Official reprint from UpToDate®

www.uptodate.com ©2018 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Clinical manifestations and diagnosis of a palpable breast mass

Author: Michael S Sabel, MD

Section Editor: Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C)
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2018. | This topic last updated: Aug 17, 2017.

INTRODUCTION — Evaluation of a palpable breast mass requires a systematic approach to the history, physical
examination, and radiographic imaging studies to ensure a correct diagnosis. A missed diagnosis of breast
cancer is one of the most frequent causes of malpractice claims in the United States [1-3].

The clinical manifestations and diagnostic evaluation of women with a palpable breast mass are reviewed here.
Screening and epidemiology of breast cancer, benign breast disease, breast pain, nipple discharge, breast cysts,
and breast cancer are reviewed separately.

● (See "Screening for breast cancer: Strategies and recommendations".)

● (See "Overview of benign breast disease".)

● (See "Breast pain".)

● (See "Nipple discharge".)

● (See "Breast cysts: Clinical manifestations, diagnosis, and management".)

● (See "Clinical features, diagnosis, and staging of newly diagnosed breast cancer".)

DEFINITION — A breast mass is a nodule or growth of tissue that represents an aggregation of coherent
material. 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. (See "Breast
cysts: Clinical manifestations, diagnosis, and management", section on 'Complex cyst'.)

CLINICAL FEATURES

Clinical manifestations

Clinical presentation — The clinical presentation of a palpable breast mass is variable. Some masses are
detected on a patient's self-breast examination while others are found on a routine clinical breast examination.
Some masses may be associated with pain and/or nipple discharge (eg, blood, green, white, yellow) [4-6].

Trauma to the breast (eg, car accident with seat belt, direct injury from a hard object) may result in a breast mass
due to the development of fat necrosis or a hematoma. In addition, trauma may be the precipitating event to
detection of an existing benign or malignant mass. Any mass after a trauma that fails to resolve will require a
complete evaluation. (See "Overview of benign breast disease", section on 'Fat necrosis'.)
 Physical examination — The physical examination of patients with benign breast disease parallels the
examination of patients with cancer, since normal breast tissue in women is often somewhat nodular. The first
goal of the physical examination is to determine whether a dominant mass, thickening, or asymmetry is present.
This is particularly important in younger women, whose breasts are more likely to be generally nodular than in
older women. In a retrospective review of 605 women under the age of 40 years who were referred to a breast
clinic for evaluation of a breast mass, a dominant mass was palpated by the surgeon in 36 percent of self-
detected masses (n = 484) and 29 percent of physician-detected masses (n = 121) [7].

On the physical examination, the palpable breast mass can be obvious or subtle; the density soft, firm, or hard;
mobile or fixed to the chest wall or skin; tender or nontender [8]. The mass may have well-defined or nondiscrete
margins and be associated with clinical findings including ecchymosis, erythema, peau d'orange, or ulceration of
the skin; nipple discharge, nipple retraction; or the mass may have no associated clinical findings. However, the
physical examination findings cannot always distinguish between a benign mass and a malignancy, even for
clinical experts, as the findings may be subtle. (See "Overview of benign breast disease" and "Clinical features,
diagnosis, and staging of newly diagnosed breast cancer", section on 'Signs and symptoms'.)

Studies that have examined the usefulness of the physical examination for diagnosing benign versus malignant
breast masses have found that clinicians can often make the right diagnosis, but not to a degree that is
sufficiently reassuring to the clinician or patient. In one report, from a study of symptomatic women, experienced
examiners who diagnosed "definite cancer" on palpation were correct in 93 percent of cases [9]. In another
series, the physical examination had a positive predictive value of 73 percent and a negative predictive value of
87 percent [10].

Imaging studies — Characteristic imaging findings of a palpable breast mass include:

● A mammogram depicts a mass as a soft tissue density. The density may have discrete or irregular
spiculated margins or demonstrate architectural distortion and, in some clinical settings, can also be
associated with gross or microscopic calcifications. While a mammogram can depict a mass that is
abnormal or suspicious for breast cancer, the imaging study cannot make a definitive diagnosis. In addition,
not all palpable masses can be imaged by mammography, such as those in premenopausal women with
dense breast tissue.

Further discussion on mammographic imaging is reviewed separately. (See "Breast imaging for cancer
screening: Mammography and ultrasonography", section on 'The mammographic examination' and "Breast
imaging for cancer screening: Mammography and ultrasonography" and "Diagnostic evaluation of women
with suspected breast cancer", section on 'Mammographic features of breast cancer'.)

