Breast nodule [Breast lump]
Breast nodule [Breast lump]: Excerpt from Professional Guide to Signs & Symptoms (Fifth Edition)
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 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.)
Medical causes
Adenofibroma
The extremely mobile or “slippery” feel of an adenofibroma—a 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, often grows rapidly, and usually is located around the nipple or on the lateral side of the upper outer quadrant.
Areolar gland abscess
A tender, palpable abscess on the periphery of the areola caused by an infection and inflammation of Montgomery’s glands. 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. In 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, and nipple retraction and sometimes by axillary lymphadenopathy.
Breast cancer
A hard, poorly delineated nodule that’s fixed to the skin or underlying tissue suggests breast cancer. Malignant nodules commonly 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 of the breast.
Malignant nodules are usually nontender and occur singly, although satellite nodules may surround the main one. 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 may include edema and dimpling (peau d’orange) of the skin overlying the mass, erythema, accentuated veins, 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 condition produces smooth, round, slightly elastic nodules that 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. A clear, watery (serous), or sticky nipple discharge may appear in one or both breasts. Signs and symptoms of premenstrual syndrome—including headache, irritability, bloating, nausea, vomiting, and abdominal cramping—may also be present.
Intraductal papilloma
Intraductal papilloma is a small, benign nodule that grows in the lactiferous ducts. A single larger nodule can sometimes be palpated, but multiple diffuse nodules usually resist palpation. Soft and poorly delineated papillomas usually lie in the subareolar margin. The primary sign of this disorder is a serous or bloody nipple discharge, typically from only one duct. Breast pain and tenderness may also occur.
Mammary duct ectasia
This disorder, which affects menopausal or postmenopausal women, produces a rubbery breast nodule that usually lies under the areola. It’s commonly accompanied by transient pain, itching, tenderness, and erythema of the areola; a thick, sticky, multicolored nipple discharge from multiple ducts; nipple retraction; and a bluish green discoloration or peau d’orange on the skin overlying the mass. Axillary lymphadenopathy may also occur.
Mastitis
In 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 high fever, chills, malaise, and fatigue.
Nipple adenoma
Although similar in symptoms to Paget’s disease, adenomas rarely produce a deep-seated mass.
Paget’s disease
Paget’s disease is a slow-growing intraductal carcinoma that begins as a scaling, eczematoid nipple lesion on one side. 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.
Special considerations
Although many women regard a breast lump as a sign of breast cancer, most nodules are benign. As a result, try to avoid alarming your patient further. 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 of the nodule for tissue examination, and cytologic examination of nipple discharge.
Postpone teaching the patient how to perform breast self-examination until she overcomes her initial anxiety at discovering the nodule. Regular breast self-examination is especially important for women who have had a previous cancer, have a family history of breast cancer, are nulliparous, or had their first child after age 30. (See How to examine your breasts,pages 128 and 129.)
Although most nodules occurring in breast-feeding women result from mastitis, the possibility of cancer demands careful evaluation. 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.
Pediatric pointers
Most nodules in children and adolescents reflect the normal response of breast tissue to hormonal fluctuations. For instance, the breasts of young teenage girls may normally contain cordlike nodules that become tender just before menstruation.
A transient breast nodule in young boys (as well as women between ages 20 and 30) may result from juvenile mastitis, which usually affects one breast. Signs of inflammation are present in a firm mass beneath the nipple.
Geriatric pointers
In women age 70 and older, three-quarters of all breast lumps are malignant.
Patient counseling
When teaching patients how to perform breast self-examination, advise them to do the examination 5 to 7 days after the first day of their last menstrual period.
Pictures
![Breast nodule [Breast lump] - 2507.2.png](/bookimages/8/2507.2.png)
![Breast nodule [Breast lump] - 2507.3.png](/bookimages/8/2507.3.png)
![Breast nodule [Breast lump] - 2507.1.png](/bookimages/8/2507.1.png)
Book Source Details
- Book Title: Professional Guide to Signs & Symptoms (Fifth Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Professional Guide to Signs & Symptoms (Fifth Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Medical Books Excerpts
- Peau d'orange
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Nipple Discharge
- "The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter" (2000)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
» Next page: Nipple Discharge (The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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