? On antipsychotics? Amenorrhoea? Visual field defects (pituitary macro-adenoma)? [6] |
The following should trigger urgent referral and fast-track triple assessment:
- New, hard, irregular, fixed, painless breast lump in a woman >30 years
- Unilateral, spontaneous, bloody, uniductal nipple discharge
- New-onset nipple inversion or retraction (not congenital)
- Unilateral nipple eczema / erosion (Paget's)
- Peau d'orange / skin tethering / skin ulceration
- Palpable axillary lymphadenopathy (hard, non-tender, fixed)
- Bone pain, SOB, jaundice, weight loss in the context of a breast mass
- Family history of BRCA + young patient with breast lump
Escalation Rule
Any discrete, new breast lump persisting after one menstrual cycle in a woman ≥30 years old warrants triple assessment (clinical + radiological + pathological). Do not adopt a "wait and see" approach without imaging.
OSCE Pitfalls to Avoid
- Forgetting to ask about the other breast — bilateral primary carcinoma is not rare [2].
- Not screening for metastatic symptoms — bone pain, SOB, jaundice. These come earlier than constitutional symptoms [2].
- Ignoring medication history — dopamine antagonists are a common cause of galactorrhoea and are easily fixable [3][6].
- Not asking about breastfeeding history — both a risk factor (none = ↑ risk) and a key context for discharge/abscess.
- Dismissing pain as "benign" — inflammatory breast cancer IS painful. Pain doesn't exclude cancer.
- Not clarifying if discharge is truly from the nipple — skin pathology (eczema, Paget's) can mimic discharge [2][4].
- Failing to ask about breast augmentation — increasingly common in HK; silicone reactions can present as lumps [2].
- Not asking O&G history in a breast complaint — examiners specifically look for menarche, menopause, parity, OCP/HRT [2][5].
| Principle | Explanation |
|---|---|
| "Triple assessment" is the gold standard | Clinical + Radiological + Pathological — always mention this framework in your viva [1][2] |
| Age-based DDx thinking | < 35: fibroadenoma, fibrocystic changes. 30–55: cyst. >50: carcinoma until proven otherwise [1][2] |
| Malignancy is the underlying cause of pathological nipple discharge in 5–15% of cases; the most common malignancy is DCIS [3] | This is why all pathological discharge needs investigation |
| Discharge cytology has poor sensitivity (17%) and specificity (66%) | Don't rely on it; ductogram and imaging are more helpful [2][4] |
| Intraductal papilloma is the most common cause of bloody nipple discharge [3] | But you must still exclude carcinoma |
| Obesity risk is menopausal-status dependent | Pre-menopausal: protective. Post-menopausal: harmful (aromatase in fat) [3] |
"Mrs Wong is a 52-year-old postmenopausal lady who presented to the Breast Clinic at QMH with a 3-week history of a painless lump in the left breast, upper outer quadrant, discovered on self-examination. The lump has been progressively enlarging without cyclical variation. She also reports a 2-week history of spontaneous, unilateral, blood-stained discharge from a single duct of the left nipple. She denies nipple inversion, skin changes, or peau d'orange. There are no constitutional symptoms, but she does report new lower back pain over the past month.
In terms of risk factors, she had menarche at age 11, menopause at age 56, is nulliparous, and never breastfed. She took combined oral contraceptive pills for 10 years in her twenties and was on hormone replacement therapy for 3 years postmenopause. Her BMI is 28.
Past medical history is significant for atypical ductal hyperplasia diagnosed on core biopsy 4 years ago at the same institution, with yearly mammographic surveillance since. She had no previous breast surgery. She is on no regular medications. She has no known drug allergies.
Family history is notable for her mother being diagnosed with bilateral breast cancer at age 42 and her maternal aunt having ovarian cancer at age 55, raising concern for a possible BRCA germline mutation.
Socially, she is a non-smoker, drinks approximately 10 units of alcohol per week, and works office hours. She lives independently with her husband.
In summary, this is a postmenopausal lady with multiple high-risk features — early menarche, late menopause, nulliparity, previous ADH, prolonged exogenous oestrogen exposure, and a strong family history suggestive of BRCA — presenting with a new dominant breast lump and pathological nipple discharge. The new back pain is concerning for possible bone metastasis. I would like to proceed with urgent triple assessment including bilateral mammography, targeted ultrasound of the left breast and axilla, core biopsy of the lump, and bloods. Given the family history, referral for genetic counselling should also be considered."
High Yield Summary
Breast Lump: Characterise → onset, duration, number, site, size, progression, cyclicity, pain, mobility. Then screen for associated breast symptoms (nipple changes — 5 Ds, skin changes), metastatic symptoms (bone, lung, liver, brain), and systematically assess risk factors (oestrogen exposure, previous breast pathology, FHx/BRCA, lifestyle). Always ask about the other breast, axillary lumps, and breast augmentation.
Nipple Discharge: Three gateway questions — (1) Is it truly from the nipple? (2) Is it pathological? (unilateral, uniductal, spontaneous, bloody, persistent = worrisome) (3) Any recent pregnancy/breastfeeding? Colour guides DDx: milky → galactorrhoea; bloody → intraductal papilloma or carcinoma; green/cheesy → duct ectasia.
The diagnosis pathway is always TRIPLE ASSESSMENT: Clinical + Radiological + Pathological.
Active Recall - History Taking
[1] Lecture slides: GC 181. Breast mass breast cancer; benign breast diseases.pdf (pp. 10, 16) [2] Senior notes: Ryan Ho Fundamentals.pdf (pp. 370–377) / Ryan Ho Urogenital.pdf (pp. 190–198) [3] Senior notes: felixlai.md (sections on Nipple Discharge, Fibrocystic Changes, Duct Ectasia, Intraductal Papilloma, Paget's Disease, Risk Factors) [4] Senior notes: Ryan Ho Urogenital.pdf (p. 198) — Key questions for nipple discharge [5] Senior notes: maxim.md (sections 8.2–8.3: Common breast complaints, Assessment of breast mass) [6] Senior notes: Ryan Ho Endocrine.pdf (p. 110: Hyperprolactinaemia) [7] Senior notes: Ryan Ho Urogenital.pdf (p. 205: CA Breast risk factors) / Lecture slides: The Management of breast cancer_Prof A Kwong 20_2_2020.pdf
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Hcc/liver Tumours
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