Examination of the Breast

Physical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation (e.g., the evaluation of a palpable breast mass or skin/nipple changes).

Last updated: 6 Jan, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Introduction

Informed consent Informed consent Informed consent is a medicolegal term describing the documented conversation between a patient and their physician wherein the physician discloses all relevant and necessary information to a patient who is competent to make an informed and voluntary decision regarding their care. Competency, disclosure, and voluntariness are the key elements upon which IC is based. Informed Consent

  • To start, the practitioner should:
    • Explain the indication for the breast examination.
    • Describe the steps of the examination and what to expect.
    • Review what information might be obtained during the exam and subsequent steps for further evaluation if needed.
  • The practitioner should ensure the individual has good understanding Understanding Decision-making Capacity and Legal Competence, questions are answered, and agrees to proceed with the examination.
  • Given the sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques of the breast exam, a chaperone may be present in the room during the examination for the individual’s comfort.

Positioning for the exam

  • The individual is examined in both the sitting and supine positions.
  • The practitioner should be positioned: 
    • In front of the individual when examining in the sitting position 
    • To the right of the individual when examining in the supine position
  • Ensure good lighting and privacy.
  • Practice proper draping to preserve modesty.

Components of the breast examination

Anatomy

The anatomy of the breast and axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy as well as the relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship to the thorax should be reviewed before starting. Knowledge of the underlying tissue anatomy makes interpreting and describing the findings easier.

  • Structures include:
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
    • Nipple
    • Areola
    • Ducts
    • Lobules Lobules Breasts: Anatomy
    • Fatty tissue
    • Lymph nodes Lymph Nodes They are oval or bean shaped bodies (1 – 30 mm in diameter) located along the lymphatic system. Lymphatic Drainage System: Anatomy
  • Breast tissue: 
    • Lies against the anterior thoracic wall, extending from the clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture and 2nd rib down to the 6th rib, and from the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy across to the midaxillary line.
    • Consists of proportionally more glandular tissue in premenopausal women, and fatty tissue in postmenopausal women (when glandular tissue regresses)
  • Axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy:
    • Axillary tail of breast tissue
    • Lymphatics

Inspection

Inspection Inspection Dermatologic Examination

  • With the individual seated, undressed from the waist up, breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy exposed, and arms relaxed, observe for:
    • Scars: may indicate previous surgery (e.g., breast augmentation, breast reduction Breast Reduction Fat Necrosis of the Breast, lumpectomy Lumpectomy Fat Necrosis of the Breast, or mastectomy Mastectomy Surgical procedure to remove one or both breasts. Fat Necrosis of the Breast)
    • Asymmetry Asymmetry Examination of the Upper Limbs: breast outline/contour and bulging areas (may represent an underlying mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast)
    • Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions changes: dimpling or retraction, edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, ulceration Ulceration Corneal Abrasions, Erosion, and Ulcers, erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, or eczematous appearance (e.g., scaly, thick, raw skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions)
    • Nipple changes: symmetry, inversion, retraction, nipple discharge, or crusting
  • The individual raises the hands over and behind the head: Observe for tethering of breast tissue to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy.
  • The individual places the hands on the hips and leans forward:
    • The position contracts the pectoralis muscle, which accentuates puckering of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions if a mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast is tethered to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy.
    • Observe for any areas of retraction.

Skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions changes associated with breast pathology

  • Puckering of breast tissue: underlying malignancy Malignancy Hemothorax invading the suspensory ligaments 
  • Peau d’orange Peau D’Orange Mastitis
    • Dimpling of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions resembling an orange peel
    • Associated with inflammatory breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion
    • Area of redness Redness Inflammation and often breast tenderness
    • Differential diagnosis includes:
      • Infection: mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis (particularly if nursing), cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis, or abscess Abscess Accumulation of purulent material in tissues, organs, or circumscribed spaces, usually associated with signs of infection. Chronic Granulomatous Disease
      • Trauma
      • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Inspection of the breasts highlighting skin dimpling (peau d’orange)

Inspection Inspection Dermatologic Examination of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts: Anatomy highlighting skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions dimpling ( peau d’orange Peau D’Orange Mastitis)

Image by Lecturio.

