Clinical Breast Examination: Lump, Pain and Benign Changes
Essentials
All palpated lumps and suspicious visual changes must be further examined.
In the investigation of palpable lesions, a triple diagnostic approach is used: clinical examination, imaging studies and needle biopsy (cytological/histological).
Benign breast changes are common; fibrocystic changes are found in every fourth woman in fertile age.
Fibrocystic changes are not associated with increased risk of breast cancer.
Breast cancer risk is to some extent increased in a radiologically dense breast tissue.
Breast cancer risk is 1.5-2.0-fold in ductal hyperplasia, lobular hyperplasia (without atypia), sclerosing adenosis, diffuse papillomatosis, complex fibroadenoma and radial scar changes.
Clinical examination
The optimal time for the examination is about 10 days after menstruation when the pain and swelling, caused by hormonal changes, are at their lowest. Symptomatic patients should be examined regardless of the phase of the menstrual cycle.
Visually inspect the breasts while the patient is sitting down, first with arms at side and then up behind her head. Note
possible asymmetry
skin: rash, coarseness, indurations, bruising, ulceration and tightening or retraction of the breast tissue or nipple.
Palpate the breast while the patient is lying down with one arm stretched to the side or over the head.
Examine the entire breast area, preferably always following the same sequence.
At first, palpate the breast tissue quadrant by quadrant using your finger tips / finger pads.
Continue palpating each area of the breast by using circular movements and applying gentle pressure against the chest wall, now using the entire length of the fingers. Pay particular attention to any areas of possible thickening. Note whether the area is painful, does it compress as anticipated, is it soft or hard and is it mobile in relation to surrounding tissue.
Note any discharge from the nipple. If the patient reports discharge from the breast palpate and gently squeeze the nipple in order to establish whether the discharge is unilateral or bilateral Nipple Discharge and Mastitis in a Non-Lactating Woman.
When examining the axilla support the patient's arm to eliminate any muscle tension that might interfere with the examination of axillary lymph nodes. Palpate the axillae carefully by feeling against the chest wall. Examine the supraclavicular fossae separately.
Follow-up studies
When investigating palpable lesions, so-called triple diagnostic approach is used: inspection and palpation, imaging studies and cytological or histological examination of needle biopsy specimen.
All palpated lumps and suspicious visual changes (retraction, skin changes) must be checked with mammography and ultrasound examination. Fine-needle biopsy or core biopsy should be carried out as indicated. If the aetiology cannot be identified, the entire lump should be surgically removed.
If tenderness and a mass with poorly defined margins are noted before the menstrual cycle, it is worthwhile to examine the breasts again after menstruation, and if the findings remain abnormal refer the patient for further investigations.
Abnormal skin changes, abnormalities noted on palpation, painful or discharging breast
Ultrasound examination is used in conjunction with mammography for diagnostics and for assistance in collection of specimens.
If less than 6 months have lapsed from previous mammography examination and ultrasound is deemed suitable for the examination of the particular change, it may be used instead of mammography.
Magnetic resonance imaging (MRI) of the breasts is used as complementary and specifying examination.
The necessary imaging studies are performed before sample taking, as bleeding caused by the puncture may impede the interpretation of mammography images.
Biopsy samples are obtained either using a thin or a core needle under ultrasound or mammography guidance.
Core-needle biopsy provides better accuracy and also information concerning the invasiveness of cancer.
Thin-needle biopsy is suitable for examination of cyst fluid.
Calcified lesions are biopsied primarily using stereotactic technique under mammography guidance.
If triple diagnostics do not provide full proof of the benign nature of the lesion, the whole affected area is removed.
Wire markers or colour marking may be used to ensure that the entire suspicious area is removed. Colour marking is used to assist the surgical excision of a discharging duct.
Biopsy can be taken from other skin lesions than those located in the nipple or in the areola (possibly Paget's disease; picture 1) but not before imaging studies of the breast are carried out. The radiologist often performs punch biopsy in association with the imaging.
Benign breast changes
Normal variation
Breasts are seldom totally symmetric. Even a fairly considerable size difference may be considered as a normal variation. One breast may be rudimentary or totally absent.
