Diagnosis of Fibrocystic breasts
Diagnostic Test list for Fibrocystic breasts:
The list of medical tests
mentioned in various sources as
used in the diagnosis of Fibrocystic breasts
includes:
Fibrocystic breasts Diagnosis: Book Excerpts
Diagnostic Tests for Fibrocystic breasts: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about diagnostis of Fibrocystic breasts.
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.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
BREAST DISCHARGE:
Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is the discharge unilateral or bilateral? If it is unilateral and watery or bloody, one should look for a neoplasm in the breast. If it is bilateral and milky, one should look for the various conditions that cause hyperprolactinemia or pregnancy.
- Is the discharge bloody? A unilateral bloody discharge is most suggestive of carcinoma of the breast. Other types of lesions of the breast, such as Paget's disease, papillary cystadenoma, and epithelioma of the nipple, are causes of a bloody discharge also.
- Is there a focal mass in the breast? A bloody discharge with a focal mass makes a neoplasm almost certain. If there is a focal mass, fever, and a nonbloody discharge, one should consider abscess.
- Is there fever? Fever or chills along with a purulent discharge from the breast is most likely acute mastitis or an abscess.
DIAGNOSTIC WORKUP
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
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
>
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Source: In a Page: Signs and Symptoms, 2004
Breast Pain & Discharge:
Differential Diagnosis
(In a Page: Signs and Symptoms)
Breast pain
-
Fibrocystic change
–Most common benign breast condition
–Clinically present in 50% and histologically
in 90% of women
-
Mastitis
–Associated with lactation
-
Extramammary causes of pain (e.g., cervical radiculitis, costochondritis, herpes zoster, angina)
-
Breast cancer
–Occurs in 1/9 women (lifetime risk)
-
Cyst
-
Breast abscess
-
Unilateral or bilateral gynecomastia
-
Phylloides tumor
-
Intraductal papilloma
-
Fat necrosis
-
Trauma
-
Fibroadenoma
-
Lipoma
-
Pregnancy
Breast discharge
-
Duct ectasia
-
Galactorrhea
-
Mondor's disease
-
Chronic nipple stimulation
-
Pregnancy
-
Hypothyroidism
-
Sarcoidosis
-
Systemic lupus erythematosus
-
Cirrhosis or other hepatic disease
-
Breast cancer
–Occurs in 1/9 women (lifetime risk)
-
Intraductal papilloma
-
Fibrocystic change
-
Medications (e.g., phenothiazines, metoclopramide, tricyclic antidepressants, reserpine, opiates, cimetidine, androgens)
-
Hypothalamic and pituitary abnormalities (e.g., prolactinoma, acromegaly, empty sella syndrome)
-
Pseudocyesis
Workup and Diagnosis
- History includes past medical history, duration and pattern of pain and/or discharge, family history of breast or gynecologic cancer, and menstrual/pregnancy history
- Breast exam 7–9 days after menstrual flow
–Fibrocystic areas: Slightly irregular, mobile, bilateral, upper outer quadrant; compression causes tenderness
–Breast cancer: Solitary, irregular, or stellate; hard, nontender, fixed; not clearly delineated from surrounding tissue, ± lymphadenopathy
–Mastitis: Inflamed, edematous, erythematous, indurated, tender areas, axillary lymphadenopathy
–Nipple discharge: Bloody or serosanguinous discharge is suspicious for cancer; oral contraceptives, estrogens, or elevated prolactin levels may result in clear, serous, or milky discharge
-
Diagnostic mammogram is indicated in patients >30 years old who present with solitary or dominant mass or asymmetric thickening
–Compare with prior mammograms if possible
-
Ultrasound is used to distinguish solid versus cystic
-
Fine-needle aspiration, breast biopsy, cytologic exam of discharge, ductogram and/or galactogram may be indicated
-
Endocrine evaluation may include prolactin levels, TSH, FSH, and LH
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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.
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Source: Differential Diagnosis in Primary Care, 2007
BREAST DISCHARGE:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of purulent breast discharge is usually simply a smear and culture and occasionally a white blood cell (WBC) count and differential. When these are fruitless, an acid–fast smear and culture may be indicated; however, this rarely occurs. It concerns me that tuberculosis is almost invariably given too much space in other differential diagnosis textbooks. Mammography is ordered next. For an endocrine workup, skull x-ray films, a CT scan or MRI of the brain, and serum prolactin levels may be done, but it is wise to refer the patient to an endocrinologist for further evaluation and diagnostic assessment.
