Breast nodule [Breast lump]
Breast nodule [Breast lump]: Excerpt from Nursing: Interpreting Signs and Symptoms
A commonly reported gynecologic sign, a breast nodule has two chief causes: benign breast disease and cancer. Benign breast disease, the leading cause of nodules, can stem from cyst formation in obstructed and dilated lactiferous ducts, hypertrophy or tumor formation in the ductal system, inflammation, or infection.
Although fewer than 20% of breast nodules are malignant, the signs and symptoms of breast cancer aren't easily distinguished from those of benign breast disease. Breast cancer is a leading cause of death among women, but can occur occasionally in men, with signs and symptoms mimicking those found in women. Thus, breast nodules in both sexes should always be evaluated.
A woman who's familiar with the feel of her breasts and performs monthly breast self-examination can detect a nodule 6.4 mm or less in size, considerably smaller than the 1-cm nodule that's readily detectable by an experienced examiner. However, a woman may fail to report a nodule because of the fear of breast cancer.
History and physical examination
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.
Medical causes
Adenofibroma.The extremely mobile or “slippery” feel of this benign neoplasm helps distinguish it from other breast nodules. The nodule usually occurs singly and characteristically feels firm, elastic, and round or lobular, with well-defined margins. It doesn't cause pain or tenderness, can vary from pinhead size to very large, commonly grows rapidly, and usually lies around the nipple or on the lateral side of the upper outer quadrant.
Areolar gland abscess.Areolar gland abscess is a tender, palpable mass on the periphery of the areola following an inflammation of the sebaceous glands of Montgomery. Fever may also be present.
Breast abscess.A localized, hot, tender, fluctuant mass with erythema and peau d'orange typifies an acute abscess. Associated signs and symptoms include fever, chills, malaise, and generalized discomfort. With a chronic abscess, the nodule is nontender, irregular, and firm and may feel like a thick wall of fibrous tissue. It's commonly accompanied by skin dimpling, peau d'orange, nipple retraction and, sometimes, axillary lymphadenopathy.
Breast cancer.A hard, poorly delineated nodule that's fixed to the skin orunderlying tissue suggests breast cancer. Malignant nodules typically cause breast dimpling, nipple deviation or retraction, or flattening of the nipple or breast contour. Between 40% and 50% of malignant nodules occur in the upper outer quadrant.
Nodules usually occur singly, although satellite nodules may surround the main one. They're usually nontender. Nipple discharge may be serous or bloody. (A bloody nipple discharge in the presence of a nodule is a classic sign of breast cancer.) Additional findings include edema (peau d'orange) of the skin overlying the mass, erythema, tenderness, and axillary lymphadenopathy. A breast ulcer may occur as a late sign. Breast pain, an unreliable symptom, may be present.
Fibrocystic breast disease.The most common cause of breast nodules, this fibrocystic condition produces smooth, round, slightly elastic nodules, which increase in size and tenderness just before menstruation. The nodules may occur in fine, granular clusters in both breasts or as widespread, well-defined lumps of varying sizes. A thickening of adjacent tissue may be palpable. Cystic nodules are mobile, which helps differentiate them from malignant ones. Because cystic nodules aren't fixed to underlying breast tissue, they don't produce retraction signs, such as nipple deviation or dimpling. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.
Mammary duct ectasia.The rubbery breast nodule in mammary duct ectasia, a menopausal or postmenopausal disorder, usually lies under the areola. It's commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; thick, sticky, multicolored nipple discharge from multiple ducts; and nipple retraction. The skin overlying the mass may be bluish green or exhibit peau d'orange. Axillary lymphadenopathy is possible.
Mastitis.With mastitis, breast nodules feel firm and indurated or tender, flocculent, and discrete. Gentle palpation defines the area of maximum purulent accumulation. Skin dimpling and nipple deviation, retraction, or flattening may be present, and the nipple may show a crack or abrasion. Accompanying signs and symptoms include breast warmth, erythema, tenderness, and peau d'orange as well as a high fever, chills, malaise, and fatigue.
Paget's disease.Paget's disease is a slow-growing intraductal carcinoma that begins as a scaling, eczematoid unilateral nipple lesion. The nipple later becomes reddened and excoriated and may eventually be completely destroyed. The process extends along the skin as well as in the ducts, usually progressing to a deep-seated mass.
Nursing considerations
▪ Provide a simple explanation of your examination, and encourage the patient to express her feelings.
▪ Prepare the patient for diagnostic tests, which may include transillumination, mammography, thermography, needle aspiration or open biopsy, and cytologic examination of nipple discharge.
▪ Postpone teaching the patient how to perform breast self-examination until she overcomes her initial anxiety at discovering a nodule.
▪ Although most nodules occurring in the breast-feeding patient result from mastitis, the possibility of cancer demands careful evaluation.
Patient teaching
▪ Advise the patient with mastitis to pump her breasts to prevent further milk stasis, to discard the milk, and to substitute formula until the infection responds to antibiotics.
▪ Explain the importance of clinical breast examination and mammography following the American Cancer Society guidelines.
▪ Teach the patient how to perform breast self-examination.
▪ Explain how to treat mastitis.
▪ Teach the patient about the cause of the breast nodule and the treatment plan after a diagnosis is established.
Book Source Details
- Book Title: Nursing: Interpreting Signs and Symptoms
- Author(s): Springhouse
- Year of Publication: 2007
- Copyright Details: Nursing: Interpreting Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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