History

Discovering a lump is the complaint of most concern in patients presenting with breast disease. The clinician must answer the questions: Is a discrete (dominant) lump really present? Then, if the answer is yes: Is it a carcinoma? Most carcinomas present as painless lumps. The other common forms of presentation of breast problems are painful breasts (often with general lumpiness), nipple discharge and skin changes.

Also important is a history of: past breast pathology; cyclical changes in the breast, particularly premenstrual tenderness and lumpiness; times of menarche and menopause; pregnancy, contraception and lactation details including the number and dates of pregnancies and complications of lactation such as milk retention, breast abscess, nipple soreness and retracted nipple; and any family history of breast disease.

Physical examination

The fully exposed breasts are examined initially in the seated and then the supine position.

On inspection any asymmetry or alteration in contour of the breasts is noted (Box 3.1). Most differences in size of the breasts are developmental. Accessory nipples may be observed along the milk line between axillae and groins. The most common site is just below the normal breast. Accessory breast tissue is most commonly seen between the true breast and the axilla and may increase in size initially with lactation but is rarely connected to the mammary ducts, although a rudimentary nipple may appear as a pore on the skin.

Box 3.1

CAUSES OF UNILATERAL ENLARGEMENT OF THE BREAST OR BREAST ASYMMETRY

Benign hypertrophy

Giant fibro-adenoma

Sarcoma

Filariasis

Localised skin retraction and dimpling is an important sign of infiltration by carcinoma. The breast stroma is traversed by fine fibrous bands that support the breast and have attachments to the dermis and to the fascia over the pectoralis major muscle. Invasive and sclerosing lesions within the breast, by involving these ligaments, can produce tethering and dimpling of the overlying skin.

The patient, while sitting, is asked successively to raise the hands fully above the head, to clasp hands behind the neck, to place hands on hips, to press the hands against the hips and to lean forwards. Asymmetry and distortion by a mass or skin tethering (Fig 3.1) and retraction, are often only detected by movements such as arm elevation or leaning forward, or by tension of the underlying chest muscles. Dermal oedema due to lymphatic obstruction causes a skin appearance resembling orange peel or pig skin (peau d’orange). This sign is a feature of a locally advanced cancer or a local inflammatory lesion such as an abscess or may follow treatment for breast cancer, particularly when the axillary lymph nodes have been dissected and when the patient has received radiotherapy to the conserved breast. Erythematous discoloration of skin may be due to underlying infection, duct obstruction during lactation or, occasionally, inflammatory malignancy. In the areola the nodules of Montgomery’s follicles are seen. These can sometimes become infected. Bilateral nipple retraction may be a developmental anomaly. A recent history of unilateral nipple retraction suggests underlying breast disease, particularly malignancy or periductal inflammation.

Figure 3.1 Skin tethering due to cancer only demonstrable when the patient raises her arms

Nipple discharge should be induced, if possible, by segmental compression around the areola, or assessed by examining the stain on underclothing. Spontaneous nipple discharge that is bloodstained or a clear sticky yellow fluid is most commonly due to duct papilloma, but occasionally indicative of serious intraduct pathology, particularly ductal carcinoma in situ. Physiological discharge may been seen in young women and during lactation. A thick creamy or green discharge suggests mammary duct ectasia and is rarely spontaneous. Hyperprolactinaemia due to a microadenoma of the pituitary gland is a rare cause of a copious milky discharge and some psychoactive medications may precipitate nipple discharge due to endocrine interactions. Cytological examination of the fluid may aid diagnosis.

Palpation is initially performed with the patient supine. A pillow is placed beneath the shoulder on the side being examined and the arm on that side is abducted with the hand placed behind the head (Fig 3.2). This spreads the breast over a larger area, reducing the depth of the breast tissue and thus facilitating palpation. The whole breast is palpated, including the axillary tail, using the palmar surfaces of the fingers with the hand flat. This avoids mistaking normal fat or glandular tissue for discrete lumps, a mistake that is common if the tips of the fingers are used. The detection of a discrete or dominant lump requires experience in palpating the normal texture of the breast and recognising the normal and cyclical variation. If a lump is discovered or the patient’s suspicion of a lump is confirmed, its physical characteristics are fully assessed. Many dominant lumps in the breast are cystic so that assessment for fluctuation is important; however, fluctuation will not be elicitable with deep cysts. The important physical characteristics of cancer are discreteness and induration. Fixity is usually a late sign except where a cancer is unusually superficial or in the infra-mammary fold of the breast.

