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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