● A targeted ultrasound will show if the mass is solid or cystic, or a combination of both. An ultrasound also
provides information about the margins (sharp or ill defined) and the presence or absence of a prominent
vascular supply. (See "Diagnostic evaluation of women with suspected breast cancer", section on
'Ultrasonography' and "Breast imaging for cancer screening: Mammography and ultrasonography".)

● Magnetic resonance imaging (MRI) studies, which categorize breast lesions as mass or nonmass lesions,
depict a breast mass as an enhancing or nonenhancing mass. More rapid uptake of contrast is
characteristic of a malignant mass. An MRI is not a necessary study for the evaluation of a palpable breast
mass. MRI interpretation is reviewed elsewhere. (See "MRI of the breast and emerging technologies", section
on 'MRI interpretation'.)

Histopathology/cytology — The definitive diagnosis of a benign or malignant breast mass is based upon the
histopathology from a core, incisional, or excisional tissue biopsy, or a fine needle aspiration (cytologic
evaluation). (See "Breast biopsy" and "Overview of benign breast disease" and "Clinical features, diagnosis, and
staging of newly diagnosed breast cancer", section on 'Pathology'.)

EVALUATION — The clinical evaluation of a palpable breast mass begins with a complete history and physical
examination [4-6]. The history should include a full review of medical and surgical illnesses, medications,
allergies, and an assessment of risk factors for breast cancer, such as a detailed family history. (See "Factors
that modify breast cancer risk in women".)

In addition, for masses identified by the patient, subjective information about how and when the mass was first
noted, if it is painful, and how it has changed over time should be recorded [4,5].

Presenting symptoms — The history of presenting symptoms includes:

● Any change in the general appearance of the breast, such as an increase or decrease in size, or a change in
symmetry.

● New or persistent skin changes.

● New nipple inversion.

● If nipple discharge is present, whether it is bilateral, unilateral, or from one specific duct. Other important
information includes the timing, color, frequency, and spontaneity of the discharge. (See "Nipple discharge".)

● The characteristics of any breast pain, the relationship of symptoms to menstrual cycles (cyclic or
noncyclic), the location within the breast (or both breasts), the duration, and whether it is aggravated or
alleviated by any activities or medications. (See "Breast pain".)

● The presence of a breast mass and its evolution, including how it was first noted (accidentally, by breast
self-examination, clinical breast examination, or mammogram), how long it has been present, and whether it
has changed in size. (See 'Benign' below.)

● The precise location of any breast mass. (See 'Documentation' below.)

● Whether a mass waxes and wanes during the menstrual cycle. Benign cysts may be more prominent
premenstrually and regress in size during the follicular phase. (See "Overview of benign breast disease",
section on 'Nonproliferative breast lesions' and "Breast cysts: Clinical manifestations, diagnosis, and
management".)

Risk factors for the development of breast cancer — A thorough risk assessment is part of the evaluation of
women with breast complaints, and significant negative as well as positive findings should be documented in the
medical record (table 1). Factors that are associated with an increased risk of breast cancer are reviewed
separately. (See "Factors that modify breast cancer risk in women".)

Physical examination — The breast examination includes the neck, chest wall, both breasts, and axillae and is
part of a complete physical examination [4,11,12]. The breast examination is best performed when hormonal
stimulation of the breasts is minimized, which is usually seven to nine days after the onset of menses in
premenopausal women. The evaluation of a clinically suspicious mass should not be influenced by the phase of
the menstrual cycle. The timing of the breast examination is not important in postmenopausal women, or
premenopausal women who are taking birth control pills or other treatments that affect ovarian suppression.

Inspection — The patient should be examined in both the upright and supine positions. The patient must be
disrobed from the waist up, allowing the examiner to visualize and inspect the breasts. The breast examination is
started with the patient in a seated position with her arms relaxed. The patient is then asked to raise her arms
over her head so the lower part of the breasts can be inspected. Finally, the patient should put her hands on her
hips and press in to contract the pectoral muscles so that any other areas of retraction can be visualized.
Inspection of the breast includes:

● Asymmetry – Observe the breast outline and contour for any bulging areas.

● Skin changes – Check for dimpling or retraction, edema, ulceration, erythema, or eczematous appearance,
such as scaly, thickened, raw skin.

● Nipples – Assess for symmetry, inversion or retraction, nipple discharge or crusting.

Palpation — After careful inspection, proceed with the palpation of regional lymph nodes and the breasts.

