This presentation done by Family resident R1 Any mistake "if there" is from the sources

1. APPROACH
TO BREAST
LUMP, PAIN,
NIPPLE
DISCHARGE
D R . L A M YA A A LG H A F L I , R 1

2. BREAST LUMP

3. DEFINITION
• A breast lump is a growth of tissue that develops within breast.
• A breast mass may be benign or malignant.
• A benign mass may be solid or cystic, whereas a malignant mass is typically solid.
• A cystic mass with solid components (complex cyst) can also be malignant.
• Thorough clinical breast examination, imaging, and tissue sampling are needed for a
definitive diagnosis.

4. RISK FACTORS FOR BREAST CANCER
1. Well-established risk factors
 Age 50 or older
 Benign breast disease, especially cystic
disease, proliferative types of
hyperplasia, and atypical hyperplasia
 Exposure to ionizing radiation
 First childbirth after age 20
 Higher socioeconomic status
 History of breast cancer
 History of breast cancer in a first-
degree relative
 Hormone therapy
 Nulliparity
 Obesity (i.e., BMI ≥ 30 kg per m2)

5. CONT…
2. Probable risk factors 3. Possible risk factors
Alcohol consumption Chemical exposure
Did not breastfeed Diet high in fat
Elevated endogenous estrogen levels Diet low in beta carotene,
vitamins A and C
High BMI Diet low in fruits and
Hormonal contraception therapy
Increased mammographic density of breast tissue
Menarche before age 12
Menopause after age 45
Mutations in BRCA 1 and BRCA 2 genes

6. INITIAL EVALUATION
HISTORY
1. Breast lump characteristics 3. Medical and surgical history
 Changes in size over time Personal history of breast cancer
 Change relative to menstrual cycle Previous breast masses and biopsies
 Duration of mass Recent breast trauma or surgery
 Pain or swelling Recent radiation therapy or
 Redness, fever, or discharge Other exposure to radiation
2. Diet and medications 4. Family history
 Current medications History of breast disease
 History of hormone therapy Relationship to patient
Relative’s age at onset

7. CONT…
5. Personal characteristics 6. Social history
 Age at menarche Radiation and chemical
 Age at menopause Smoking
 Current age
 Current lactation status
 History of breastfeeding
 Number of children

8. PHYSICAL EXAMINATION
• Includes assessment of both breasts and the chest, axillae, and regional lymphatics.
• In premenopausal women, it is best done the week following menses, when breast
tissue is least engorged.
• With the patient in an upright position, Inspect the breasts:
Noting asymmetry
Nipple discharge
Obvious masses
Skin changes, such as dimpling, inflammation, rashes, and unilateral nipple retraction
or inversion

9. CONT…
• With the patient supine and one arm raised, palpate:
Breast tissue on the raised-arm side in the superficial, intermediate, and deep tissue
planes (i.e., the “triple touch” technique)
Axilla
Supraclavicular area
Neck
Chest wall
• Assessing the size, texture, and location of any masses.

10. CONT…
• Benign masses generally cause no skin change and are smooth, soft to
firm, and mobile, with well-defined margins.
• Diffuse, symmetric thickening, which is common in the upper outer
quadrants, may indicate fibro-cystic changes.
• Malignant masses generally are hard, immobile, and fixed to surrounding
skin and soft tissue, with poorly defined or irregular margins.
• Mobile or nonfixed masses can be cancerous.
• Infections such as mastitis and cellulitis tend to be erythematous, tender,
and warm to the touch. They may be more circumscribed if an abscess
formed.
• Similar symptoms may occur in patients with inflammatory breast cancer.
Therefore, caution should be used in assessing patients with suspected
breast infections.

11. APPROACH TO BREAST LUMP
• After the clinical breast examination is performed, the evaluation
depends largely on the patient’s age and examination characteristics,
and the physician’s experience in performing fine-needle aspiration.
• Fibroadenoma is the most common benign breast mass; invasive ductal
carcinoma is the most common malignancy.
• Trauma to the breast may result in a breast mass due to the
development of fat necrosis or a hematoma. Any mass after a trauma
that fails to resolve will require a complete evaluation.

