Transcript Disorders of the Breast

Disorders of the Breast
Breast Exam
Inspection
Size
Symmetry (some variation is normal)
Shape
Contour (flattening, masses, and dimpling)
Skin (color, edema, rashes, thickening, and venous
pattern)
Scars (previous surgery, injuries)
Inspection
Patient arm maneuvers
Overhead
Waist
Leaning forward
Palpation
Lymph nodes
Cervical
Axillary
Supraclavicular
Palpation
Bimanual palpation with patient sitting
Use right hand above the left hand below to palpate
right breast. Use pads of fingers to compress breast
tissue (check for consistency, nodules, masses, and
tenderness).
Repeat for left side by standing on left side and
reversing hands (left on top, right on bottom)
Palpation
Palpation while patient supine
Ask patient to put arm overhead
Use flat part of fingers (and a rotary motion) against
chest wall using radial or spiral pattern
Note tissue consistency, elasticity, nodules, indurations,
masses, and tenderness
Palpate all quadrants of breast (including up to clavicle
and towards axilla)
Palpation
While supine
Inspect and palpate nipples
Look for size, shape, inversion, rashes, ulceration, discharge,
scaling, crusting, elasticity, retraction, areolar edema and masses
Gently grasp and compress nipple and areolar tissue between
thumb and index finger, noting color consistency and quantity
of any discharge
Exam findings suspicious for
breast cancer
Hard, immovable lesion with irregular borders
Axillary adenopathy
Skin changes – erythema, thickening, dimpling (peau
d’orange)
Inflammatory breast cancer
Metastatic disease
Bone (back or leg pain)
Liver (abdominal pain, nausea, jaundice)
Lungs (SOB, cough)
Risk for Breast Cancer
1 in 8 women cumulative lifetime risk of breast cancer
Woman age 50-59, lifetime risk of having breast cancer
is 1 in 36
Woman age 70-79, risk increases to 1 in 24
Risk Factors for Breast Cancer
Late childbearing
Age
1st pregnancy > 30 years
Smoking
Early menarche
Prior personal history
Late menopause
Mammographic breast density
Fibrocystic changes with atypia
Family history
Genetics
BRCA 1&2 mutations
Nullparity
History of breast radiation
Hormone exposure
Obesity
Excessive alcohol use
>2 drinks/day
Benign Breast Disorders
Fibrocystic changes
Most common
Cyclical, bilateral, pain, and engorgement
No discrete or well-defined mass, but breast tissue
frequently nodular
Fibroadenoma
2nd most common
Fibrous and glandular tissue
Occurs in young women
Firm, painless, mobile mass
Benign Breast Disorders
Intraductal Papilloma
Commonly found in peri and menopausal women
Bloody, serous, or turbid nipple discharge
Excisional biopsy often needed
Galactocele
Cystic dilation of duct filled with thick, milky fluid
Common in women breast feeding
Secondary infection causes mastitis
Needle aspiration often curative
Benign Breast Disorders
Fat necrosis
Occurs after blunt trauma, operative procedures, or
radiation therapy
Breast cyst
Algorithm for palpable breast
abnormalities < 30 years old
* If no cytologic
expertise available,
initial ultrasound
preferred.
• If cytology
indicates cancer,
treat as appropriate.
If nondiagnostic,
indeterminate or
atypia, do
ultrasound.
Algorithm for palpable breast
abnormalities > 30 years old
When lesions are palpable,
clinically directed biopsies
are often the most
efficient. Fine-needle
aspiration (FNA) is the
biopsy of choice
* May be useful to
incorporate a staging MRI
into the management
Nipple Discharge
Lactation
Galactorrhea
Bilateral milky nipple discharge
Usually caused by hyperprolactinemia
Medications (antipsychotics, antidepressants, antiemetics,
antihypertensive, opioid)
Endocrine tumors
Endocrine abnormalities (hypothyroid)
Neurogenic stimulation
Stress
Purulent nipple discharge – associated with periductal mastitis
Nipple Discharge
Pathologic (suspicious)
Unilateral, localized to a single duct, persistent, and
spontaneous
Can be serous, sanguineous, or serosanguineous
Algorithm for spontaneous nipple
discharge (non-lactating)
* Breast ultrasound is
recommended for
imaging all patients
with nipple discharge.
Mammograms are
recommended for
women ≥ age 30.
Mastalgia
Cyclical
Associated with changes in menstrual cycle
Bilateral, most severe in upper outer quadrant of breast
Noncyclical
More likely unilateral and variable location
Some causes:
Large pendulous breasts
Hormone replacement therapy
Duct ectasia
Mastitis or breast abscess (common in lactating women)
Inflammatory breast cancer
Hidradenitis suppurativa
Workup mastalgia
History and physical exam
Looking for signs suggesting malignancy
Clinical judgment on any diagnostic imaging studies
For focal pain without a mass, or a history/exam not
consistent with classic cyclical pain
Targeted ultrasound or mammogram
BI-RADS mammographic
assessment categories
Management algorithm for
abnormal mammograms
Resources
https://www.apgo.org/education/clinical/breastexam.html
https://www.apgo.org/binary/TC40.pdf
http://www.uptodate.com