Merck Manual

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Evaluation of Breast Disorders

By

Lydia Choi

, MD, Karmanos Cancer Center

Last full review/revision Mar 2022
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Evaluation

History

History includes the following:

  • Presence and type of pain or discharge and duration of symptoms

  • Relation of symptoms to menses and pregnancy

  • Presence of skin changes

  • Use of hormone therapy

  • Personal and family history of breast cancer

  • Date and results of last mammogram

Breast examination

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 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 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).

Breast examination

Positions include the patient seated or standing (A) with arms at sides; (B) with arms raised over the head, elevating the pectoral fascia and breasts; (C) with hands pressed firmly against hips; or (D) with palms pressed together in front of the forehead, contracting the pectoral muscles. (E) Palpation of axilla; arm supported as shown, relaxing the pectoral muscles. (F) Patient supine with pillow under the shoulder and with the arm raised above the head on the side being examined. (G) Palpation of breast in a circular pattern from the nipple outward.

Breast examination

The axillary and supraclavicular lymph nodes are most easily examined with the patient seated or standing (see figure Breast examination: E Breast examination 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 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 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.

Red flags

The following findings are of particular concern:

  • A mass or thickening that feels distinctly different from other breast tissue

  • A mass that is fixed to the skin or chest wall

  • A persistent mass

  • Persistent breast swelling

  • Peau d'orange (pitting, puckering, reddening, thickening, or dimpling in the skin of the breast)

  • Scaly skin around the nipple

  • Changes in the shape of the breast

  • Changes in the nipple (eg, retraction)

  • A unilateral discharge from the nipple, especially if it is bloody and/or occurs spontaneously

Testing

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 a concern... read more Evaluation reference ). 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 Mammography Breast cancers are most often epithelial tumors involving the ducts or lobules. Most patients present with an asymptomatic mass discovered during examination or screening mammography. Diagnosis... read more Mammography 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 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).

Table

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:

  • Evaluate masses, pain, and nipple discharge

  • Determine size and location of a lesion and provide images of surrounding tissues and lymph nodes

  • Guide biopsy

  • After surgery, image the breast to check for recurrence

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:

  • Provide initial imaging of breast abnormalities detected in women < 30

  • Identify abnormal axillary nodes that may require core biopsy

  • Evaluate abnormalities detected by MRI or mammography (eg, determine whether they are solid or cystic)

  • Guide biopsy needle into abnormal breast tissue

MRI can be used to do the following:

  • Diagnose breast abnormalities

  • Before surgery, accurately determine tumor size, chest wall involvement, and number of tumors, especially in women with dense breast tissue

  • Identify abnormal axillary lymph nodes (to help stage breast cancer)

Evaluation reference

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NOTE: This is the Professional Version. CONSUMERS: Click here for the Consumer Version
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