Abnormal Findings (Chapter 17: Breast and Regional Lymphatics)

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Signs of Retraction and Inflammation


The shallow dimple (skin tether) is a sign of retraction. Cancer cases fibrosis which contracts the suspensory ligaments. They dimple may be apparent at risk, with compression, or with lifting of the arms. Also note the distortion of the areola here as the fibrosis pulls the nipple toward it.

Nipple retraction. The retracted nipple looks flatter and broader, like an underlying crater. A recent retraction suggests cancer, which causes fibrosis of the whole duct system and pull in the nipple. It also may occur with benign lesions such has ectasia of the ducts.

Do not confuse retraction with the normal long-standing type of nipple inversion, which has not broadening and is not fixed


Signs of Retraction and Inflammation

Edema (Peau d'Orange)

Lymphatic obstruction produces edema. This thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look. The condition suggests cancer. Edema usually begins in the skin around and beneath the areola, the most dependent area of the breast.

Also note nipple infiltration here.


Signs of Retraction and Inflammation


Asymmetry, distortion or decreased mobility with the elevated arm maneuver. As cancer becomes invasive, the fibrosis fixes the breast to the underlying pectoral muscles.


Signs of Retraction and Inflammation

Deviation in Nipple Pointing

An underlying cancer causes fibrosis in the mammary ducts, which pulled the nipple angle toward it.


Breast Lumps

Benign ("Fibrocystic") Breast Disease

Multiple tender masses that occurs with numerous symptoms and physical findings:

  • Swelling and tenderness (cyclic discomfort)
  • Mastalgia (severe pain, both cyclic and noncyclic)
  • Nodularity (significant lumpiness, both cyclic and noncyclic)
  • Dominant lumps (including cysts and fibroadenomas)
  • Nipple discharge (including intraductal papilloma and duct ectasia)
  • Infections and inflammations (including subareolar abscess, lactational mastitis, breast abscess, and Mondor disease)

Many women have some form of benign breast disease. Nodularity occurs bilaterally; regular, firm nodules are mobile, will demarcated,and feel rubbery like small water balloons.

Pain may be dull, heavy and cyclic as nodules enlarge. Some women have nodular but not pain and vice versa.

Cysts are discrete, fluid-filled sacs. Dominant lumps and nipple discharge must be investigated carefully. Nodularity itself is not premalignant but produces difficulty in detecting other cancerous lumps.


Breast Lumps


Solitary, unilateral, nontender mass. Single focus in one area, although it may be interspersed with other nodules.

Solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Borders are irregular and poorly delineated. Grows constantly. Often painless, although the person may have pain.

Most common upper outer quadrant.

Found in women 30-80 years of age; increased risk across all ages until 80. As cancer advances, signs include firm and hard irregular axillary nodes; skin dimpling; nipple retraction, elevation, and discharge.


Breast Lumps


Benign tumors; most commonly present as self-detected in late adolescence. Solitary nontender mass that is solid, firm, rubbery and elastic. Round, oval, or lobulated; 1-5 cm.

Freely moveable, slippery; fingers slide it easily through tissue. Usually no axially lymphadenopathy.

Dx by triple test (palpation, ultrasound, and needle biopsy).

Because risk of deformity of surgery to a growing breast, excision surgery is reserved for masses >5 cm; for continuously enlarging, well-circumscribed, multiple masses; or with suspicious ultrasound findings


Abnormal Nipple Discharge

Mammary Duct Ectasia

Paste like matter in subareolar ducts produces sticky, purulent discharge that may be white, gray, brown, green, or bloody.

Caused by stagnation of cellular debris and secretions in the cuts, leading to obstruction, inflammation, and infection.

Usually occurs in perimenopause.

Itching, burning, or drawing pain occurs around nipple. May have subareolar redness and swelling. Duct are palpable as rubbery, twisted tubules under areola. May have palpable mass, soft or firm, poorly delineated. Not malignant but needs biopsy


Abnormal Nipple Discharge

Intraductal Papilloma

Discrete benign tumors that arise in the single or multiple papillary duct(s). May have serous or serosanguineous discharge. Often there is a palpable nodules in underlying duct.

Most common in women ages 40-60 years.

Most are benign, although multiple papillomas have a higher risk of subsequent cancer than do solitary ones. Requires core needle biopsy and possible excision.


Abnormal Nipple Discharge


Bloody nipple discharge that is unilateral and from a single duct requires further investigation.


Abnormal Nipple Discharge

Paget Disease (Intraductal Carcinoma)

Early lesion has unilateral, clear, yellow discharge and dry scaling crusts, fixable at nipple apex. Spreads outward to areola with erythematous halo on areola and crusted, eczematous, retracted nipple.

Later lesion shows nipple reddened, excoriated, and ulcerated with blood discharge, and an erythematous plaque surrounding the nipple.

Symptoms include tingling, burning, itching. Except for the redness and occasional cracking from the initial breastfeeding, any dermatitis of the nipple area must be explored carefully and referred immediately.


Disorders Occurring During Lactation


This is uncommon; an inflammatory mass before abscess formation. Usually occurs in a single quadrant. Area is read, swollen, tender, very hot, and hard.

s/s: headache, malaise, fever, chills, sweating, increased pulse, flulike symptoms

May occur during first 4 months of lactation from infection or from stasis from plugged duct.

Tx: rest, local heat to area, antibiotics, and frequent nursing to keep breast as empty as possible. Must not wean now, or breast will become engorged, and the pain will increase.

Mother's antibiotic not harmful to infant. Usually resolves within 2-3 days


Disorders Occurring During Lactation

Plugged Duct

This is common when milk is not removed completely because poor latching, ineffective suckling, infrequent nursing, or switching to second breast too soon.

There is no tender lump that may be reddened and warm to touch. No infection. It is important to keep breast as empty as possible and milk flowing. The woman should nurse her baby frequently on affected side first to ensure complete emptying and manually express any remaining milk.

A plugged duct usually resolves in less than 1 day.


Male Breast Abnormalities


Benign enlargement of male breast that occurs when estrogen concentration exceeds testosterone levels. It is a mobile disk of tissue located central under nipple-areola. At puberty it is usually mild and transient.

In older men, it is bilateral, tender and firm but not as hard as breast cancer.

Occurs with Cushing syndrome, liver cirrhosis (because estrogens cannot be metabolized), adrenal disease, hyperthyroidism, and numerous drugs: alcohol and marijuana; estrogen Tx for prostate cancer; antibiotics (metronidazole, isoniazid); spironolactone, digoxin, ACE inhibitor; psychoactive drugs (diazepam, tricyclic antidepressants)


Male Breast Abnormalities

Male Breast Cancer

1% of breast cancers occur in men.

There is no standard screening mammography; thus it is detected by clinical symptoms.

It presents as a painless palpable mass - hard, irregular, nontender, fixed to the area; may have nipple retraction.

Nipple discharge, with or without a palpable mass, is a significant earning of early breast cancer.

Early spread to axillary lymph nodes occurs because of minimal breast tissue. Because of lack of screening and general awareness, men are Dx 10 years later than women and at later stages, with the mean age between 60-70 years.

The stage at Dx is the most important indicator for survival