12. Key clinical recommendation Label
Ultrasonography-guided CNB to diagnose malignancy in women with palpable breast
lesions.
C
In young women with dense breast tissue, ultrasonography should be used to detect
breast lesions.
C
Mammography should be used to detect in situ carcinomas of the breast. C
Diagnostic mammography is indicated in women older than 40 years if FNA reveals a
solid mass.
C
Excisional biopsy should be performed in women with clinically suspicious lesions, or
lesions that are equivocal on imaging, FNA, or CNB.
C
Cystic lesions that resolve after FNA do not require further evaluation unless they recur. C
If CBE, FNA, and imaging indicate benign disease, the CBE should be repeated in four
six weeks.
C
CNB = core-needle biopsy; FNA = fine-needle aspiration; CBE = clinical breast examination.

13. TRIPLE TEST
• The triple test is the combination of results from CBE, imaging, and tissue sampling.
• When the three assessments are performed adequately and produce concordant
results, the triple test diagnostic accuracy approaches 100 percent.
• A three-point scale is used to score each component of the triple test (1 = benign, 2 =
suspicious, 3 = malignant).
• A TTS of 3 or 4 is consistent with a benign lesion; a TTS of 6 or more indicates
possible malignancy that may require surgical intervention.
• Excisional biopsy is recommended in patients with a TTS of 5 to obtain a definitive
diagnosis.

15. BI-RADS CLASSIFICATION
• Normal mammography does not exclude the presence of cancer because it misses
about 10 to 15 percent of clinically palpable breast cancers.
• BI-RADS classification developed to describe mammography results.
• In general, most palpable masses are considered suspicious for malignancy and are
assessed as BI-RADS 4 or higher.
• A palpable breast mass that is not visualized on mammography warrants further
workup.
• Routine follow-up is acceptable in patients with benign findings.
• Suspicious abnormalities should be biopsied.

17. BREAST PAIN

18. INTRODUCTION
• Evaluation of breast pain (mastalgia) is important to determine whether the pain is due
to normal physiological changes related to hormonal fluctuation or to a pathologic
process such as breast cancer.
• Breast pain is usually mild, affect approximately 11 percent women.
• Breast pain may be cyclical (two-thirds) or noncyclical (one-third).

19. CYCLICAL PAIN
• Cyclical pain associated with hormonal changes of the menstrual cycle, usually
presenting in the week prior to onset of menses, bilateral, and most severe in the
upper outer quadrant of the breasts.
• For many women, cyclical breast pain can cause problems with their activities of daily
living. This interfered with:
●Sexual activity
●Physical activity
●Social activity
●School activity

20. NONCYCLICAL PAIN
• Noncyclical pain is more likely related to a breast or chest wall lesion and may be
constant or intermittent. Solitary cysts, when the presentation is abrupt, are frequently
painful.
• Noncyclical breast pain does not follow the usual menstrual pattern and is more likely
to be unilateral and variable in its location in the breast. Multiple etiologies can cause
noncyclical breast pain.

21. CONT…
Noncyclical breast pain:
• Large pendulous breasts: cause pain due to stretching of Cooper's ligaments. Neck,
back, and shoulder pain, rash and headache may be present.
• Diet and lifestyle:
Nicotine may increase breast pain.
• Hormone replacement therapy.
• Ductal ectasia characterized by distention of subareolar ducts due to inflammation
unrelated to infection associated with fever and acute local pain and tenderness
caused by penetration of the duct wall by lipid material, which may resolve to leave a
subareolar nodule.

22. CONT…
• Mastitis or breast abscess: most common in lactating women in the first month after
giving birth, but can also occur in women not lactating. It is usually caused by an
obstructive lactopathy
When initiating lactation, the nipple and areolar skin often undergo local inflammation
and swelling. This swelling results in relative obstruction to milk flow that can then be
seeded by skin bacteria (Staphylococcus aureus or Streptococcal species) leading to
bacterial mastitis. The breast becomes diffusely painful, swollen, and red; with an area of
fluctuance and eventually pointing if an abscess develops.

23. CONT…
• Inflammatory breast cancer: present with pain and a rapidly progressing tender, firm,
enlarged breast. The skin over the breast is warm and thickened, with a "peau
d'orange" (orange skin) appearance, but there is often no fever or leukocytosis.
• Hidradenitis suppurativa: can involve the breast and present as breast nodules and
pain.
• Other: pregnancy, thrombophlebitis, trauma, macrocysts, prior breast surgery, and a
variety of medications (hormones as well as some antidepressants, cardiovascular
agents, and antibiotics).

24. EXTRAMAMMARY PAIN
Extramammary pain may be from musculoskeletal sources such as chest wall pain, spinal or
paraspinal problem, trauma or scarring from prior biopsy.
• It may also be related to medical problems such as biliary, pulmonary, esophageal, or
cardiac disease.
• Chest wall pain: is frequently due to the pectoralis major muscle, related to actions that
strain or use the pectoral muscle repetitively. The pain can be reproduced by asking the
patient to place her hand flat on the iliac wing and push inward.
 usually presenting bilateral, parasternal discomfort, can arise from costochondritis (typically
the second through fifth costochondral junctions) or Tietze's syndrome (typically second
and third costochondral junctions).
 Local heat, analgesics and reassurance are the management.

25. CONT…
• Spinal and paraspinal disorders: occurs in older women in whom vertebral, spinal, and
paraspinal problems in the neck and upper thorax accumulate with age.
• Other – Chest wall pain induced by trauma or trauma-induced fat necrosis, intercostal
neuralgia often due to a respiratory infection, and underlying pleuritic lesions can mimic
benign breast disease. Gallbladder disease or ischemic heart disease may present as
intermittent chest pain.
 Postthoracotomy syndrome is an unusual disorder in which a healing chest wound
simulates the effect of a suckling infant. It can be associated with an elevated prolactin
concentration, breast pain, and milk production. A similar effect can be seen with other
forms of chest wall irritation, including burns and chafing from clothing overlying the
nipple.

26. ASSOCIATION WITH BREAST CANCER
• Mastalgia has not been shown to be a risk factor for breast cancer.
• The presence of an associated breast cancer in a patient who presents with only pain is
extremely low, ranging from 0.5 to 3.3 percent.
• The pain is typically associated with adjacent benign, cystic breast tissue rather than
the cancer.
• Pain may also occur following a core biopsy of the cancer rather than being associated
with the cancer itself.

27. MALE BREAST PAIN
• Breast pain in men is usually due to gynecomastia.

28. HISTORY
-Pain site -Concurrent neck, back, or shoulder problem
-Unilateral or bilateral -Fever
-Pain character -Local erythema
-Pain severity -Phasic or not
-Drug history specially OCP
-Beginning of the pain after a recent birth or pregnancy loss or termination
-Related to vigorous or repetitive use of the pectoral muscle group
-Recent trauma to the chest, affecting her daily activity

29. PHYSICAL EXAMINATION
• The four breast quadrants, subareolar areas, axillae, supraclavicular and infraclavicular areas
should be examined with the woman both lying and sitting with her hands on her hips and
then above her head.
• Check for skin changes noting the symmetry and contour of the breasts, position of the
nipples, scars, skin retraction, dimpling, edema or erythema, ulceration or crusting of the
nipple, and changes in skin color
• Check for enlarged axillary, supraclavicular, or infraclavicular lymph nodes
• Delineate and document breast masses
• Check for nipple discharge
• Identify localized areas of tenderness and relate them to areas of pain noted by the woman
and to other physical findings

30. EVALUATION
• For most women who present with breast pain, If the pain is diffuse and symptoms
classic for cyclical breast pain, neither a mammogram nor ultrasound are needed.
• In that clinical setting, a targeted ultrasound is the optimal study for women under age
30 with no high risk factors for breast cancer (eg, family history of premenopausal
breast cancer).
• For women over age 30, a mammogram and a targeted ultrasound can be performed.
• For women with focal pain without a mass, a targeted ultrasound or a mammogram
should be performed.

31. CONT…
• In the clinical setting of a suspicious finding, a mammogram is performed for women
of any age.
• Positive imaging studies require appropriate follow-up.