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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.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast pain [Mastalgia]:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it's intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a nursing mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced flulike symptoms or sustained injury to the breast? Has she noticed a change in breast shape or contour?
Ask the patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.
Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?
Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient's arms raised above her head and then with her hands pressed against her hips.
Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Common causes and associated findings.)
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Breast cancer:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The most reliable method of detecting breast cancer is the clinical breast examination, followed by immediate evaluation of any abnormality. Other diagnostic measures include mammography, ultrasound, needle biopsy, and surgical biopsy. Mammography is indicated for any woman whose physical examination suggests breast cancer. It should be done as a baseline on women between ages 35 and 39 and annually on all women older than age 40, on those who have a family history of breast cancer, and on those who have had unilateral breast cancer (to check for new disease).
ELDER TIP Unfortunately, many older women don't receive regular mammograms, even when recommended by health care professionals, either because they fear radiation, discovering cancer, or discomfort during the procedure or because they're embarrassed about exposing their breasts.
The value of mammography is questionable for women under age 35 (because of the density of the breasts), except for those women who are strongly suspected of having breast cancer. False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a negative mammogram should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. Ultrasonography, which can distinguish a fluid-filled cyst from a tumor, can also be used instead of an invasive surgical biopsy.
Bone scan, brain scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and liver biopsy can detect distant metastases. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen or progesterone dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Mastitis and breast engorgement:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Confirming diagnosis Diagnosis is usually easily made if pus is expressed from the nipple; culture may be helpful in confirming mastitis.
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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.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Breast pain [Mastalgia]:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it’s intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient a breast-feeding mother? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced any flulike symptoms or sustained an injury to the breast? Has she noticed any change in breast shape or contour?
Ask your patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.
Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?
Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient’s arms raised above her head and then with her hands pressed against her hips.
Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement. (See Breast pain: Causes and associated findings, page 134.)
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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).
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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.
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Source: Field Guide to Bedside Diagnosis, 2007
Breast cancer:
Diagnosis
(Handbook of Diseases)
Diagnostic measures for breast cancer include the following.
Breast self-examination
Although not proven to lower mortality rates, breast self-examination may detect palpable breast lumps, allowing the woman to contact her physician for early evaluation.
Mammography and biopsies
Other diagnostic measures include mammography, a needle biopsy, and a surgical biopsy. Mammography is indicated for any woman whose physical examination might suggest breast cancer. It should be done as a baseline on women ages 35 to 39, every 1 to 2 years for women ages 40 to 49, and annually for women older than age 50, women who have a family history of breast cancer, and women who have had unilateral breast cancer, to check for new disease. However, the value of mammography is questionable for women younger than age 35 (because of the density of the breasts), except those who are strongly suspected of having breast cancer.
False-negative results can occur in as many as 30% of all tests. Consequently, with a suspicious mass, a normal mammogram result should be disregarded, and a fine-needle aspiration or surgical biopsy should be done. Ultrasonography, which can distinguish a fluid-filled cyst from a tumor, can also be used instead of an invasive surgical biopsy.
Other tests
Bone scan, computed tomography scan, measurement of alkaline phosphatase levels, liver function studies, and a liver biopsy can detect distant metastasis. A hormonal receptor assay done on the tumor can determine if the tumor is estrogen- or progesterone-dependent. (This test guides decisions to use therapy that blocks the action of the estrogen hormone that supports tumor growth.)