● Regional lymph node examination – While the patient is sitting, the regional lymph nodes are examined, with
attention to the cervical, supraclavicular, infraclavicular, and axillary nodal basins. The best examination of
the axillary nodes requires that the patient relax her shoulders and allow the examiner to support her arm
while the axilla is palpated. It is important to note the presence of any palpable nodes and their
characteristics, whether they are soft and mobile or firm, hard, tender, fixed, or matted (figure 1).

● Breast examination – A bimanual examination of the breasts is performed while the patient is still in the
sitting position, supporting the breast gently with one hand and examining the breast with the other hand.
The examination is completed with the patient in a supine position, with the ipsilateral arm raised above her
head. This allows the examiner to flatten the breast tissue against the patient's chest. It is sometimes useful
to have the patient roll onto her contralateral hip to flatten the lateral part of the breast.

The entire breast must be examined, including the breast tissue that comprises the axillary tail of Spence,
which extends laterally toward the axilla. To be sure that all breast tissue is included in the examination, it is
best to cover a rectangular area bordered by the clavicle superiorly, the midsternum medially, the midaxillary
line laterally, and the lower rib cage inferiorly (figure 1).

The examination technique should be systematic, using concentric circles, a radial approach, or vertical strips
[11-13]. Palpation should be done with the finger pads rather than the fingertips. Circular motions with light,
medium, and deep pressure ensure palpation of all levels of breast tissue [11,14]. One hand stabilizes the breast
while the other hand is used to perform the examination [12].

Documentation — The location of the mass as well as any abnormality found on examination should be
accurately documented. The size of any mass should be measured in centimeters and its location, mobility, and
consistency recorded. It is helpful to record the location of any abnormality by documenting both the position on
the breast and the distance in centimeters from the areola. In this manner, the precise location can be easily
identified on subsequent follow-up examinations, by the initial examiner as well as other practitioners.

The "clock" system can be used for documentation, comparing the breast to a clock and using the location on
the clock to indicate the location of a lesion (eg, 1 o'clock position). The entire examination should be clearly and
completely documented in detail, including significant negatives, even if it is completely normal. Distance from
the radial edge of the areola can be used to document location of the mass.

Diagnostic imaging

Mammography — A diagnostic mammogram is the first imaging study performed for a woman with a new,
palpable breast mass and should be performed even if a recent mammogram was negative. While the false
negative rate of mammograms is less than 5 percent for clinically palpable breast cancers [15], a normal
mammogram does not eliminate the need for further evaluation of a suspicious mass [5].
For women under age 30 years, the breasts are hypersensitive to radiation exposure [16]; however, if the clinical
findings are suspicious, a mammogram should be performed [5].

Ultrasonography — For young women with a clinically benign mass, such as a fibroadenoma, and no family
history of premenopausal breast cancer, an ultrasound is a useful initial diagnostic imaging study (see "Breast
imaging for cancer screening: Mammography and ultrasonography" and "Diagnostic evaluation of women with
suspected breast cancer" and "Overview of benign breast disease"). Targeted ultrasonography is a useful
diagnostic test to evaluate a palpable mass and is frequently ordered concurrent with the mammogram. It is
particularly useful for assessing whether a mass is solid or cystic in nature. (See "Breast cysts: Clinical
manifestations, diagnosis, and management", section on 'Ultrasonography'.)

Ultrasound is the first line of imaging in a woman who is pregnant and/or lactating. (See "Breast imaging for
cancer screening: Mammography and ultrasonography".)

MRI — Breast magnetic resonance imaging (MRI) is not indicated for the workup of an undiagnosed mass.
MRI is best reserved for diagnostic dilemmas and used with discretion, as there is a significant false positive
rate, which dramatically increases the rate of benign biopsies. Diagnostic breast MRIs should only be performed
in institutions that have the capacity for MRI-directed biopsy, as lesions seen on MRI may not be visible on other
imaging modalities [17].

An MRI machine with a dedicated breast coil is employed for the test, and gadolinium dye is injected
intravenously before the procedure. The dye can cause serious reactions in patients with underlying renal
disease (nephrogenic systemic fibrosis and worsening renal failure). Baseline BUN and creatinine are routinely
checked before the test is performed. (See "Diagnostic evaluation of women with suspected breast cancer" and
"Principles of magnetic resonance imaging".)

DIAGNOSIS — The diagnosis of a benign or malignant breast mass is confirmed by a breast biopsy. (See "Breast
biopsy".)