32. TREATMENT
• Role of diet and lifestyle:
A low fat, high complex carbohydrate diet has been effective in some observational
studies.
Elimination of caffeine has not been effective in controlled trials, although it seems to be
helpful in some women.
• Symptomatic relief:
Support garments: A well-fitting brassiere to better support breast.
The use of support bra with steel underwire tends to reduce mastalgia in women with
pendulous breasts.
Use of a "sports bra" during exercise has been shown to reduce pain related to breast
movement.
Compresses: Some women obtain relief from application of warm compresses or ice
or gentle massage.

33. CONT…
• Medical therapy:
Acetaminophen or NSAID, or both can be used to relieve breast pain. Topical NSAIDs
may also be useful.
Postmenopausal hormone therapy can cause breast pain and should be decreased
discontinued.
Oral contraceptives can reduce breast pain severity and duration in some women
cyclical symptoms.
Progestogens also improve breast pain symptoms in some women.

34. CONT…
Danazol is the only medication approved by the US FDA for the treatment of mastalgia.
It is effective at relieving breast pain and tenderness but it causes significant
androgenic effects.
For patients with more severe mastalgia, tamoxifen 10 mg can provide breast pain
relief. Tamoxifen also increases the risk of blood clots, strokes, uterine cancer, and
cataracts. Tamoxifen is infrequently used for this indication.

35. Clinical recommendation Evidence rating
Ultrasonography should be performed
in all patients with focal breast pain,
with adjunctive mammography in
patients 30 years and older.
C
Danazol can be used to treat mastalgia.
Dosing only during the luteal phase
may reduce androgenic effects.
A

36. APPROACH TO THE PATIENT WITH BREAST PAIN

37. NIPPLE DISCHARGE

38. NIPPLE DISCHARGE
• Nipple discharge is the one of the most commonly encountered breast complaints.
• Most nipple discharge is benign origin.
• The clinical history is most helpful in distinguishing benign from suspicious or
pathologic nipple discharge.
• Benign nipple discharge is usually bilateral, multiductal, and occurs with breast
manipulation.
• Conversely, the risk of cancer is higher when the discharge is spontaneous, bloody,
unilateral, uniductal, associated with a breast mass, and/or occurs in a woman over 40
years of age.

39. HISTORY
• If discharge is spontaneous or provoked by manipulation of the breast
• History of recent trauma
• Color of the discharge
• Associating with a mass
• Unilateral or bilateral

40. PHYSICAL EXAMINATION
• the skin covering the breast and nipple areolar complex should be examined for
lesions.
• Gentle, firm pressure should be applied at the base of the areola (not on the nipple),
massage from the periphery towards the nipple areolar complex may also help to
detect nipple discharge.

41. PHYSIOLOGIC DISCHARGE
• Bilateral milky nipple discharge is appropriate during pregnancy and lactation, and
may persist for up to one year postpartum or after cessation of breastfeeding.
• Usually bilateral, involves multiple ducts, and is associated with nipple stimulation or
breast compression.
• Bilateral nonpathologic milky white discharge in persons who are not pregnant or
lactating is called galactorrhea; a human chorionic gonadotropin pregnancy test
should be performed in patients with galactorrhea to rule out pregnancy.
• If negative, prolactin and thyroid-stimulating hormone levels should be obtained to
determine the presence of an endocrinopathy.

42. CONT…
• Stresses such as trauma, surgical procedures, and anesthesia may also inhibit
dopamine release, thereby causing hyperprolactinemia and inducing galactorrhea.
• Purulent nipple discharge can be seen in association with periductal mastitis.
• Neurogenic stimulation represses the secretion of hypothalamic prolactin inhibitory
factor, resulting in hyperprolactinemia and galactorrhea.
• Decreases in nipple stimulation and breast compression expedite the resolution of
physiologic discharge.