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Source: Handbook of Diseases, 2003
Breast nodule:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If your 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 any 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 CUE:Breast cancer incidence and mortality are about five times higher in North America and northern Europe than in Asia and Africa.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Breast Enlargement:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Infectious
Cellulitis/Abscess
Cellulitisor breast abscess can occur in the newborn.Breast infections are unusual in adolescentgirls except for postpartum mastitis. Most common pathogen is S.aureus.Breast is inflamed, painful, and tender.Fluctuance is usually found with abscess. Noninfectious
Infancy
Physiologic Hypertrophy
Transplacentalpassage of estrogen from mother to fetus causes unilateral or bilateral breasthypertrophy in the newborn, which is usually apparent during firstweek of life.Hypertrophy usually resolves withina few months but sometimes persists until 1 or 2 yrs of age.If breast enlargement does not progressand growth velocity remains normal, no other investigation is necessary. Childhood
Premature Thelarche
Definedas breast enlargement (unilateral or bilateral) that occurs withoutother pubertal changes.Resolution occurs in a few months ormay persist until puberty.See Chap.48, Precocious Puberty. Precocious Puberty
Exists whensigns of sexual development besides breast development occur, includingdevelopment of axillary and pubic hair, accelerated growth, andonset of menses.See Chap.48, Precocious Puberty. Gynecomastia
Male breastenlargement is uncommon before puberty.Cause in most cases is idiopathic.Unusual causes include exogenous estrogen exposure and tumors (adrenal,testicular).Obese boys often appear to have breastenlargement, but no breast tissue is palpable. Adolescence
Girls
Cysts
Single ormultiple breast cysts may cause mild pain and tenderness.U/S can confirm diagnosis. Trauma
Contusionto the breast may produce firm, tender, diffuse mass, whereas hematoma ismore sharply defined.Fat necrosis may develop after traumaas firm, superficial mass that does not enlarge but resolves slowlywith time. Macromastia
Defined as development of large but histologicallynormal breasts. Juvenile Hypertrophy
Definedas breast enlargement secondary to marked increase in fibrous connective tissueand ductal proliferation.Breasts are firm and may be nodular. Fibrocystic Disease
Fibrocysticchanges of one or both breasts are physiologic response to cyclichormonal stimulation.Pain and tenderness usually occur justbefore menstrual period as cysts enlarge. Cordlike thickenings andcystic masses may be palpable. Nonbloody nipple discharge also maybe seen.Usually diagnosed clinically; however,U/S can confirm cystic nature of masses. Neoplasm
Benign
Most commonbreast mass found in girls is fibroadenoma, which usually occursin adolescence and can be multiple and bilateral.Discrete, mobile, nontender, firm massesare usually 2–3 cm in diameter. Larger ones that are 10–15cm in diameter may need excision. Otherwise, these tumors can befollowed clinically.Besides fibroadenoma, breast tumorsare rare in childhood and adolescence. Ductal papilloma usuallyappears as nodule beneath areola, and firm pressure may producebrown or bloody fluid. Lipomas and lymphangiomas appear as soft,painless breast masses.Cystosarcoma phyllodes is firm, circumscribedmass with occasional nipple discharge. Often benign but may be malignant. Malignant
Rare inpediatric population.Primary tumors include carcinomas,lymphomas, and sarcomas.Carcinoma of breast usually appears as unilateral,firm mass that adheres to skin and sometimes produces dischargeor bleeding from nipple.Sarcomas also present as firm, unilateral,breast masses. Metastatic lesions from leukemia, lymphoma,rhabdomyosarcoma, and neuroblastoma also occur.Malignancy should be suspected wheneverunilateral, hard, fixed, rapidly growing breast mass is noted.Only way to make definitive diagnosisis by biopsy. Boys
Physiologic Gynecomastia
Any growthof breast tissue in males is called gynecomastia, a common occurrence inadolescence.Mechanism of enlargement is thoughtto be increased ratio of estrogens to androgens or change in sensitivityof breast tissue receptors during puberty.Palpable breast tissue involving 1or both breasts is 1–2 cm in diameter.Enlargement usually lasts for 1–2years and gradually recedes. Drugs
Drugs that have been implicated in causingbreast enlargement in girls before puberty and in boys includeHormones(estrogens, estrogen agonists, androgens, anabolic steroids, chorionicgonadotropin)Psychoactive agents (tricyclic antidepressants,diazepam, phenothiazines, haloperidol)Cardiovascular drugs (captopril, enalapril,verapamil, nifedipine, digitoxin)Diuretics (thiazides, spironolactone)Antibiotics (isoniazid, ketoconazole,metronidazole)Cytotoxic drugs (vincristine, cyclophosphamide,methotrexate)Gastric acid inhibitors (ranitidine,cimetidine, omeprazole)Drugs of abuse (alcohol, heroin, methadone,marijuana, amphetamines)Others (phenytoin, penicillamine) Klinefelter Syndrome
Adolescentboys with Klinefelter syndrome are tall and have small testes. Gynecomastiamay occur but is not evident until puberty.Serum concentrations of follicle-stimulatinghormone (FSH) and luteinizing hormone (LH) are elevated.Most common karyotype is 47,XXY. Neoplasm
