Diagnostic Tests for Breast Cancer
Breast Cancer: Diagnostic Tests
The list of diagnostic tests
mentioned in various sources as
used in the diagnosis of Breast Cancer
includes:
- Self breast examination
- Clinical breast examination
- Screening mammogram
- Diagnostic mammograms - more detailed mammograms than the basic screening.
- Ultrasonography
- Breast biopsy
- Pathology test - the cells from a biopsy are sent to a pathologist or lab for analysis.
- HER-2 gene test - tests for the human epidermal growth factor receptor-2 (HER-2) gene that indicates how fast a tumor may grow.
- Tests for spreading (metastisis) of breast cancer to other areas of the body:
Breast Cancer Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Breast Cancer:
- Colon & Rectal Cancer: Home Testing
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Breast Cancer: Related Home Tests:
- Cancer-Related Home Testing:
Breast Cancer Diagnosis: Book Excerpts
Tests and diagnosis discussion for Breast Cancer:
Breast Cancer: NWHIC (Excerpt)
As a matter of routine, women should perform monthly breast
self-examinations, go for a breast exam by a doctor or nurse, and have a
mammogram (an x-ray picture of the breast that can detect breast cancer
when it is in its earliest, most treatable stage, up to 2 years before a
lump can be felt) performed every 1 to 2 years. This will increase the
chance of discovering breast cancer early. When detected and treated at an
early stage, chances for survival will increase and the woman will have
more options for treatment. (Source: excerpt from Breast Cancer: NWHIC)
What You Need To Know About Cancer - An Overview: NCI (Excerpt)
A screening mammogram
is the best tool available to find breast cancer before
symptoms appear. A mammogram is a special kind of x-ray
image of the breasts. Breast cancer screening has been shown
to reduce the risk of dying from this disease. The National
Cancer Institute recommends that women in their forties and
older have mammograms on a regular basis, every 1 to 2
years. (Source: excerpt from What You Need To Know About Cancer - An Overview: NCI)
What You Need To Know About Breast Cancer: NCI (Excerpt)
Women can take an active part in the early detection of
breast cancer by having regularly scheduled screening
mammograms and clinical breast exams (breast exams performed
by health professionals). Some women also perform breast
self-exams.
A screening mammogram is the best tool available for
finding breast cancer early, before symptoms appear. A
mammogram is a special kind of x-ray .
Screening mammograms are used to look for breast changes in
women who have no signs of breast cancer.
Mammograms can often detect a breast lump before it can be
felt. Also, a mammogram can show small deposits of calcium in
the breast. Although most calcium deposits are benign, a
cluster of very tiny specks of calcium (called microcalcifications )
may be an early sign of cancer.
If an area of the breast looks suspicious on the screening
mammogram, additional (diagnostic) mammograms may be needed.
Depending on the results, the doctor may advise the woman to
have a biopsy .
Although mammograms are the best way to find breast
abnormalities early, they do have some limitations. A
mammogram may miss some cancers that are present (false
negative) or may find things that turn out not to be cancer
(false positive). And detecting a tumor early does not
guarantee that a woman's life will be saved. Some fast-growing
breast cancers may already have spread to other parts of the
body before being detected.
Nevertheless, studies show that mammograms reduce the risk
of dying from breast cancer. Most doctors recommend that women
in their forties and older have mammograms regularly, every 1
to 2 years.
Some women perform monthly breast self-exams to check for
any changes in their breasts. When doing a breast self-exam,
it's important to remember that each woman's breasts are
different, and that changes can occur because of aging, the menstrual
cycle , pregnancy, menopause, or taking birth
control pills or other hormones .
It is normal for the breasts to feel a little lumpy and
uneven. Also, it is common for a woman's breasts to be swollen
and tender right before or during her menstrual period. Women
in their forties and older should be aware that a monthly
breast self-exam is not a substitute for regularly scheduled
screening mammograms and clinical breast exams by a health
professional. (Source: excerpt from What You Need To Know About Breast Cancer: NCI)
What You Need To Know About Breast Cancer: NCI (Excerpt)
To help find the cause of any sign or symptom, a doctor
does a careful physical exam and asks about personal and
family medical history. In addition, the doctor may do one or
more breast exams:
-
Clinical breast exam. The doctor can tell a lot
about a lump by carefully feeling it and the tissue around
it. Benign lumps often feel different from cancerous ones.
The doctor can examine the size and texture of the lump and
determine whether the lump moves easily.
-
Mammography .
X-rays of the breast can give the doctor important
information about a breast lump.
-
Ultrasonography .
Using high-frequency sound waves, ultrasonography can often
show whether a lump is a fluid-filled cyst
(not cancer) or a solid mass (which may or may not be
cancer). This exam may be used along with
mammography.
Based on these exams, the doctor may decide that no further
tests are needed and no treatment is necessary. In such cases,
the doctor may need to check the woman regularly to watch for
any changes.
Biopsy
Often, fluid or tissue must be removed from the breast so
the doctor can make a diagnosis. A woman's doctor may refer
her for further evaluation to a surgeon or other health care
professional who has experience with breast diseases. These
doctors may perform:
-
Fine-needle
aspiration . A thin needle is used to remove
fluid and/or cells from a breast lump. If the fluid is
clear, it may not need to be checked by a lab.
-
Needle biopsy .
Using special techniques, tissue can be removed with a
needle from an area that looks suspicious on a mammogram but
cannot be felt. Tissue removed in a needle biopsy goes to a
lab to be checked by a pathologist
for cancer cells.
-
Surgical biopsy. In an incisional biopsy, the
surgeon cuts out a sample of a lump or suspicious area. In
an excisional biopsy, the surgeon removes all of a lump or
suspicious area and an area of healthy tissue around the
edges. A pathologist then examines the tissue under a
microscope to check for cancer cells.
|
When a woman needs a biopsy, these are some questions
she may want to ask her doctor:
-
What type of biopsy will I have? Why?
-
How long will it take? Will I be awake? Will it
hurt?
-
How soon will I know the results?
-
If I do have cancer, who will talk with me about
treatment? When? |
(Source: excerpt from
What You Need To Know About Breast Cancer: NCI)
What You Need To Know About Breast Cancer: NCI (Excerpt)
Special lab tests of the tissue help the doctor learn more
about the cancer. For example, hormone
receptor tests (estrogen
and progesterone
receptor tests) can help determine whether hormones help the
cancer to grow. If test results show that hormones do affect
the cancer's growth (a positive test result), the cancer is
likely to respond to hormonal
therapy . This therapy deprives the cancer cells of
estrogen. More information about hormonal therapy can be found
in the "Planning
Treatment " section.
Other tests are sometimes done to help the doctor predict
whether the cancer is likely to progress. For example, the
doctor may order x-rays and lab tests. Sometimes a sample of
breast tissue is checked for a gene (the human epidermal
growth factor receptor-2 or HER-2 gene) that is associated
with a higher risk that the breast cancer will come back. The
doctor may also order special exams of the bones, liver, or
lungs because breast cancer may spread to these areas. (Source: excerpt from What You Need To Know About Breast Cancer: NCI)
Diagnosis of Breast Cancer: medical news summaries:
The following medical news items
are relevant to diagnosis of Breast Cancer:
Diagnostic Tests for Breast Cancer: Online Medical Books
16 MEDICAL BOOKS ONLINE!
Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Breast Cancer.
BREAST DISCHARGE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
If there is a bloody discharge, one should not hesitate to refer the patient to a general surgeon, who will probably order mammography and perform a biopsy. The type of biopsy may be either a fine-needle aspiration or fine-needle biopsy or excisional biopsy, but the general surgeon can decide which is appropriate for any given patient. A unilateral nonbloody discharge may be studied further by ordering tests for occult blood, cytology, and mammography before referral. Remember that exploratory surgery may be the only way to get a diagnosis.
If the discharge is bilateral and milky, a serum prolactin should be ordered. If the prolactin is high, referral to an endocrinologist is probably the best step to take next. The endocrinologist will probably order a CT scan of the brain and pituitary and do further workup studies based on his examination.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Nipple discharge:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last period. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Nipple retraction:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Peau d'orange:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when she first detected peau d’orange. Has she noticed lumps, pain, or other breast changes? Does she have related signs and symptoms, such as malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?
In a well-lit examining room, observe the patient’s breasts. Estimate the extent of the peau d’orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d’orange, noting warmth or induration. Then palpate the entire breast, noting fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Finally, take the patient’s temperature.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
CULTURAL CLUE: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Common causes and associated findings, page 106.)
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Nipple discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; and with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nipple retraction:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first noticed retraction of the nipple. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, and with her arms overhead; and with the patient leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Peau d'orange:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when she first detected peau d’orange. Has she noticed any lumps, pain, or other breast changes? Does she have related signs and symptoms, such as malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?
In a well-lit examining room, observe the patient’s breasts. Estimate the extent of the peau d’orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d’orange, noting warmth or induration. Palpate the entire breast, noting any fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Take the patient’s temperature.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast nodule [Breast lump]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports a lump, ask her how and when she discovered it and whether its size and tenderness vary with her menstrual cycle. Has the lump changed since she first noticed it? Has she noticed any other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? If so, does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient’s medical and family history for factors that increase her risk of breast cancer. These include a high-fat diet, having a mother or sister with breast cancer, or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Cultural Cue: Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are its borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant. (See Breast nodule: Causes and associated findings.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nipple Discharge:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Clinical breast examination (Chapter 11.2)
1. Inspection. Observe the skin of the breast for crusting or a rash on the nipple or areolar region. Document the color of any discharge. Look for evidence of nipple retraction. Locate the site of the discharge on the nipples. Magnification can assist localization. Look for chest wall scars, evidence of viral infections (e.g., herpes zoster or simplex), and signs of eczema or inflammation.
2. Palpation. Feel the skin surface for warmth in the presence of erythema. Palpate both breasts for evidence of a mass or tenderness. Palpate regional nodes for evidence of lymphadenopathy (Chapters 11.2 and 15.2).
3. Compression. Compress the nipple and areolar area of both breasts with the thumb and index finger in an effort to elicit a discharge. Perform this examination in several directions. Note the location of any discharge and the number of ducts involved, as well as whether the discharge is unilateral or bilateral.
B. Other examination components. Palpate the thyroid and liver if history indicates the need. Perform a neurologic examination, including visual fields, in patients with visual disturbance or headache.
Testing
A. Clinical laboratory. Order blood tests looking for evidence of thyroid, renal, and liver diseases or establishing a prolactin level, based on clinical history.
B. Discharge. Test for occult blood if blood is not readily apparent. The specificity and sensitivity of cytology limits its effectiveness and is not necessary.
C. Imaging. Mammography is indicated to look for nonpalpable masses or calcifications. Ductography may help distinguish the location of ductal pathology in a localized discharge but is not a substitute for exploration of the ductal system.
D. Ductal exploration. The patient who does not have a good physiologic explanation for her discharge should be referred for surgical exploration or biopsy.
Diagnostic assessment (1,2)
A. Categories of risk. The four categories of risk described by Arnold and Neiheisel include lactation, physiologic, pathologic, and false discharge (1).
1. Physiologic discharges are usually bilateral, multiductal, painless, and associated with either stimulation of the nipple or medications. Color may be white, yellow, gray, or green, and the consistency is usually milky. Occasionally, blood is present.
2. Pathologic discharges are usually unilateral, uniductal, and spontaneous. Color is variable and blood or purulence may be apparent. Cancer, benign tumors, infections, and systemic disease are pathologic causes of discharges of this type.
3. Pseudodischarge. A false discharge is often associated with staining on clothing or crusting on the nipple. This is different from the “droplets” of a true discharge. Eczema, viral infections (herpes zoster or simplex), or Paget’s disease can cause a pseudodischarge.
B. Specific disorders of interest
1. Intraductal papilloma is the most common cause of benign pathologic discharges.
2. Ductal ectasia is the result of a progression of ductal stagnation and resultant inflammatory process. The incidence of this disorder is higher in smokers and is most prominent in those aged 40 to 60 years. Induration and noncyclic burning pain are characteristic of this disorder.
3. Paget’s disease involves the skin of the nipple and areola. It is usually associated with ductal carcinoma. Send any areolar lesion that does not respond to antibiotics or topical treatment for biopsy to exclude this disorder.
References
1. Arnold G, Neiheisel M. A comprehensive approach to evaluating nipple discharge. Nurse Pract 1997;22(7):96–108.
2. Andolsek K, Copeland J. Conditions of the breast. In: Taylor RB, ed. Family medicine: principles and practice, 5th ed. New York: Springer-Verlag, 1998.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Breast Mass/Discharge:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Breast Mass: Breast lumps should be approached with a high index of suspicion for breast cancer, as approximately 20% of solitary or dominant breast masses are breast cancers. The physical examination is an important part of the diagnostic “triple test,” which includes mammography and fine needle aspiration cytology. When all three are positive, 99.4% have breast cancer. When all three tests suggest a benign lesion, only 0.7% have breast cancer.
Screening clinical breast examination detects approximately 50% of breast cancers. There is some but not total overlap with mammography; about 10% of screen-detected cancers are detected by physical examination and missed by mammography, while about 40% are detected by mammography and missed by physical examination. Techniques which increase the sensitivity of the examination include flattening of the breast against the chest wall (arm overhead), circular motions using the pads of the fingers, and spending greater time with the examination.
Cyclical pain and tenderness are usually due to fibrocystic disease. Although breast cancer can present with pain, it is often atypical and there is usually no tenderness. Characteristics of pain with alternative diagnoses include the following: heavy or full of milk (fibrocystic), sharp and radiating (radiculitis), itching, burning, drawing (duct ectasia), burning and stinging (mastodynia), sore, bruised, stabbing (trauma), throbbing (infectious), aching, and locally tender (costochondritis). Benign cysts are more prominent premenstrually and become smaller during the follicular phase of the menstrual cycle. Palpation characteristics suggestive of cancer include a mass that is firm, has indistinct borders, and has attachments to the skin or deep fascia. Dimpling of the skin, retraction of the nipple, bloody discharge from the nipple, and axillary nodal enlargement are all important clues to breast cancer.
