1. Disorders of the Breast

2. Breast Exam

3. Inspection Size Symmetry (some variation is normal) Shape
Contour (flattening, masses, and dimpling)
Skin (color, edema, rashes, thickening, and venous pattern)
Scars (previous surgery, injuries)

4. Inspection
Patient arm maneuvers
Overhead
Waist
Leaning forward

5. Palpation
Lymph nodes
Cervical
Axillary
Supraclavicular

6. Palpation Bimanual palpation with patient sitting
Use right hand above the left hand below to palpate right breast. Use pads of fingers to compress breast tissue (check for consistency, nodules, masses, and tenderness).
Repeat for left side by standing on left side and reversing hands (left on top, right on bottom)

7. Palpation Palpation while patient supine
Ask patient to put arm overhead
Use flat part of fingers (and a rotary motion) against chest wall using radial or spiral pattern
Note tissue consistency, elasticity, nodules, indurations, masses, and tenderness
Palpate all quadrants of breast (including up to clavicle and towards axilla)

8. Palpation While supine Inspect and palpate nipples
Look for size, shape, inversion, rashes, ulceration, discharge, scaling, crusting, elasticity, retraction, areolar edema and masses
Gently grasp and compress nipple and areolar tissue between thumb and index finger, noting color consistency and quantity of any discharge

9. Exam findings suspicious for breast cancer
Hard, immovable lesion with irregular borders
Axillary adenopathy
Skin changes – erythema, thickening, dimpling (peau d’orange)
Inflammatory breast cancer
Metastatic disease
Bone (back or leg pain)
Liver (abdominal pain, nausea, jaundice)
Lungs (SOB, cough)

10. Risk for Breast Cancer
1 in 8 women cumulative lifetime risk of breast cancer
Woman age 50-59, lifetime risk of having breast cancer is 1 in 36
Woman age 70-79, risk increases to 1 in 24

11. Risk Factors for Breast Cancer
Age
Smoking
Prior personal history
Mammographic breast density
Family history
Genetics
BRCA 1&2 mutations
Nullparity
Late childbearing
1st pregnancy > 30 years
Early menarche
Late menopause
Fibrocystic changes with atypia
History of breast radiation
Hormone exposure
Obesity
Excessive alcohol use
>2 drinks/day

12. Benign Breast Disorders
Fibrocystic changes
Most common
Cyclical, bilateral, pain, and engorgement
No discrete or well-defined mass, but breast tissue frequently nodular
Fibroadenoma
2nd most common
Fibrous and glandular tissue
Occurs in young women
Firm, painless, mobile mass

13. Benign Breast Disorders
Intraductal Papilloma
Commonly found in peri and menopausal women
Bloody, serous, or turbid nipple discharge
Excisional biopsy often needed
Galactocele
Cystic dilation of duct filled with thick, milky fluid
Common in women breast feeding
Secondary infection causes mastitis
Needle aspiration often curative

14. Benign Breast Disorders
Fat necrosis
Occurs after blunt trauma, operative procedures, or radiation therapy
Breast cyst

15. Algorithm for palpable breast abnormalities < 30 years old
* If no cytologic expertise available, initial ultrasound preferred.
• If cytology indicates cancer, treat as appropriate. If nondiagnostic, indeterminate or atypia, do ultrasound.

16. Algorithm for palpable breast abnormalities > 30 years old
When lesions are palpable, clinically directed biopsies are often the most efficient. Fine-needle aspiration (FNA) is the biopsy of choice
* May be useful to incorporate a staging MRI into the management

17. Nipple Discharge Lactation Galactorrhea
Bilateral milky nipple discharge
Usually caused by hyperprolactinemia
Medications (antipsychotics, antidepressants, antiemetics, antihypertensive, opioid)
Endocrine tumors
Endocrine abnormalities (hypothyroid)
Neurogenic stimulation
Stress
Purulent nipple discharge – associated with periductal mastitis

18. Nipple Discharge Pathologic (suspicious)
Unilateral, localized to a single duct, persistent, and spontaneous
Can be serous, sanguineous, or serosanguineous

19. Algorithm for spontaneous nipple discharge (non-lactating)
* Breast ultrasound is recommended for imaging all patients with nipple discharge. Mammograms are recommended for women ≥ age 30.

20. Mastalgia Cyclical Noncyclical
Associated with changes in menstrual cycle
Bilateral, most severe in upper outer quadrant of breast
Noncyclical
More likely unilateral and variable location
Some causes:
Large pendulous breasts
Hormone replacement therapy
Duct ectasia
Mastitis or breast abscess (common in lactating women)
Inflammatory breast cancer
Hidradenitis suppurativa

21. Workup mastalgia History and physical exam
Looking for signs suggesting malignancy
Clinical judgment on any diagnostic imaging studies
For focal pain without a mass, or a history/exam not consistent with classic cyclical pain
Targeted ultrasound or mammogram

22. BI-RADS mammographic assessment categories

23. Management algorithm for abnormal mammograms
This algorithm helps to guide management of the patient who presents with an abnormal mammogram, whether it is performed at your institution or outside. BIRADS 4 is a broad category that includes patients with a probability of malignancy that ranges from 2 to 95 percent. The management of more suspicious lesions (>50 percent probability) should include surgical evaluation before percutaneous biopsy. The designation often implies lower suspicion of malignancy. Also, some patients and some lesions are not appropriate candidates for percutaneous biopsy.

24. Resources https://www.apgo.org/education/clinical/breast- exam.html