Althoughprimary breast tumors in boys are rare, they may be benign (hemangioma, lipoma,lymphangioma, neurofibroma) or malignant (carcinoma). Malignanttumor should be suspected with irregular, hard, fixed mass; bloodynipple discharge; and axillary adenopathy.Leydig cell testicular tumors secreteestrogen and can present with gynecomastia and precocious puberty.Testicular mass is usually palpable.Adrenal estrogen-producing tumors (adenoma,carcinoma) are rare but may cause gynecomastia. Abdominal U/Sand CT are useful in locating tumor mass.hCG-secreting germ cell tumors stimulateandrogen and estrogen production in testes and may present withgynecomastia and precocious puberty. Other
Gynecomastia also may be associated withcystic fibrosis, ulcerative colitis, chronic liver disease, hypothyroidism,hyperthyroidism, and HIV infection. Diagnostic Approach
Historyand physical exam are diagnostic in many cases of breast enlargement.Important features are gender, ageof onset, history of drug ingestion, signs of infection, whetherphysical and sexual development are normal, stage of sexual development,and presence of breast mass. Girls
Before puberty,except for the newborn, premature thelarche and precocious puberty aremost common causes of breast enlargement.Girls with unilateral subareolar massesin early puberty usually have normal enlarging breast bud, and excisionalbiopsy should be avoided.In pubertal girl suspected of havingfibrocystic disease, clinical observation for 3 menstrual cyclesis appropriate.Nature of discrete palpable mass (solidvs cystic) can be determined by U/S. Needle aspirationcan be considered if mass persists.Palpable mass that cannot be delineatedby imaging should be followed and excisional biopsy should be considered. Boys
Before puberty,breast enlargement is rare.In obese boys, breasts seem to be enlargedbut no breast tissue is palpable.In pubertal boys, most common causeof breast enlargement is physiologic.Body habitus and testicular size shouldbe noted. If testes are small and serum concentrations of FSH andLH are elevated, diagnosis is almost certainly Klinefelter syndrome.Chromosomal karyotype confirms diagnosis.Drugs, chronic liver disease, and neoplasmsare rare causes of breast enlargement in boys during childhood andadolescence.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Breast pain [Mastalgia]:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by asking the patient if breast pain is constant or intermittent. For either type, ask about onset and character. If it's intermittent, determine the relationship of pain to the phase of the menstrual cycle. Is the patient breast-feeding? If not, ask about any nipple discharge and have her describe it. Is she pregnant? Has she reached menopause? Has she recently experienced flulike symptoms or sustained injury to the breast? Has she noticed a change in breast shape or contour?
Ask the patient to describe the pain. She may describe it as sticking, stinging, shooting, stabbing, throbbing, or burning. Determine if the pain affects one breast or both, and ask the patient to point to the painful area.
Instruct the patient to place her arms at her sides, and inspect the breasts. Note their size, symmetry, and contour and the appearance of the skin. Remember that breast shape and size vary and that breasts normally change during menses, pregnancy, and lactation and with aging. Are the breasts red or edematous? Are the veins prominent?
Note the size, shape, and symmetry of the nipples and areolae. Do you detect ecchymosis, a rash, ulceration, or a discharge? Do the nipples point in the same direction? Do you see signs of retraction, such as skin dimpling or nipple inversion or flattening? Repeat your inspection, first with the patient's arms raised above her head and then with her hands pressed against her hips.
Palpate the breasts, first with the patient seated and then with her lying down and a pillow placed under her shoulder on the side being examined. Use the pads of your fingers to compress breast tissue against the chest wall. Proceed systematically from the sternum to the midline and from the axilla to the midline, noting any warmth, tenderness, nodules, masses, or irregularities. Palpate the nipple, noting tenderness and nodules, and check for discharge. Palpate axillary lymph nodes, noting any enlargement.
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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.
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Source: Differential Diagnosis in Primary Care, 2007
Breast Discharge:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of purulent breast discharge is usually simply a smear and
culture and occasionally a white blood cell (WBC) count and differential.
When these are fruitless, an acid-fast smear and culture may be indicated;
however, this rarely occurs. It concerns me that tuberculosis is almost
invariably given too much space in other differential diagnosis textbooks.
Mammography is ordered next. For an endocrine workup, skull x-ray films, a
CT scan or MRI of the brain, and determination of serum prolactin levels may
be done, but it is wise to refer the patient to an endocrinologist for
further evaluation and diagnostic assessment.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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