TREATMENTS &
RESEARCH

Search the
latest
treatment
information
here.

Dr. Huntley's
Diagnosis
Checklist

Have a symptom?
See what questions
a doctor would ask.
 
Next Prev
Diseases » Breast Cancer » Diagnosis
 

Diagnosis of Breast Cancer

Diagnostic Test list for Breast Cancer:

The list of medical tests mentioned in various sources as used in the diagnosis of Breast Cancer includes:

  • Self breast examination
  • Clinical breast examination
  • Screening mammogram
  • Diagnostic mammograms - more detailed mammograms than the basic screening.
  • Ultrasonography
  • Breast biopsy
  • Pathology test - the cells from a biopsy are sent to a pathologist or lab for analysis.
  • HER-2 gene test - tests for the human epidermal growth factor receptor-2 (HER-2) gene that indicates how fast a tumor may grow.
  • Tests for spreading (metastisis) of breast cancer to other areas of the body:

Breast Cancer Diagnosis: Book Excerpts

Tests and diagnosis discussion for Breast Cancer:

Breast Cancer: NWHIC (Excerpt)

As a matter of routine, women should perform monthly breast self-examinations, go for a breast exam by a doctor or nurse, and have a mammogram (an x-ray picture of the breast that can detect breast cancer when it is in its earliest, most treatable stage, up to 2 years before a lump can be felt) performed every 1 to 2 years. This will increase the chance of discovering breast cancer early. When detected and treated at an early stage, chances for survival will increase and the woman will have more options for treatment. (Source: excerpt from Breast Cancer: NWHIC)

What You Need To Know About Cancer - An Overview: NCI (Excerpt)

A screening mammogram is the best tool available to find breast cancer before symptoms appear. A mammogram is a special kind of x-ray image of the breasts. Breast cancer screening has been shown to reduce the risk of dying from this disease. The National Cancer Institute recommends that women in their forties and older have mammograms on a regular basis, every 1 to 2 years. (Source: excerpt from What You Need To Know About Cancer - An Overview: NCI)

What You Need To Know About Breast Cancer: NCI (Excerpt)

Women can take an active part in the early detection of breast cancer by having regularly scheduled screening mammograms and clinical breast exams (breast exams performed by health professionals). Some women also perform breast self-exams.

A screening mammogram is the best tool available for finding breast cancer early, before symptoms appear. A mammogram is a special kind of x-ray . Screening mammograms are used to look for breast changes in women who have no signs of breast cancer.

Mammograms can often detect a breast lump before it can be felt. Also, a mammogram can show small deposits of calcium in the breast. Although most calcium deposits are benign, a cluster of very tiny specks of calcium (called microcalcifications ) may be an early sign of cancer.

If an area of the breast looks suspicious on the screening mammogram, additional (diagnostic) mammograms may be needed. Depending on the results, the doctor may advise the woman to have a biopsy .

Although mammograms are the best way to find breast abnormalities early, they do have some limitations. A mammogram may miss some cancers that are present (false negative) or may find things that turn out not to be cancer (false positive). And detecting a tumor early does not guarantee that a woman's life will be saved. Some fast-growing breast cancers may already have spread to other parts of the body before being detected.

Nevertheless, studies show that mammograms reduce the risk of dying from breast cancer. Most doctors recommend that women in their forties and older have mammograms regularly, every 1 to 2 years.

Some women perform monthly breast self-exams to check for any changes in their breasts. When doing a breast self-exam, it's important to remember that each woman's breasts are different, and that changes can occur because of aging, the menstrual cycle , pregnancy, menopause, or taking birth control pills or other hormones . It is normal for the breasts to feel a little lumpy and uneven. Also, it is common for a woman's breasts to be swollen and tender right before or during her menstrual period. Women in their forties and older should be aware that a monthly breast self-exam is not a substitute for regularly scheduled screening mammograms and clinical breast exams by a health professional. (Source: excerpt from What You Need To Know About Breast Cancer: NCI)

What You Need To Know About Breast Cancer: NCI (Excerpt)

To help find the cause of any sign or symptom, a doctor does a careful physical exam and asks about personal and family medical history. In addition, the doctor may do one or more breast exams:

  • Clinical breast exam. The doctor can tell a lot about a lump by carefully feeling it and the tissue around it. Benign lumps often feel different from cancerous ones. The doctor can examine the size and texture of the lump and determine whether the lump moves easily.

