Evaluation of Breast Disorders

History includes the following:

Breasts are inspected for asymmetry in shape (bulging, irregular contour), nipple abnormalities (inversion, retraction, discharge, crusting), and skin changes (dimpling, retraction, edema, erythema, scaling, ulceration—see figure Breast examination: A and B Breast examination for usual positions). A size difference between breasts is common.

Examining the patient in more than one position may help detect abnormalities. An underlying cancer is sometimes detected by having the patient press both hands against the hips or the palms together in front of the forehead (see figure Breast examination: C and D Breast examination ). In these positions, the pectoral muscles are contracted, and a subtle dimpling of the skin may appear if a growing tumor has entrapped one of the Cooper ligaments (vertical cutaneous ligaments that attach to the chest wall and support the shape of the breast).

The axillary and supraclavicular lymph nodes are most easily examined with the patient seated or standing (see figure Breast examination: E Breast examination ). Supporting the patient’s arm during the axillary examination allows the arm to be fully relaxed so that nodes deep within the axilla can be palpated.

The breast is palpated with the patient seated and again with the patient supine, the ipsilateral arm above the head, and a pillow under the ipsilateral shoulder (see figure Breast examination: F Breast examination ). Having the patient roll to one side, so that the breast on the examined side falls medially, may help differentiate breast and chest wall tenderness because the chest wall can be palpated separately from breast tissue.

The breast should be palpated with the palmar surfaces of the 2nd, 3rd, and 4th fingers, moving systematically in a small circular pattern from the nipple to the outer edges (see figure Breast examination: G Breast examination ). Precise location and size (measured with a caliper) of any abnormality should be noted; some clinicians use a drawing of the breast for documentation. A written description of the consistency of the abnormality and degree to which it can be distinguished from surrounding breast tissue should also be included.

Clinicians apply pressure, moving clockwise, to the areola to check for a discharge and, if a discharge is elicited, to determine its source (eg, whether it is multiductal). The discharge is examined to determine whether it is bloody or blood-tinged. A bright light and magnifying lens can help determine whether nipple discharge is uniductal or multiductal.

The following findings are of particular concern:

Imaging tests are used for

Women should be screened for breast cancer (1 Evaluation reference Breast symptoms (eg, masses, nipple discharge, pain) are common, accounting for > 15 million physician visits/year. Although > 90% of symptoms have benign causes, breast cancer is always... read more ). All professional societies and groups agree on this concept, although they differ on the recommended age at which to start screening and the precise frequency of screening.

Screening mammography Breast Cancer Screening and Prevention Breast cancer screening is recommended for all women in the United States, but major medical organizations vary regarding the starting age and frequency of screening (see table ) ( 1, 2). Determining... read more recommendations for average-risk women vary, but generally, screening starts between ages 40 and 50 and is repeated every year or two until age 75 or until life expectancy is < 10 years (see table Recommendations for Breast Cancer Screening Mammography in Women With Average Risk Recommendations for Breast Cancer Screening Mammography in Women With Average Risk ). Mammography is more accurate in women over 50 years of age because with aging, fibroglandular tissue in breasts tends to be replaced with fatty tissue, which can be more easily distinguished from abnormal tissue. Mammography is less sensitive in women with dense breast tissue; some states mandate informing patients that they have dense breast tissue when it is detected by screening mammography. Women with dense breast tissue may require additional imaging tests (eg, breast tomosynthesis [3-dimensional mammography], MRI).

In mammography, low-dose x-rays of both breasts are taken in 1 (oblique) or 2 views (oblique and craniocaudal).

Breast tomosynthesis(3-dimensional mammography) done with digital mammography increases the rate of cancer detection slightly and decreases the rate of recall imaging; this test is helpful for women with dense breast tissue. However, the test exposes women to almost twice as much radiation as traditional mammography.

MRI is used to screen women with a high (eg, > 20%) risk of breast cancer, such as those with a BRCA gene mutation. For these women, screening should include MRI as well as mammography and clinical breast examination (CBE). MRI has higher sensitivity but may be less specific.

Diagnostic mammography is used to do the following:

Diagnostic mammography requires more views than screening mammography. Views include magnified views and spot compression views, which provide better visualization of suspect areas.

Ultrasonography can be used to do the following:

MRI can be used to do the following: