Diagnosis of Fibroadenoma
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BREAST MASS:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the mass tender? A tender mass is most likely due to an infectious process such as mastitis or an abscess. However, chronic cystic mastitis may present with a tender mass. Also, advanced carcinoma of the breast usually produces a tender mass.
- Is there a discharge? A bloody discharge from the breast means that the mass is most likely due to a malignant process. If there is a purulent discharge, abscess or mastitis must be considered. A watery discharge is often associated with chronic cystic mastitis, and this occasionally may become bloody.
- Does it transilluminate? Cysts of the breasts and galactoceles customarily transilluminate. A mass that does not transilluminate is probably a benign or malignant tumor.
- Is there a deformity of the breast associated with the mass? An orange peel appearance of the skin over a tumor certainly suggests that it is a carcinoma. Retraction of the skin or the nipple suggests carcinoma. Also, in carcinoma there may be necrosis and ulceration of the tissues overlying the tumor.
- Is there fever? Fever would suggest an acute mastitis or abscess.
DIAGNOSTIC WORKUP
A breast mass is a clear indication for a referral to a general surgeon. The general surgeon will probably perform mammography and a biopsy before proceeding with surgery. If a cystic lesion is suspected, ultrasonography may be done, followed by fine-needle aspiration and biopsy. When there is a definite mass on physical examination, surgery is indicated even if mammography and other tests are negative.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Breast Masses:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Fibroadenoma
–Most common cause of a unilateral discrete breast mass in young women
–May be bilateral and/or multiple
–Common in women with “fibrocystic
changes” of the breast
-
Intraductal papilloma
-
Fibrocystic changes
-
Gynecomastia
- Breast cancer
–Most common cause of discrete mass in women older than 50
–Types include infiltrating ductal (most common), infiltrating lobular, and medullary carcinoma
–Increased incidence with obesity, infertility, late first pregnancy (age >30), uterine cancer, history of breast cancer in first degree relatives (3–10-fold increase), and postirradiation
–Usually presents with nontender breast mass, nipple discharge, or occasionally nipple bleeding
-
Galactocele
–Presents during or shortly after breast-feeding
-
Cystosarcoma phylloides
-
Mammary duct ectasia
-
Breast abscess
-
Fat necrosis
-
Cyst
-
Cystic mastitis
-
Lymphoma
-
Lipoma
-
Trauma
Workup and Diagnosis
-
History and physical exam should include breast examination with careful attention to area(s) of mass, supraclavicular and axillary lymphadenopathy, skin changes (e.g., dimpling, edema, erythema, ulceration, or crusting), and nipple discharge
-
Bilateral diagnostic mammogram should be the initial test, but may not be helpful if below age 35 because of high breast density
–Suggestive of malignancy: Increased density, irregular margins, spiculation, irregular microcalcifications
Ultrasound is used as an adjunct to mammography to delineate masses that cannot be seen on mammogram, to determine whether a lesion is solid or cystic, and if age <35
MRI may be considered for indeterminate mammogram or ultrasound
Biopsy of masses, nonpalpable lesions, or suspicious calcifications on mammogram may be indicated
–Fine needle aspiration extracts cells for cytologic examination to distinguish benign versus malignant
–Core needle biopsy of solid lesions or complex cysts extracts tissue and provides a definitive diagnosis
–Excisional biopsy is definitive and may be curative if the full lesion is removed
Perform cytologic assessment of any nipple discharge
>
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
BREAST MASS OR SWELLING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
When faced with a mass in the breast, the physician’s first step should be a careful examination of the breasts and the surrounding area. If the mass is tender, it is likely to be inflammatory or traumatic. If it is not tender, one should suspect tumor. If it transilluminates, it is probably a cyst. Obviously, the primary concern of both physician and patient is whether the mass is a neoplasm. A careful search for enlarged lymph nodes in the axilla and the neck or a mass in the other breast is important. Mammography and ultrasonography are the next most important steps, but a breast biopsy is still necessary in most cases. A truly cystic mass may be punctured for fluid analysis and Papanicolaou tests. A suspicious mass should be biopsied even if mammography findings are negative.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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
Introduction: Malignant Neoplasms:
Diagnostic methods
(Professional Guide to Diseases (Eighth Edition))
A thorough medical history and physical examination should precede sophisticated diagnostic procedures. Useful tests for the early detection and staging of tumors include X-ray, endoscopy, isotope scan, computed tomography scan, and magnetic resonance imaging, but the single most important diagnostic tool is a biopsy for direct histologic study of tumor tissue. Biopsy tissue samples can be taken by curettage, fluid aspiration (pleural effusion), fine-needle aspiration biopsy (breast), dermal punch (skin or mouth), endoscopy (rectal polyps), and surgical excision (visceral tumors and nodes).
An important tumor marker, carcinoembryonic antigen (CEA), although not diagnostic by itself, can signal malignancies of the large bowel, stomach, pancreas, lungs, and breasts. CEA titers range from normal (less than 5 ng) to suspicious (5 to 10 ng) to suspect (over 10 ng). CEA serves many valuable purposes:
❑as a baseline during chemotherapy to evaluate the extent of tumor spread
❑to regulate drug dosage
❑to prognosticate after surgery or radiation
❑to detect tumor recurrence.