There may be several mammary glands. Excessive nipples or additional mammary gland tissue in the axillary region is fairly common (and requires no further management).
Fibrocystic changes
Fibrocystic breast changes occur in approximately 25% of menstruating women and in up to half of perimenopausal women. Cysts or epithelial hyperplasia may form in the mammary ducts leading to fibrosis.
Characteristic symptoms include tenderness, pain and swelling 1-2 weeks before menstruation.
There are three main types of change: cystic changes, ductal hyperplasia and connective tissue reactions.
The cysts are usually 1-2 mm in diameter, but in one case out of three they may develop up to 2-3 cm in size and become tender. The size may vary according to the menstrual cycle.
Mammary ductectasia
Usually an asymptomatic incidental finding in a menopausal woman.
Occasionally, inflammation around the dilated mammary duct causes fibrosis and a scar lump, and the nipple may invert.
Watery or bloody discharge from the nipple.
Epithelial hyperplasia may lead to the formation of a fibrotic, tender breast lump.
Hyperplastic changes are associated with an increased risk of becoming malignant, particularly if the patient has a strong family history of breast cancer (up to 10-fold increased risk), the change is partly calcified or the needle biopsy shows lobular hyperplasia.
Fibroadenoma
In 10% of women, most common in young women
Typically a smooth mass that is mobile to adjacent structures and non-tender (size does not vary according to menstrual cycle)
The changes are seen well circumscribed in mammography and hyperechoic in ultrasonography.
Lipoma
Soft, non-tender, fairly mobile against the surrounding tissue.
Usually occur around the age of 45 years.
Density in mammography responds to the density of surrounding adipose tissue.
Intraductal papilloma
Hyperplastic change, in 75% of cases associated with nipple discharge
Not palpable
May be single or multiple; in the latter case, the term papillomatosis is used.
Papillomatosis is associated with a risk of malignancy, single lesions only seldom.
Phylloid tumour
Large lesion of the same type as fibroadenoma
Poorly defined borders
Needle biopsy will show hypercellular stroma.
May be benign, borderline or malignant.
Treated by surgical removal
Fat necrosis
May follow previous trauma, inflammation or surgical procedure.
The process may mimic malignancy.
The area of fat necrosis is irregular and tender on palpation. Induration, attachment to surrounding tissues and skin retraction may also be present.
Calcium deposits will form at the site of fat necrosis with time.
Mastalgia (mastodynia, pain in the breast)
Mastalgia may be unilateral or bilateral, cyclic (about 70%) or continuous (about 25%). In over 5% of cases, mastalgia proves to be of chondorcostal origin in the breast area.
Mastalgia associated with breast cancer is unilateral and usually continuous.
Pain is the only sign of cancer in only 5% of cases.
Investigations
Careful history
Clinical breast examination
Mammography and ultrasound examination if indicated
Treatment
If no tumour is detected, the majority of patients will be satisfied knowing that the complaint is benign.
After specialist consultation, bromocriptine 2.5 mg/day, starting on day 14 of the menstrual cycle, may be tried in rare cases.
References
Dagistan E, Kizildag B, Gürel S et al. Radiologic and histopathologic review of rare benign and malignant breast diseases. Diagn Interv Radiol 2017;23(4):286-292. [PubMed]
Guirguis MS, Adrada B, Santiago L et al. Mimickers of breast malignancy: imaging findings, pathologic concordance and clinical management. Insights Imaging 2021;12(1):53. [PubMed]
Evans A, Trimboli RM, Athanasiou A et al. Breast ultrasound: recommendations for information to women and referring physicians by the European Society of Breast Imaging. Insights Imaging 2018;9(4):449-461. [PubMed]
Stachs A, Stubert J, Reimer T et al. Benign Breast Disease in Women. Dtsch Arztebl Int 2019;116(33-34):565-574. [PubMed]
Xiang W, Huang Z, Tang C et al. Use of ultrasound combined with magnetic resonance imaging for diagnosis of breast masses and fibroids. J Int Med Res 2019;47(7):3070-3078. [PubMed]
Catanzariti F, Avendano D, Cicero G et al. High-risk lesions of the breast: concurrent diagnostic tools and management recommendations. Insights Imaging 2021;12(1):63. [PubMed]