Nipple findings

  • Differential diagnosis of nipple/areolar scaling associated with erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion and pruritus Pruritus An intense itching sensation that produces the urge to rub or scratch the skin to obtain relief. Atopic Dermatitis (Eczema) includes:
    • Paget disease
    • Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema)
    • Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis
  • Nipple inversion:
    • Can be a normal finding
    • Possible underlying pathological causes:
      • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
      • Breast abscess Breast Abscess Benign Breast Conditions
      • Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis
      • Mammary duct ectasia
  • Accessory nipple(s):
  • Nipple discharge: 
    • Note if the discharge is spontaneous or only present when expressed with palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination of the nipple/areolar complex.
    • Potential causes of breast discharge:
      • Milky discharge:
        • Normal in pregnancy Pregnancy The status during which female mammals carry their developing young (embryos or fetuses) in utero before birth, beginning from fertilization to birth. Pregnancy: Diagnosis, Physiology, and Care and breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding
        • Medications: oral contraceptives, antidepressants, and antipsychotics 
        • Pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types tumor Tumor Inflammation (i.e., prolactinoma Prolactinoma A pituitary adenoma which secretes prolactin, leading to hyperprolactinemia. Clinical manifestations include amenorrhea; galactorrhea; impotence; headache; visual disturbances; and cerebrospinal fluid rhinorrhea. Hyperprolactinemia)
      • Purulent discharge Purulent Discharge Dacryocystitis:
        • Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis
        • Central breast abscess Breast Abscess Benign Breast Conditions
      • Bloody discharge:
        • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer (rare)
        • Ductal carcinoma in situ
        • Intraductal papilloma Intraductal Papilloma Benign Breast Conditions
        • Mammary duct ectasia

Palpation

Positioning

  • The individual lies supine with the ipsilateral arm Arm The arm, or “upper arm” in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm: Anatomy raised overhead and shoulders resting on the exam table. 
  • The position stretches out breast tissue against the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy making palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination easier.

Draping

To preserve modesty, cover the individual with an extra gown/sheet and expose only the breast to be examined.

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination technique

  • Includes the breast and axillary tail (also known as the tail of Spence), the part of the breast extending into the axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy
  • Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination procedure:
    • Use small, overlapping, concentric circles with the pads (not the tips TIPS A type of surgical portasystemic shunt to reduce portal hypertension with associated complications of esophageal varices and ascites. It is performed percutaneously through the jugular vein and involves the creation of an intrahepatic shunt between the hepatic vein and portal vein. The channel is maintained by a metallic stent. The procedure can be performed in patients who have failed sclerotherapy and is an additional option to the surgical techniques of portocaval, mesocaval, and splenorenal shunts. It takes one to three hours to perform. Cirrhosis) of the middle 3 fingers.
    • Start at the axillary tail and move toward the anterior axillary line.
    • Overlap concentric circles in a vertical strip pattern (lawnmower approach) to cover the entire breast; the breast tissue extends from the sternum Sternum A long, narrow, and flat bone commonly known as breastbone occurring in the midsection of the anterior thoracic segment or chest region, which stabilizes the rib cage and serves as the point of origin for several muscles that move the arms, head, and neck. Chest Wall: Anatomy to the midaxillary line, and from the 2nd rib ( clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture) to the 6th rib.
  • Perform palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination at 3 depths:
    • Superficial, medium, and deep layers of the breast 
    • Use light, medium, and deep pressure in each area.
    • Include palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination of the subareolar tissue.
  • Palpate the nipple-areola complex to assess for nipple discharge:
    • Place the pad of the index finger in radial positions around the nipple, compressing the areolar tissue towards the nipple.
    • Note expression of discharge from any of the duct openings.
  • Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination technique for regional lymph nodes Lymph Nodes They are oval or bean shaped bodies (1 – 30 mm in diameter) located along the lymphatic system. Lymphatic Drainage System: Anatomy:
    • Axillary nodes:
      • Lay the individual supine with relaxed shoulders.
      • When examining the right axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy, the individual’s right forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term “forearm” is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm: Anatomy should be held with the right hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy and palpated with the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand: Anatomy (vice versa for examination of the left axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus: Anatomy).
    • Supraclavicular nodes:
      • Start medially in the supraclavicular fossa.
      • Work outwards towards the lateral border.
    • Infraclavicular nodes:
      • Start medially, inferior to the clavicle Clavicle A bone on the ventral side of the shoulder girdle, which in humans is commonly called the collar bone. Clavicle Fracture.
      • Work laterally.

