New breast lump — triple assessment, fibroadenoma versus phyllodes, papilloma split and atypia counsel

Examiner prompts with model answers

Triple assessment first — concordance decides. Physical examination, sonography and tissue diagnosis together distinguish fibroadenoma from cancer, and the triple-test series reports 98% accuracy with 100% sensitivity, 95.2% specificity and 96.7% positive predictive value — so act on concordance and re-biopsy discordance.^[14][15]

Fibroadenoma — watch the concordant lesion. Fibroadenomas account for half of all breast biopsies, transformation is rare and regression is frequent — observe with interval review and explicit triggers (growth, discordance, complex or atypical features, BIRADS 4, preference) rather than booking by centimetres.^[14][13]

Size does not book surgery. In 1392 provisionally-fibroadenoma patients the largest diameter was insignificant (p = 0.99) while age and BIRADS score were significant — the tumour size alone should not be used as an indication for surgical intervention, with caution above age 35 or with BIRADS 4 imaging.^[13]

Phyllodes — grade, then margins. The WHO three-tier classification (benign, borderline, malignant) sets recurrence expectations, the ideal margin is at least 1 cm, grade 1 to 2 disease needs in-sano excision and grade 2 disease needs 10-mm margins — with no nodal staging and no routine mastectomy.^[16]

Papilloma — atypia is the fork. Benign intraductal papilloma upgrades at 5.0% against 36.0% with atypia, concordant benign disease without atypia at only 1.4% suits surveillance, and any atypia or predictor (higher BI-RADS, mass-calcification patterns, discharge, discordance, peripheral site, palpability, larger size) moves to excision.^[11][10]

Radial scar — restrain the concordant impalpable lesion. Pure radial scar without atypia upgrades near 1% and may avoid open excision with mammographic surveillance and multidisciplinary agreement — while palpable, discordant or atypical B3 lesions proceed to vacuum-assisted or open excision.^[20]

Atypia — extent, then prevention. Atypical hyperplasia carries 4- to 5-fold risk, extent stratifies it stepwise across two cohorts (combined ductal 2.65, 5.19 and 8.94 for 1, 2 and 3 or more foci), tamoxifen cuts it by more than 70% (P1) and 60% (IBIS-I) with aromatase inhibitors also highly effective — and usual-type hyperplasia has no such prevention data.^[4][3]