Figure 3.2 Breast examination

Finally the patient is brought back to the seated position to complete the examination. Any lumps are assessed by palpation with one hand, then by both hands compressing the breast between them. Fixation of the lump to the underlying muscle is tested by assessing for change in mobility upon contraction of the pectoralis major muscle. The patient is asked to press her hand against the hip in order to contract the muscle. The axilla is palpated while resting the patient’s forearm on the examiner’s forearm. Palpable nodes are common in the normal axilla; firm nodes of 1 cm or more suggest involvement by metastatic tumour. Enlarged and tender nodes may indicate an inflammatory or infective process. The examination is completed by looking for signs of metastatic disease, palpation for supraclavicular nodes and for hepatomegaly and bone tenderness, particularly in the spine, and auscultation of the chest. A diagramatic record can then be made of the findings (Fig 3.3).

Figure 3.3 Scheme for recording the characteristics of breast lesions

Diagnostic tests

Percutaneous aspiration of a breast lump is often part of the routine physical examination, both to obtain a cytological specimen for diagnosis and to definitively treat breast cysts. Simple aspiration of breast cysts is both diagnostic and therapeutic. Cytological examination of the greenish-yellow fluid is not worthwhile, but cytology should be done if the aspirate is bloodstained or if the cyst is recurrent or if an ultrasound shows a complex lesion.

Imaging techniques: mammography, ultrasound

Imaging of breast tissue commonly utilises mammography and ultrasound. Mammography provides the most sensitive and specific method of screening an asymptomatic woman for signs of breast cancer. Examination of a symptomatic patient generally involves both mammography and ultrasound and ultrasound should be regarded as a focused investigation rather than a screening strategy. High-resolution ultrasound is useful in providing diagnostic information about solid and cystic masses and is increasingly used as a clinical tool to differentiate between ‘lumpy normal’ and breast pathology. Mammography is least useful in breasts with dense glandular tissue in women aged under 30 years. Imaging of dense breast tissue, particularly in women identified at high risk of developing breast cancer, is challenging. At present MRI (magnetic resonance imaging) has promising sensitivity and improving specificity and is of particular use in young women at high risk of breast cancer because of a genetic predisposition.

Positive signs of malignancy on mammography include an irregular infiltrating mass and focal pleomorphic microcalcification. Differentiation of mass lesions and calcified lesions uses a combination of mammographic workup including magnification, ultrasound and image-guided biopsy (Fig 3.4).

Figure 3.4 Mammographic and sonographic images of the breast

Mammographic and sonographic images of the breast often demonstrate the features of benign and malignant breast lesions.

(a) Breast cancer typically appears on a mammogram as a focal density with spiculate edges.

(b) Microcalcification can be associated with benign and malignant breast pathology and is graded according to its morphology. Typically malignant calcification is variable in size and shape and may cast the branching pattern of the milk ducts.

(c) Simple cysts may show as a discrete density on mammography, but ultrasound best demonstrates the smooth cyst wall and anechoic cyst fluid.

(d) Fibroadenomas may also appear as a discrete density on mammography and on ultrasound. A benign solid lesion should have more breadth than height.

Courtesy of Dr Manish Jain, MIA

Common causes

Clinical features and diagnosis

In most instances breast pain is cyclical. This condition is very common. Sometimes the pain is continuous, severe and disabling. There is often a premenstrual increase in pain and lumpiness. The condition is most common between the ages of 30 and 50 years and is unusual after menopause. Breast pain may be cyclical or noncyclical — the former is much more common. The severity of pain varies widely and cyclical pain may be regarded as a minor variation to normal swelling, tenderness and tenseness before or with the period. Severe symptoms may be associated with increased circulating prolactin.

On examination, tender lumpiness is felt in the breast, usually without a dominant lump. The association of a lump will require appropriate imaging and percutaneous cytological aspiration cytology or biopsy; management of the lump in such instances is the main problem. The diagnosis of pain can be established by regular review without recourse to radiological examination or biopsy. Patients are frequently reassured simply to have an explanation for their pain and may not require specific treatment. Appropriate diagnostic and screening tests should be undertaken on the basis of clinical signs and estimated risk of cancer (particularly age).

Treatment plan

Managing breast pain is often difficult. The principles of treatment are:

Bromocriptine (which reduces the circulating level of prolactin), danazol (an androgen), tamoxifen (a selective oestrogen receptor modulator (SERM) antagonist) and evening primrose oil (a source of essential fatty acid) have all been used with some success. The side effects of prolactin antagonists, SERMs and androgens can be severe and are usually unacceptable in a benign condition unless symptoms are severe. Evening primrose oil has been assessed by RCT and approximately 80% of women with cyclical breast pain respond to treatment, although the effect is not immediate. Danazol is used as a short course of treatment.