  • Mammography . X-rays of the breast can give the doctor important information about a breast lump.

  • Ultrasonography . Using high-frequency sound waves, ultrasonography can often show whether a lump is a fluid-filled cyst (not cancer) or a solid mass (which may or may not be cancer). This exam may be used along with mammography.

Based on these exams, the doctor may decide that no further tests are needed and no treatment is necessary. In such cases, the doctor may need to check the woman regularly to watch for any changes.

Biopsy

Often, fluid or tissue must be removed from the breast so the doctor can make a diagnosis. A woman's doctor may refer her for further evaluation to a surgeon or other health care professional who has experience with breast diseases. These doctors may perform:

  • Fine-needle aspiration . A thin needle is used to remove fluid and/or cells from a breast lump. If the fluid is clear, it may not need to be checked by a lab.

  • Needle biopsy . Using special techniques, tissue can be removed with a needle from an area that looks suspicious on a mammogram but cannot be felt. Tissue removed in a needle biopsy goes to a lab to be checked by a pathologist for cancer cells.

  • Surgical biopsy. In an incisional biopsy, the surgeon cuts out a sample of a lump or suspicious area. In an excisional biopsy, the surgeon removes all of a lump or suspicious area and an area of healthy tissue around the edges. A pathologist then examines the tissue under a microscope to check for cancer cells.

When a woman needs a biopsy, these are some questions she may want to ask her doctor:

  • What type of biopsy will I have? Why?

  • How long will it take? Will I be awake? Will it hurt?

  • How soon will I know the results?

  • If I do have cancer, who will talk with me about treatment? When?

(Source: excerpt from What You Need To Know About Breast Cancer: NCI)

What You Need To Know About Breast Cancer: NCI (Excerpt)

Special lab tests of the tissue help the doctor learn more about the cancer. For example, hormone receptor tests (estrogen and progesterone receptor tests) can help determine whether hormones help the cancer to grow. If test results show that hormones do affect the cancer's growth (a positive test result), the cancer is likely to respond to hormonal therapy . This therapy deprives the cancer cells of estrogen. More information about hormonal therapy can be found in the "Planning Treatment " section.

Other tests are sometimes done to help the doctor predict whether the cancer is likely to progress. For example, the doctor may order x-rays and lab tests. Sometimes a sample of breast tissue is checked for a gene (the human epidermal growth factor receptor-2 or HER-2 gene) that is associated with a higher risk that the breast cancer will come back. The doctor may also order special exams of the bones, liver, or lungs because breast cancer may spread to these areas. (Source: excerpt from What You Need To Know About Breast Cancer: NCI)

Diagnosis of Breast Cancer: medical news summaries:

The following medical news items are relevant to diagnosis and misdiagnosis issues for Breast Cancer:

Diagnostic Tests for Breast Cancer: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Breast Cancer.


BREAST DISCHARGE: Ask the following questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. 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.
  2. 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.
  3. 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.
  4. 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.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

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

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

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.

» READ BOOK EXCERPT ONLINE »

Source: Differential Diagnosis in Primary Care, 2007

Nipple discharge: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.

Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last period. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.

Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.

Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Nipple retraction: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.

Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)

Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

Peau d'orange: History and physical examination
(Handbook of Signs & Symptoms (Third Edition))

Ask the patient when she first detected peau d’orange. Has she noticed lumps, pain, or other breast changes? Does she have related signs and symptoms, such as malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?

In a well-lit examining room, observe the patient’s breasts. Estimate the extent of the peau d’orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d’orange, noting warmth or induration. Then palpate the entire breast, noting fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Finally, take the patient’s temperature.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Signs & Symptoms (Third Edition), 2006

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

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.)

» 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

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.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Nipple discharge: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency.

Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.

Start your physical examination by characterizing the discharge. If the discharge isn’t frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; and with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d’orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.

Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Nipple retraction: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when she first noticed retraction of the nipple. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.

Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides, with her hands pressing on her hips, and with her arms overhead; and with the patient leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)

Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Peau d'orange: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Ask the patient when she first detected peau d’orange. Has she noticed any lumps, pain, or other breast changes? Does she have related signs and symptoms, such as malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?