Although no more specific than CEA, alpha-fetoprotein — a fetal antigen uncommon in adults — can suggest testicular, ovarian, gastric, and hepatocellular cancers. Beta human chorionic gonadotropin may point to testicular cancer or choriocarcinoma. Other commonly used tumor markers include prostate-specific antigen to detect and monitor prostatic cancer, and CA-125, useful for monitoring ovarian, colorectal, and gastric cancers.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Malignant spinal neoplasms:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
❑Spinal and lumbosacral magnetic resonance imaging confirm spinal tumor.
❑ X-rays show distortions of the intervertebral foramina; changes in the vertebrae or collapsed areas in the vertebral body; and localized enlargement of the spinal canal, indicating an adjacent block.
❑ Myelography identifies the level of the lesion by outlining it if the tumor is causing partial obstruction; it shows anatomic relationship to the cord and the dura. If obstruction is complete, the injected dye can't flow past the tumor. (This study is dangerous if cord compression is nearly complete because withdrawal or escape of cerebrospinal fluid (CSF) will allow the tumor to exert greater pressure against the cord.)
❑ Radioisotope bone scan demonstrates metastatic invasion of the vertebrae by showing a characteristic increase in osteoblastic activity.
❑ Computed tomography scan shows cord compression and tumor location.
❑ Frozen section biopsy at surgery identifies the tissue type.
❑ Lumbar puncture may be normal, abnormal, or nonspecific. It may show clear yellow CSF as a result of increased protein levels if the flow is completely blocked. If the flow is partially blocked, protein levels rise, but the fluid is only slightly yellow in proportion to the CSF protein level. Cytology of the CSF may show malignant cells of metastatic carcinoma.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
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
Breast Mass:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Current medical history and chief complaint
1. When and how was the mass discovered? Does the patient perform regular breast self-examinations? What, if any, changes have occurred since discovery of the mass?
2. Age and menstrual status. Cancer is more prominent in women aged more than 50 years, although it can be seen in 3% of women who are aged 20 to 29 years. In the postmenopausal age group, 85% of masses prove to be cancer (1). Postmenopausal women have a higher risk for breast cancer (BC). Pregnancy expands the list of possible causes of a mass to include mastitis, galactocele, or a breast abscess.
3. Is the mass painful? If so, is there any cyclic variation in the pain? Has there been any nipple discharge (Chapter 11.6)? Cyclic pain suggests a cystic origin. Persistent pain may represent BC or an inflammatory process.
B. Past medical history
1. What is the reproductive history and current menstrual status? Has the patient ever breastfed an infant? Is she on estrogen replacement therapy (ERT)? A woman who breastfeeds for 2 or more years may decrease her risk for BC. ERT has a controversial role in the cause or advancement of breast cancer.
2. Breast history. The patient should be questioned about any previous breast mass, breast biopsy, or surgery and the clinical outcome. Has she had a personal history of breast cancer or atypical hyperplasia on a previous biopsy? A prior history of BC or atypical hyperplasia on a biopsy increases the risk for malignancy.
C. Family history. Is there a family history of breast cancer? If yes, what is the relationship of the family member and at what age was the cancer diagnosed and what was the relative’s menstrual status? A mother or sister with premenopausal BC increases risk to the highest level.
Physical examination
A. Inspection. Inspect the breasts for symmetry, contour, skin retraction, rashes, peau d’orange, nipple discharge, erythema, or edema.
1. Symmetry and contour can be disrupted on any breast. Retraction suggests either chronic inflammation or BC caused by skin adherence to the mass.
2. Peau d’orange is a puckering or indentation of the skin over a mass. A rash can be related to Paget’s disease with a related ductal carcinoma.
B. Palpation and compression. Palpate both breasts, including the nipple and areolar region. Palpate the supraclavicular, infraclavicular, and axillary region for adenopathy. Evaluate the consistency, regularity, location, mobility, and tenderness of the mass. Hard, immobile, irregular masses raise the suspicion for BC. Smooth, cystic, or rubbery masses suggest a cyst or fibroadenoma. Fibrocystic changes are often nondiscrete and irregular, but are also mobile and relatively soft. Compressing the nipple may express a discharge (Chapter 11.6).
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Breast Mass/Discharge:
Differential Overview
(Field Guide to Bedside Diagnosis)
Breast Mass
❑ Fibrocystic disease
❑ Fibroadenoma
❑ Breast cancer
❑ Intraductal papilloma
❑ Mastitis
❑ Hematoma
❑ Thrombophlebitis
❑ Galactocele
Breast Discharge
❑ Drugs
❑ Postpartum lactation
❑ Prolactin-secreting pituitary adenoma
❑ Intraductal papilloma
❑ Fibrocystic disease
❑ Breast cancer
❑ Mammary duct ectasia
❑ Repeated nipple stimulation
Diagnostic Approach
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
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
BREAST MASS OR SWELLING:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
When faced with a mass in the breast, the physician’s first step should
be a careful examination of the breasts and the surrounding area. If the
mass is tender, it is likely to be inflammatory or traumatic. If it is not
tender, one should suspect a tumor. If it transilluminates, it is probably a
cyst. Obviously, the primary concern of both physician and patient is
whether the mass is a neoplasm. A careful search for enlarged lymph nodes in
the axilla and the neck or a mass in the other breast is important.
Mammography and ultrasonography are the next most important steps, but a
breast biopsy is still necessary in most cases. A truly cystic mass may be
punctured for fluid analysis and Papanicolaou tests. A biopsy should be
taken of a suspicious mass even if mammography findings are negative.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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