43. CONT…
• Postthoracotomy syndrome is an unusual disorder in which the healing chest wound
simulates the effect of a suckling infant. It can be associated with an elevated prolactin
concentration, breast pain, and milk production. It can be seen with other forms of
chest wall injury, including burns, cervical spine lesions, and herpes zoster.
• There are some medications that inhibit dopamine and are associated with physiologic
nipple discharge

45. PATHOLOGIC DISCHARGE
• Secretory production of fluids other than milk may be due to a pathological process in
the breast.
• It is spontaneous, unilateral, localized to a single duct and persistent
• The most common cause is intraductal papilloma.
• The discharge associated with a papilloma can be clear or grossly bloody.
• Mammography and subareolar ultrasonography should be performed in patients with
nipple discharge that is unilateral, spontaneous, clear, serous, bloody, or associated
with a mass.

46. CONT…
• Those with pathologic discharge, even with normal imaging findings, should be
referred to a surgeon for duct excision.
• Cytology of the nipple discharge is not recommended, because the absence of
malignant cells does not exclude cancer.

47. DIFFERENTIAL DIAGNOSIS
• The color of nipple discharge can provide an indicator of the risk of underlying
malignancy.

48. STRAW-COLORED OR CLEAR
TRANSPARENT DISCHARGE
• It is typically due to a papilloma but may be associated with a malignancy.
• This discharge is typically a straw-colored, transparent, sticky fluid.
• It is very much like plasma.
• Unilateral spontaneous serous discharge is considered suspicious and requires a full
workup.

49. BLOODY DISCHARGE
• Grossly bloody nipple discharge simply means that a lesion in the duct is bleeding.
• The bleeding can be caused by an intraductal carcinoma (in-situ or invasive), a
bleeding papilloma, or benign fibrocystic changes with an active intraductal
component (eg, plasma cell mastitis, ductal ectasia, intraductal hyperplasia, or
papillomatosis).
• The cause of bloody nipple discharge in women during pregnancy and lactation is
usually hypervascularity of developing breast tissue, which is benign and requires no
treatment.

50. STAINING OF THE BRA WITHOUT
OBVIOUS NIPPLE DISCHARGE
• A woman may report finding a stain or spot of blood on her brassiere or underclothing
which merits careful examination of the skin around the nipple and nipple-areolar
complex.
• While skin changes such as dermatitis or eczema and associated excoriations can
occur, it is important to rule out Paget disease with a skin biopsy if the lesions persist
after conservative treatment.
• Paget disease is a breast cancer, characterized clinically by an eczematoid appearance
with nipple crusting, scaling, or erosion.

51. APPROACH TO THE PATIENT WITH NIPPLE DISCHARGE

52. RESOURCES

55. • A 15-year-old adolescent boy comes to your office complaining of bilateral breast
enlargement. He is otherwise healthy and on no medications. On examination, there is
mildly tender palpable breast tissue bilaterally. The rest of his physical examination,
including his testicular examination, is normal. Which of the following is true?
a. No further workup is necessary.
b. Serum liver studies will help to elucidate the cause.
c. Thyroid function assessment will help to elucidate the cause.
d. Serum estradiol, testosterone, and leutinizing hormone levels are needed to elucidate
the cause.
e. His serum chorionic gonadotropin level is likely to be elevated.

56. The answer is a.
Gynecomastia is a benign enlargement of the male breast. It may be asymptomatic or
painful, bilateral, or unilateral. It commonly occurs around the time of puberty, and if
requires only a history, physical, examination, and reassurance if there are no
abnormalities found. Most cases resolve within 1 year. Outside the pubertal period,
assessment of hepatic, renal, and thyroid functions may help uncover a cause. Sex
hormones are only tested if progressive enlargement is noted.

57. A 14-year-old boy presents with tenderness associated with the right breast. There are
no other findings. Testicular examination is unremarkable. Appropriate management of
this patient includes
A) Mammogram
B) Ultrasound of the breast
C) Genetic typing
D) Biopsy
E) Reassurance and continued observation

58. The answer is E.
Benign gynecomastia of adolescence is a very common finding among boys in middle
late puberty. The breast tissue is usually asymmetric and often tender to palpation.
Provided the history and physical examination, including palpation of the testicles, are
unremarkable, reassurance and periodic reevaluation are all that is necessary. Most
resolve in 1 to 2 years. Familial gynecomastia is a common genetic disorder transmitted
as a X-linked recessive trait or a sex-limited dominant trait causing limited breast
development around the time of puberty. It requires no further evaluation in an
otherwise normal boy unless there is evidence of hypogonadism. In rare cases, those
severe gynecomastia may require cosmetic surgery. Pathologic gynecomastia occurs in
cases of Klinefelter’s syndrome and prolactin-secreting adenomas and with a wide
of drug use including marijuana and phenothiazines.