In a well-lit examining room, observe the patient’s breasts. Estimate the extent of the peau d’orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d’orange, noting warmth or induration. Palpate the entire breast, noting any fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Take the patient’s temperature.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

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

Nipple Discharge: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

 A. Presentation. How old is the patient? When and how was the discharge first discovered? Discharges that have been apparent for longer periods of time are more likely to be benign. The risk of cancer increases with advancing age.

 B. Discharge characteristics. What is the color and consistency of the discharge? Is the discharge spontaneous or associated with manipulation or sexual activity only? Is the discharge unilateral or bilateral, uniductal or multiductal? What part of the nipple is affected?

1. A bloody, red discharge or a discharge that has the appearance of old blood is suggestive of, but not specific to, breast cancer.

 2. A spontaneous, unilateral, uniductal discharge raises the level of suspicion for cancer. This does not exclude cancer from the differential diagnosis in the multiductal presentation.

 C. Pain. Cyclic pain suggests a physiologic cause. Continuous pain and burning may indicate pathology related to inflammation (e.g., ductal ectasia or infection).

D. Reproductive history. What is the patient’s menstrual history? Has she had a recent pregnancy or abortion? Amenorrhea or irregular menses in a premenopausal woman with a nipple discharge suggests the need to evaluate the patient for pregnancy, hypothyroidism, or a disruption of the hypothalamic-pituitary axis (Chapters 11.1 and 11.5).

 E. Medical history. Is there a history of significant chest wall trauma? Is there a recent history of herpes zoster infection? Does she have a history of atopic dermatitis? Does the patient have a history of breast cancer or breast surgery?

 1. Chest wall trauma (e.g., a thoracotomy) and herpes zoster infection have been reported to cause nipple discharge.

 2. Any systemic disease that affects the hypothalamic-pituitary axis or alters the clearance of prolactin can result in hyperprolactinemia. Visual disturbance or headache can be associated with the presence of a pituitary adenoma.

 F. Medication. Is the patient taking any medications? Offending agents include:

 1. Phenothiazines, haloperidol, and numerous other antipsychotics

 2. Tricyclic antidepressants, benzodiazepines, selective serotonin reuptake inhibitors

 3. Metoclopramide, cimetidine

4. Reserpine, methyldopa, digitalis, verapamil

5. Oral contraceptives, estrogens, progestins

6. Heroin, marijuana, amphetamines, cocaine

7. Isoniazid, danazol

G. Activity and lifestyle. Is the patient a jogger or does she participate in aerobic exercise? Does she smoke; if so, how much? Has the patient deliberately manipulated or traumatized the nipple? Friction of clothing on the nipple can create discharge, bleeding, and tenderness, which can result in bleeding, crusting, or traumatic erosions. Smoking increases the risk of cancer and ductal ectasia.

H. Family history. Is there a family history of breast cancer?

 I. Review of symptoms. A review of systems for thyroid, renal, liver, adrenal, or pituitary disease should be included in the query. Ask about visual disturbances or headache, which can be associated with a pituitary adenoma.

Physical examination

A. Clinical breast examination (Chapter 11.2)

 1. Inspection. Observe the skin of the breast for crusting or a rash on the nipple or areolar region. Document the color of any discharge. Look for evidence of nipple retraction. Locate the site of the discharge on the nipples. Magnification can assist localization. Look for chest wall scars, evidence of viral infections (e.g., herpes zoster or simplex), and signs of eczema or inflammation.

 2. Palpation. Feel the skin surface for warmth in the presence of erythema. Palpate both breasts for evidence of a mass or tenderness. Palpate regional nodes for evidence of lymphadenopathy (Chapters 11.2 and 15.2).

 3. Compression. Compress the nipple and areolar area of both breasts with the thumb and index finger in an effort to elicit a discharge. Perform this examination in several directions. Note the location of any discharge and the number of ducts involved, as well as whether the discharge is unilateral or bilateral.

 B. Other examination components. Palpate the thyroid and liver if history indicates the need. Perform a neurologic examination, including visual fields, in patients with visual disturbance or headache.

» 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 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.)

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Nipple discharge: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Is the patient taking hormones (hormonal contraceptives or hormone replacement therapy)? Is the discharge spontaneous, or does it have to be expressed?

Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for any risk factors of breast cancer — family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nipple retraction: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when she first noticed retraction of the nipple. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Obtain a history, noting risk factors for breast cancer, such as a family history or previous malignancy.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Peau d'orange: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Ask the patient when she first detected peau d’orange. Has she noticed any lumps, pain, or other breast changes? Does she have related signs and symptoms, such as malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

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.

» READ BOOK EXCERPT ONLINE »

Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Nipple discharge: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when she first noticed the discharge, and determine its duration, extent, quantity, color, consistency, and smell, if any. Is the discharge spontaneous or does it have to be expressed? Has she had other nipple and breast changes, such as pain, tenderness, itching, warmth, changes in contour, and lumps? If she reports a lump, question her about its onset, location, size, and consistency. Ask about other symptoms, such as fever and malaise.

Obtain a complete gynecologic and obstetric history, and determine her normal menstrual cycle and the date of her last menses. Ask if she experiences breast swelling and tenderness, bloating, irritability, headaches, abdominal cramping, nausea, or diarrhea before or during menses. Note the number, date, and outcome of her pregnancies and, if she breast-fed, the approximate time of her last lactation. Also, check for risk factors of breast cancer—family history, previous or current malignancies, nulliparity or first pregnancy after age 30, early menarche, or late menopause.

Is the patient taking hormones (such as hormonal contraceptives or hormone replacement therapy), antihypertensives, or psychotropic drugs?

Start your physical examination by characterizing the discharge. If the discharge isn't frank, try to elicit it. (See Eliciting nipple discharge.) Then examine the nipples and breasts with the patient in four different positions: sitting with her arms at her sides; with her arms overhead; with her hands pressing on her hips; and leaning forward so her breasts are suspended. Check for nipple deviation, flattening, retraction, redness, asymmetry, thickening, excoriation, erosion, or cracking. Inspect her breasts for asymmetry, irregular contours, dimpling, erythema, and peau d'orange. With the patient in a supine position, palpate the breasts and axillae for lumps, giving special attention to the areolae. Note the size, location, delineation, consistency, and mobility of any lump you find.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Nipple retraction: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when she first noticed the nipple retraction. Has she experienced other nipple changes, such as itching, discoloration, discharge, or excoriation? Has she noticed breast pain, lumps, redness, swelling, or warmth? Has she had a fever? Obtain a history, noting risk factors of breast cancer, such as a family history or previous malignancy.

Carefully examine both nipples and breasts with the patient sitting upright with her arms at her sides; with her hands pressing on her hips; with her arms overhead; and leaning forward so her breasts hang. Look for redness, excoriation, and discharge; nipple flattening and deviation; and breast asymmetry, dimpling, or contour differences. (See Differentiating nipple retraction from inversion.)

Try to evert the nipple by gently squeezing the areola. With the patient in a supine position, palpate both breasts for lumps, especially beneath the areola. Mold breast skin over the lump or gently pull it up toward the clavicle, looking for accentuated nipple retraction. Also, palpate axillary lymph nodes.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Peau d'orange: History and physical examination
(Nursing: Interpreting Signs and Symptoms)

Ask the patient when she first detected peau d'orange. Has she noticed lumps, pain, or other breast changes? Does she have related signs and symptoms, such as fever, malaise, achiness, and weight loss? Is she lactating, or has she recently weaned her infant? Has she noticed any nipple discharge? Has she had previous axillary surgery that might have impaired lymphatic drainage of a breast?

In a well-lit examining room, observe the patient's breasts. Estimate the extent of the peau d'orange and check for erythema. Assess the nipples for discharge, deviation, retraction, dimpling, and cracking. Gently palpate the area of peau d'orange, noting warmth or induration. Then palpate the entire breast, noting fixed or mobile lumps, and the axillary lymph nodes, noting enlargement. Finally, take the patient's temperature.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 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 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


 » Next page: Signs of Breast Cancer

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
 
HONcode We subscribe to the HONcode principles

By using this site you agree to our Terms of Use. Information provided on this site is for informational purposes only; it is not intended as a substitute for advice from your own medical team. The information on this site is not to be used for diagnosing or treating any health concerns you may have - please contact your physician or health care professional for all your medical needs. Please see our Terms of Use.

Home | Symptoms | Diseases | Diagnosis | Videos | Tools | Forum | About Us | Terms of Use | Privacy Policy | Site Map | Advertise

Copyright © 2009 Health Grades Inc. All rights reserved.