Breast Discharge: Galactorrhea occurs when high levels of prolactin act upon a breast primed by estrogen and progesterone. Therefore, it is extremely rare in men unless there is a feminizing state. Milky discharge can usually be visually differentiated from a serous or bloody discharge. If confirmation is needed, microscopic examination for oval fat bodies (or use of Sudan stain) can be performed.
Bloody discharge is due to an ductal carcinoma (in situ or invasive) in one third of patients, a bleeding intraductal papilloma in another third, and fibrocystic breasts with an intraductal component (e.g. ductal ectasia, intraductal hyperplasia) in the remainder. All require further evaluation. When expressed by exam, discharge coming from one duct is more worrisome than discharge from multiple ducts. Bilateral multiductal discharge that is guaiac negative is usually benign regardless of color (milky, brown, green, yellow, blue, or clear), and due to an endocrine or physiologic process.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Nipple discharge:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Start your physical assessment by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nipple retraction:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, and with her arms overhead; and with the patient leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Peau d'orange:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
In a well-lit examining room, observe the patient’s breasts. Estimate the extent of the peau d’orange, and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d’orange, noting warmth or induration. Then palpate the entire breast, noting any fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Finally, take the patient’s temperature.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Breast nodule:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule’s delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that’s spontaneous, unilateral, and nonmilky (serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nipple discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Is the discharge spontaneous or does it have to be expressed? Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Ask about other symptoms, such as fever and malaise.
Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.
Is the patient taking hormones (such as hormonal contraceptives or hormone replacement therapy), antihypertensives, or psychotropic drugs?
Start your physical examination by characterizing the discharge. If the discharge isn't frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Nipple retraction:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Has she had a fever? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.
Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides; with her hands pressing on her hips; with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)
Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Peau d'orange:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when she first detected peau d'orange. Has she noticed lumps, pain, or other breast changes? Does she have related signs and symptoms, such as fever, malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she noticed any nipple discharge? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?
In a well-lit examining room, observe the patient's breasts. Estimate the extent of the peau d'orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d'orange, noting warmth or induration. Then palpate the entire breast, noting fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Finally, take the patient's temperature.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Breast nodule [Breast lump]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports a lump, ask her how and when she discovered it. Does the size and tenderness of the lump vary with her menstrual cycle? Has the lump changed since she first noticed it? Has she noticed other breast signs, such as a change in breast shape, size, or contour; a discharge; or nipple changes?
Is she breast-feeding? Does she have fever, chills, fatigue, or other flulike signs or symptoms? Ask her to describe any pain or tenderness associated with the lump. Is the pain in one breast only? Has she sustained recent trauma to the breast?
Explore the patient's medical and family history for factors that increase her risk of breast cancer. These include having a mother or sister with breast cancer or having a history of cancer, especially cancer in the other breast. Other risk factors include nulliparity and a first pregnancy after age 30.
Next, perform a thorough breast examination. Pay special attention to the upper outer quadrant of each breast, where one-half of the ductal tissue is located. This is the most common site of malignant breast tumors.
Carefully palpate a suspected breast nodule, noting its location, shape, size, consistency, mobility, and delineation. Does the nodule feel soft, rubbery, and elastic or hard? Is it mobile, slipping away from your fingers as you palpate it, or firmly fixed to adjacent tissue? Does the nodule seem to limit the mobility of the entire breast? Note the nodule's delineation. Are the borders clearly defined or indefinite? Does the area feel more like a hardness or diffuse induration than a nodule with definite borders?
Do you feel one nodule or several small ones? Is the shape round, oval, lobular, or irregular? Inspect and palpate the skin over the nodule for warmth, redness, and edema. Palpate the lymph nodes of the breast and axilla for enlargement.
Observe the contour of the breasts, looking for asymmetry and irregularities. Be alert for signs of retraction, such as skin dimpling and nipple deviation, retraction, or flattening. (To exaggerate dimpling, have your patient raise her arms over her head or press her hands against her hips.) Gently pull the breast skin toward the clavicle. Is dimpling evident? Mold the breast skin and again observe the area for dimpling.
Be alert for a nipple discharge that's spontaneous, unilateral, and nonmilky (for example, serous, bloody, or purulent). Be careful not to confuse it with the grayish discharge that can be elicited from the nipples of a woman who has been pregnant.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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