59. • A 22-year-old woman is seeing her physician with complaints of breast pain. It is
associated with her menstrual cycle and is described as a bilateral “heaviness” that radiates
to the axillae and arms. Examination reveals groups of small breast nodules in the upper
outer quadrants of each breast. They are freely mobile and slightly tender. Which of the
following statements is most accurate?
a. The patient has bilateral fibroadenomas, and reassurance is all that is necessary.
b. The patient has bilateral fibroadenomas, and a mammogram is necessary for further
evaluation.
c. The patient has bilateral fibrocystic changes, and reassurance is all that is necessary.
d. The patient has bilateral fibrocystic changes, and a mammogram is necessary for further
evaluation.
e. The patient has bilateral mastitis and antibiotic therapy is needed.

60. The answer is c.
Fibrocystic changes are the most common benign condition of the breast. Cysts may
range in size from 1 mm to more than 1 cm in size. Fibroadenomas are usually rubbery,
smooth, well-circumscribed, nontender, and freely mobile. Mammograms are not
necessary for women younger than 30 years of age, as they are less sensitive in
women with denser breast tissue. Mastitis generally occurs with nursing, and is
characterized by inflammation, edema, and erythema in areas of the breast.

61. • A 35-year-old woman presents to you concerned about a breast mass. Examination
reveals no skin changes, diffusely nodular breasts bilaterally with a more dominant, firm,
and nontender fixed nodule on the left side. The nodule is approximately 7 mm in size,
in the upper outer quadrant of the left breast. Her mammogram is negative. Which of
the following statements is true?
a. The patient should be reassured and resume routine care.
b. The mass should be closely followed with repeat mammogram in 3 to 6 months.
c. The patient should undergo testing for breast cancer genetic mutations, and base
further workup on the results.
d. The patient should be referred for an ultrasound and possible biopsy.
e. If clear amber fluid is aspirated from the mass, it is likely benign, and no further workup
is necessary.

62. The answer is d.
Up to 15% of breast cancers are mammographically silent. Therefore, a palpable mass
deserves further workup, even if the mammogram is negative. Workup may include an
ultrasound to determine if the mass is cystic or solid, and possible biopsy. Aspiration of
the mass may be appropriate, but biopsy is still necessary if the mass is palpable after
aspiration, if the fluid is bloody, or if the mass reappears within 1 month. The
characteristics of the fluid otherwise do not dictate workup. Genetic testing is of no
in the workup of a breast mass, but can be considered based on family history, and
under the direction of an experienced genetic counselor.

63. • A 28-year-old woman comes to see you for a tender and erythematous area on her
breast. She is nursing her 6-week-old son. You diagnose mastitis. Which of the
following is true regarding this condition?
a. Restricting caffeine and methylxanthine may be efficacious.
b. Evening primrose oil has been shown to help with symptoms.
c. Applying ice several times a day will help relieve symptoms.
d. The patient should discontinue nursing.
e. Antibiotic therapy is indicated.

64. The answer is e.
Patients with mastitis should be encouraged to continue nursing, and should be started
on an antibiotic that covers streptococcal and staphylococcal infections. Reducing
caffeine and methylxanthines, or using evening primrose oil may decrease symptoms of
fibrocystic breast disease, but has no impact on mastitis. Applying heat may help
symptoms, but ice will not have the desired effect.

65. • You are seeing a 36-year-old woman with a complaint of nipple discharge. Which of
the following characteristics of the discharge is most suspicious for breast cancer?
a. Spontaneous discharge
b. Green discharge
c. Bilateral discharge
d. Discharge associated with menses
e. Bloody discharge

66. The answer is a.
Spontaneous, unilateral discharge is most suspicious for breast cancer. The
characteristics of the discharge cannot be used to distinguish benign versus malignant
causes; however, bloody, serous, serosanguineous, or watery discharge deserves a
workup.