The triple test or assessment refers to the concurrent use of physical examination, mammography, and needle
biopsy for diagnosing palpable breast mass [18]. Either a fine needle aspiration (FNA) biopsy or core biopsy can
be employed. However, successful FNA requires experienced cytopathologists, as invasive cancers may not be
differentiated from noninvasive cancers. In institutions where experienced cytopathologists are not available, the
initial diagnostic procedure of choice should be core needle biopsy (CNB) rather than FNA. Another advantage of
the CNB is that sufficient tissue can usually be obtained for hormone receptor analysis. Very few breast cancers
are missed using the triple test. (See "Breast biopsy" and "Hormone receptors in breast cancer: Clinical utility and
guideline recommendations to improve test accuracy".)

FNA- or CNB-proven benign masses that change clinically or radiographically, such as increasing in size on
annual examinations, should be reevaluated and excised.

The appropriate interval of follow-up for patients with benign biopsy is controversial, and although various
intervals (four or six months) have been proposed, no evidence-based guidelines are available to aid this decision
[19]. Whether a short follow-up interval is necessary has been questioned [20,21]. A study using the Breast
Cancer Surveillance Consortium (BCSC) registry compared cancer detection rates and stage for patients with
short-interval follow-up (three to eight months) with those who returned to routine screening (9 to 18 months)
following benign core breast biopsy (stereotactic or ultrasonography-guided) [19]. A total of 17,631 biopsies with
benign findings were identified. Similar rates of later cancer were detected for the short interval follow-up and
routine screening groups with no significant differences in stage, tumor size, or nodal status. Thus, it may be
safe for those with a benign radiologic-pathologic-concordant percutaneous breast biopsy to return to routine
screening; however, the study did not identify the spatial relationship between the finding that prompted the initial
biopsy and the site of the subsequent cancer (which could have represented a false negative result). (See
"Screening for breast cancer: Strategies and recommendations".)

DIFFERENTIAL DIAGNOSIS — The differential diagnosis of a palpable breast mass includes benign and
malignant histologies.

Benign — Palpable breast masses are very common in women, and most palpable masses are benign [4,22,23].
Approximately 90 percent or more of palpable breast masses in women in their 20s to early 50s are benign;
however, excluding breast cancer is a crucial step in the assessment of a breast mass in a woman of any age
[24].

The following types of masses are among the most common benign breast masses palpated. A review of these
and additional nonproliferative and proliferative breast lesions is found elsewhere. (See "Overview of benign
breast disease".)

● Fibroadenoma – A simple fibroadenoma is a benign solid mass. It typically is identified in young women but
can also be identified as a calcified mass in older women. The mass is firm and described as "mobile," as it
can be rolled onto an edge. A fibroadenoma may be solitary, multiple, and bilateral. (See "Overview of benign
breast disease", section on 'Simple fibroadenomas'.)

● Cyst – A simple cyst is a benign fluid-filled mass that can be palpated as a component of fibrocystic
changes of the breast or as a discrete, compressible, or ballotable solitary mass. Breast cysts are commonly
found in premenopausal, perimenopausal, and occasionally postmenopausal women. (See "Breast cysts:
Clinical manifestations, diagnosis, and management".)

● Fibrocystic changes – Fibrocystic changes in the breast are common, particularly in premenopausal women,
and may be prominent and organized. However, the breast tissue tends to be more diffuse and tender, and
generally does not form a discrete or well-defined mass. Most patients present with breast pain that may be
cyclical or constant, bilateral or unilateral or focal. The breast tissue, particularly in the upper outer
quadrants, may increase in size prior to the onset of menses, then return to baseline after the onset of the
menstrual flow. On the clinical examination, the breast tissue frequently is nodular. (See "Overview of benign
breast disease", section on 'Nonproliferative breast lesions'.)

● Galactocele – A galactocele is a milk retention cyst common in women who are breastfeeding. (See
"Common problems of breastfeeding and weaning", section on 'Galactoceles'.)

● Fat necrosis – Fat necrosis is a benign breast mass that can develop after blunt trauma to the breast;
injection of native or foreign substances such as fat [25], paraffin, or silicone [26,27]; an operative procedure
such as breast reductive surgery [28] or autologous breast reconstruction [29]; and radiation therapy [30,31]
to the breast. Fat necrosis from trauma is generally associated with skin ecchymosis. Fat necrosis can often
be clinically difficult to distinguish from a malignant mass. (See "Overview of benign breast disease", section
on 'Fat necrosis'.)