Describe and Report Findings

Describe findings accurately to allow the practitioner to monitor for changes and, when imaging is required, communicate findings to the radiologist.

Inspection Inspection Dermatologic Examination

  • Symmetry or asymmetry Asymmetry Examination of the Upper Limbs
  • Any skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions changes
  • Any nipple changes

Palpation Palpation Application of fingers with light pressure to the surface of the body to determine consistency of parts beneath in physical diagnosis; includes palpation for determining the outlines of organs. Dermatologic Examination

  • Describe masses or changes in the texture Texture Dermatologic Examination of the breast tissue:
    • Size in cm
    • Location:
      • Quadrant of the breast and distance from the nipple in cm 
      • Quadrant of the breast: upper outer, upper inner, lower outer, and lower inner
      • May also be described by numbers on a clockface and distance from the nipple
    • Shape: round, disc-like or irregular in contour
    • Consistency Consistency Dermatologic Examination: soft, firm, or hard
    • Delimitation: well-circumscribed or not
    • Tenderness
    • Fluctuance
    • Mobility: fixed or mobile:
      • Moves freely
      • Moves with overlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions
      • Moves with pectoral contraction
  • Describe any overlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions changes (e.g., erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion or puckering).
  • Describe any nipple discharge:
  • Describe any palpable lymph nodes Lymph Nodes They are oval or bean shaped bodies (1 – 30 mm in diameter) located along the lymphatic system. Lymphatic Drainage System: Anatomy:
    • Size in cm
    • Location: axillary, supraclavicular, or infraclavicular
    • Consistency Consistency Dermatologic Examination: soft, firm, or hard
    • Tender or nontender
    • Fluctuance
    • Mobility: fixed or mobile

Important conditions

Table: Common breast masses
Fibroadenoma Fibroadenoma Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenoma Fibrocystic Fibrocystic Fibrocystic Change changes Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
Usual age 15–35 years old 30–50 years old with regression Regression Corneal Abrasions, Erosion, and Ulcers after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause (except on estrogen replacement therapy Estrogen Replacement Therapy The use of hormonal agents with estrogen-like activity in postmenopausal or other estrogen-deficient women to alleviate effects of hormone deficiency, such as vasomotor symptoms, dyspareunia, and progressive development of osteoporosis. This may also include the use of progestational agents in combination therapy. Menopause) 30–90 years old (most common over the age of 50)
Number Usually single but may be multiple Single or multiple Usually single although may coexist with other nodules
Shape Round, small Round Irregular or stellate
Consistency Consistency Dermatologic Examination Firm Soft to firm, usually elastic Elastic Connective Tissue: Histology Firm or hard
Delimitation Well-delineated Well-delineated Not clearly delineated from surrounding tissues
Mobility Mobile Mobile May be fixed to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Skin: Structure and Functions or underlying tissues
Tenderness Usually nontender Often tender Usually nontender
Retraction signs Absent Absent May be present

