Breast Mass/Discharge
Breast Mass/Discharge: Excerpt from Field Guide to Bedside Diagnosis
Differential Overview
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.
Clinical Findings
Fibrocystic disease The underlying substrate is lumpy breasts with radially arranged fine nodular cysts. A mobile, rubbery (feels fluid-filled) nodule will be present, which will be similar in consistency to the other smaller nodules. It usually increases in size just before the period or after breast trauma. It may be painful or tender. Two diagnostic strategies include needle aspiration of thick yellow-green fluid, which should make a cyst disappear, or
re-examination during the follicular phase of the menstrual cycle 5 to 7 days after the menses, at which time the nodule should be smaller.
Fibroadenoma The mass is highly mobile, rubbery, firm, well-demarcated, nontender, and may have a kidney-like notch. It may increase in size with adolescence, pregnancy, menopause, or hormonal treatment.
Breast cancer Classically, the mass is as hard as a stone, fixed to the underlying tissue, and has indistinct borders. These findings are not reliable, however, because 60% of cancers are freely mobile, 40% are soft or cystic, and 40% have regular borders. Additional findings, usually at more advanced stages of disease, include peau d’orange (orange peel) changes of the overlying skin, and axillary adenopathy. Infiltrating ductal carcinoma is stony hard. Papillary cancer is multicentric. Infiltrating lobular cancer produces a vague thickening. Inflammatory carcinoma produces erythema and edema of the skin of the breast. Paget disease produces eczematous skin changes of the nipple or discharge.
Intraductal papilloma A papilloma presents with unilateral discharge and a rounded subareolar mass. The discharge is usually straw-colored and transparent like plasma, the source of the fluid.
Mastitis There is a radially oriented mass, which is quite tender, red, warm, and localized to one quadrant. It is usually caused by an obstructed duct.
Hematoma It is usually posttraumatic and tender.
Thrombophlebitis Superficial tenderness over the inferolateral breast and a palpable cord are found.
Galactocele It occurs only during lactation.
Drugs Oral contraceptives, phenothiazines, tricyclic antidepressants, benzodiazepines, verapamil, reserpine, methyldopa, isoniazid, and opiates have all been associated with galactorrhea, through inhibition of dopamine secretion by the hypothalamus, with resulting prolactin production.
Postpartum lactation Normal milk production, it can persist for years after cessation of nursing.
Prolactin-secreting pituitary adenoma Galactorrhea occurring concurrently with amenorrhea, and persistent galactorrhea after childbirth are common scenarios. Visual field defect and headache may be additional clues.
Mammary duct ectasia Ectasia presents as bilateral discharge in a perimenopausal woman, associated with pain, itching, and swelling of the nipple. A tubular “bag of worms” structure is felt on palpation of the areola. The discharge is gray-green.
Repeated nipple stimulation Galactorrhea may occur in a woman previously pregnant, as in the wet nurse phenomenon, or through stimulation by the patient or her partner.
Pictures
Book Source Details
- Book Title: Field Guide to Bedside Diagnosis
- Author(s): David S. Smith
- Year of Publication: 2007
- Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.
More About Breast Cancer
More Medical Textbooks Online about Breast Cancer
Review other book chapters online related to Breast Cancer:
Medical Books Excerpts
- Peau d'orange
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
- [ read ]
- Nipple Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
- [ read ]
Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
|
|
More About This Book:
Title: Field Guide to Bedside Diagnosis
Authors: David S. Smith
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 0-78178-165-5
|
|
» Next page: Breast cancer (Handbook of Diseases)
Rate This Website
What do you think about the features of this website?
Take our user survey and have your say:
Website User Survey
Medical Tools & Articles:
Next articles:
Tools & Services:
Medical Articles:
Forums & Message Boards
- Ask or answer a question at the Boards:
