So let's now move on to the evaluation of a breast lump.
This is a 44-year-old woman who's
presenting with a lump in her right breast.
She first noticed it about 4 months ago and
says that it is painful just before menstruation.
So we're going to talk about the difference
between benign versus malignant breast lumps,
and we'll go through some basic features
of these two different kinds of lumps.
And then, of course, we'll move on to the physical
exam, which will be important in our assessment.
So typically benign breast lumps are slow growing.
They tend to be painful or
they're more likely to be painful.
They're encapsulated, which means that they
typically have a nice, smooth contour with symmetry
and they're rubbery.
You can push on them and they will compress.
They're not rock hard.
In contrast, malignant tumors
tend to be faster growing.
They are most often painless unless very advanced.
They're not encapsulated so
they don't have smooth edges.
They're much firmer, of course.
And importantly, we'd be looking
for signs of lymphadenopathy
if there's evidence of metastatic spread.
Quick review of the anatomy of the breast, remember
that most of the breast is composed of fatty tissue.
And then heading towards the nipple, we
have lobules that are emptying into ducts
and then the ducts converge at the
areola and exit via the nipple.
Common benign breast tumors include
fibroadenomas, which are most common
between the ages of 15 and 35.
These do not change with menstruation and they
can be brought on by oral contraceptive pills.
In contrast, fibrocystic changes are very common.
They tend to be exacerbated
around the time of menses.
So women will often report that they
have more painful breasts prior to menses
and then they can resolve after
the menstrual period is over.
And thirdly, Galactoceles.
These occur in women of childbearing age.
They are relatively firm subareaolar masses.
In contrast, here we have
the malignant breast cancers.
Ductal carcinoma, which are the most
invasive types of breast cancer.
Lobular carcinoma, which oftentimes
presents in both breasts simultaneously.
And then inflammatory carcinoma, which can actually
look all the world like cellulitis or mastitis
involving the breast.
Which is a good transition to talk about
infectious manifestations for breast enlargement.
Mastitis, particularly in
women who are breastfeeding,
and then the progression of mastitis can
lead to an actual abscess with fluctuants
within the wall of the breast.
In the assessment of any patient with a
breast lump, it's going to be very important
to make sure we do a thorough lymphatic exam.
This will be useful for screening, for
malignancy and of course, also for infection.
In general, lymph nodes are expected to be
less than a centimeter in size to be normal.
However, in the axilla, we'll actually
tolerate up to 2 or 3 centimeters in size
before we would get too concerned.
You'll always want to be comparing one
side to the other as symmetry is important
when we're comparing the different sizes
of lymph nodes that we can palpate.
Honing in on the lymphatic exam of the head
and neck, there are predictable regions
where lymph nodes tend to come together and
we may or may not be able to palpate them
in asymptomatic people, but it's
important to know where to look for them.
And we'll be covering those details more
when we move on to the physical exam.
Moving down from the head and neck,
we'll remind ourselves that the lymphatic
systems follow predictable lines of drainage,
with both extremities emptying
into the great vessels of the neck,
but the lower extremities
draining into the thoracic duct,
which then will drain into the left great vessels.
We were just talking about the size of lymph nodes.
And as I mentioned, in general,
a lymph node is more concerning
if it's greater than 2 centimeters in size,
if it's growing very quickly over time,
if there's asymmetry, the mobility of the
lymph node can also correlate with the
extent of concern that we should have.
Those that are mobile are
less likely to be malignant.
And lastly, lymph nodes that are tender are more
likely to be associated with infection than malignancy.
So returning to our case of our
middle aged woman with breast pain,
things that are on our differential would
include fibrocystic changes, a fibroadenoma,
breast cancer, of course, galactocele and mastitis.