Breast symptoms (eg, masses Breast Masses (Breast Lumps) The term breast mass (lump) may be discovered by patients incidentally or during breast self-examination or by the clinician during routine physical examination. Masses may be painless or painful... read more , nipple discharge Nipple Discharge Nipple discharge is a common complaint in women who are not pregnant or breastfeeding, especially during the reproductive years. Nipple discharge is not necessarily abnormal, even among postmenopausal... read more , pain Mastalgia (Breast Pain) Mastalgia (breast pain) is common and can be localized or diffuse and unilateral or bilateral. Localized breast pain is usually caused by a focal disorder that causes a mass, such as a breast... read more ) are common, accounting for > 15 million physician visits/year. Although > 90% of symptoms have benign causes, breast cancer Breast Cancer 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 is always a concern. Because breast cancer is common and may mimic benign disorders, the approach to all breast symptoms and findings is to conclusively exclude or confirm cancer.
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
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).
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.
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:
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
Imaging tests are used for
Diagnosis: Evaluation of breast abnormalities (eg, masses, nipple discharge)
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 ). 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 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:
Evaluate masses, pain, and nipple discharge
Determine size and location of a lesion and provide images of surrounding tissues and lymph nodes
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)