Clinical Relevance

  • Fibroadenoma Fibroadenoma Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenoma: the most common benign Benign Fibroadenoma breast tumor Tumor Inflammation. The etiology is unknown, but a hormonal relationship Relationship A connection, association, or involvement between 2 or more parties. Clinician–Patient Relationship exists. Exam findings include a well-defined, mobile, firm mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. A diagnosis is made using a core biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Most fibroadenomas do not require intervention, but surgical excision may be indicated to confirm the diagnosis.
  • Breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer: the most commonly diagnosed malignancy Malignancy Hemothorax globally (surpassing lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer). A hard, immobile, single, dominant mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast with irregular borders on exam, which requires further evaluation with imaging studies and biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Suspicion for cancer can also be raised on screening Screening Preoperative Care mammography Mammography Radiographic examination of the breast. Breast Cancer Screening in the absence of a palpable mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Management includes surgical removal ( lumpectomy Lumpectomy Fat Necrosis of the Breast or mastectomy Mastectomy Surgical procedure to remove one or both breasts. Fat Necrosis of the Breast) and may also include chemotherapy Chemotherapy Osteosarcoma, radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma, and/or hormone therapy.
  • Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis: lactational or nonlactational inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body’s defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of breast tissue, which may or may not be accompanied by infection. Mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis is often caused by a blocked milk duct. Exam findings include erythema Erythema Redness of the skin produced by congestion of the capillaries. This condition may result from a variety of disease processes. Chalazion, swelling Swelling Inflammation, induration Induration Dermatologic Examination, tenderness, and warmth to the touch. Diagnosis is clinical. Management is symptomatic of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways and swelling Swelling Inflammation, complete emptying of the breast (lactational), and sometimes antibiotic therapy.
  • Breast abscess Breast Abscess Benign Breast Conditions: a localized collection of inflammatory exudate Exudate Exudates are fluids, cells, or other cellular substances that are slowly discharged from blood vessels usually from inflamed tissues. Pleural Effusion in the breast tissue. A breast abscess Breast Abscess Benign Breast Conditions is the 1st sign of a breast infection, or a consequence of mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis or cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis not responding to antibiotic treatment. Exam findings include a fluctuant Fluctuant Dermatologic Examination, tender, palpable mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast. Diagnosis is made clinically and can be confirmed via ultrasonography. Management is by incision and drainage Incision And Drainage Chalazion or ultrasound-guided aspiration. 
  • Paget disease of the breast: a rare breast carcinoma presenting with scaly, itching, bleeding or ulcerative lesions, beginning on the nipple and spreading to the areola. Exam findings include scaling of the nipple/areola and occasionally bloody nipple discharge. Diagnosis is made by biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma. Management is by surgery and may include chemotherapy Chemotherapy Osteosarcoma and/or radiation Radiation Emission or propagation of acoustic waves (sound), electromagnetic energy waves (such as light; radio waves; gamma rays; or x-rays), or a stream of subatomic particles (such as electrons; neutrons; protons; or alpha particles). Osteosarcoma therapy.
  • Galactorrhea Galactorrhea Excessive or inappropriate lactation in females or males, and not necessarily related to pregnancy. Galactorrhea can occur either unilaterally or bilaterally, and be profuse or sparse. Its most common cause is hyperprolactinemia. Hyperprolactinemia: milky, unilateral or bilateral nipple discharge unrelated to breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding. Common causes include excessive breast stimulation, benign Benign Fibroadenoma pituitary Pituitary A small, unpaired gland situated in the sella turcica. It is connected to the hypothalamus by a short stalk which is called the infundibulum. Hormones: Overview and Types tumor Tumor Inflammation ( prolactinoma Prolactinoma A pituitary adenoma which secretes prolactin, leading to hyperprolactinemia. Clinical manifestations include amenorrhea; galactorrhea; impotence; headache; visual disturbances; and cerebrospinal fluid rhinorrhea. Hyperprolactinemia), hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism, and medications. Management involves addressing the underlying cause.

References

  1. Potter, L. (2021). Breast examination – OSCE guide. Geeky Medics. Retrieved from https://geekymedics.com/breast-examination-osce-guide/
  2. Bickley, L.S. (2017). The Breasts and Axillae. Bates’ Guide to Physical Examination and History Taking (12th edition, pp. 419-445).
  3. Drake W.M. et al. (2018). General patient examination and differential diagnosis. In Glynn M. et al. (Ed.), Hutchison’s Clinical Methods (24th edition, pp. 26-27)
  4. Sabel, M.S. (2021). Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass. In Chagpar A.B. et al. (Ed.), UpToDate. Retrieved October 4, 2021, from: https://www.uptodate.com/contents/clinical-manifestations-differential-diagnosis-and-clinical-evaluation-of-a-palpable-breast-mass
  5. Newton, E.V. (2018). Breast Examination. In Isaacs C. et al. (Ed.), Medscape. Retrieved October 4, 2021, from: https://emedicine.medscape.com/article/1909276
  6. Sung, H.S., Ferlay, J., Siegal, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians. 04 February. Retrieved from: https://doi.org/10.3322/caac.21660

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