● Breast abscess - A breast abscess is a localized collection of inflammatory exudate (ie, pus) in the breast
tissue. Primary breast abscesses develop when mastitis or cellulitis does not respond to antibiotic
treatment. Patients with primary breast abscess present with localized, painful inflammation of the breast
associated with fever and malaise, along with a fluctuant, tender, palpable mass. The diagnosis is
established via ultrasonography demonstrating a fluid collection. (See "Primary breast abscess".)

Malignant — The differential diagnosis of a malignant breast mass includes multiple invasive histologies and
noninvasive cancer. Further review of the pathology of breast cancer is discussed separately. (See "Clinical
features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Differential diagnosis' and
"Pathology of breast cancer".)

● The most common breast cancer is an infiltrating ductal breast carcinoma [23]. This invasive histology
accounts for approximately 70 to 80 percent of invasive breast cancers. Other invasive breast cancers
include infiltrating lobular carcinoma and mixed ductal/lobular carcinoma. There are also variants of the
invasive ductal carcinomas that can be detected as a palpable mass. (See "Pathology of breast cancer" and
"Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Pathology'.)

Most palpable breast cancers present as a hard mass, although some less aggressive histologies, such as
tubular carcinoma, may present as a very firm mass. (See "Pathology of breast cancer", section on 'Other
histologic types'.)

Infiltrating lobular carcinoma often presents as a prominent diffuse thickening of the breast rather than as a
discrete mass. (See "Pathology of breast cancer", section on 'Infiltrating lobular carcinoma'.)

Locally advanced breast cancer frequently presents as a large mass that may be fixed to the chest wall or skin
and may be associated with matted or fixed axillary lymph nodes. Patients with inflammatory breast cancer
typically present with a painful, enlarging, erythematous breast and may not have a palpable mass detected. (See
"Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Staging'.)

● Less commonly, noninvasive cancers with or without microinvasion can develop into a palpable mass. (See
"Pathology of breast cancer", section on 'Ductal carcinoma in situ' and "Clinical features, diagnosis, and
staging of newly diagnosed breast cancer", section on 'Differential diagnosis'.)

● Second primary – For patients treated with breast conservation, a new breast mass palpated in the
ipsilateral or contralateral breast may be a second primary breast cancer. The evaluation of a new breast in a
breast cancer patient is performed as described. (See 'Evaluation' above and 'Diagnosis' above and
"Diagnostic evaluation of women with suspected breast cancer".)

● Local recurrence – An ipsilateral palpable mass at the site of a previously treated breast cancer may
represent a local recurrence. A biopsy provides the definitive diagnosis. (See "Management of locoregional
recurrence of breast cancer after breast-conserving therapy".)

RADIOGRAPHICALLY IDENTIFIED MASSES — The history and physical examination described in this topic is also
performed for patients who present with a mass or any other finding identified on mammography and/or
ultrasound or magnetic resonance imaging (MRI). Management of imaging-detected lesions is reviewed
separately. (See "Breast imaging for cancer screening: Mammography and ultrasonography" and "MRI of the
breast and emerging technologies" and "Breast biopsy".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade
reading level, and they answer the four or five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond
the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written
at the 10th to 12th grade reading level and are best for patients who want in-depth information and are
comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these
topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)
 ● Basics topics (see "Patient education: Common breast problems (The Basics)")

● Beyond the Basics topics (see "Patient education: Common breast problems (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● The clinical presentation of a palpable breast mass is variable. The characteristics of the mass to be
evaluated include density (such as soft, hard, firm), skin changes, nipple areolar changes, and/or fixation to
the chest wall. (See 'Clinical manifestations' above and "Factors that modify breast cancer risk in women".)

● Imaging studies of a breast mass include mammography, which depicts a mass as a soft tissue density with
sharp or spiculated margins. An ultrasound documents if the mass is solid or cystic and the character of the
margins and presence of a blood supply. Not all palpable masses can be imaged by mammography, such as
for women with dense breast tissue. (See 'Imaging studies' above.)

● A systematic history, including risk factors for breast cancer, and physical examination are performed for
every woman who presents with a new breast mass. Diagnostic evaluation includes radiographic imaging
and, frequently, a breast biopsy. (See 'Evaluation' above.)

● For all women with a suspicious breast mass, a mammogram is the first diagnostic test performed.
Frequently, an ultrasound is also performed concurrently as a component of the evaluation. Magnetic
resonance imaging (MRI) should be reserved for diagnostic dilemmas. Breast masses in young women
(under age 30 years) that are clinically consistent with a benign lesion, such as a fibroadenoma, and in
whom there is no family history of breast cancer, can be first imaged by an ultrasound. (See 'Diagnostic
imaging' above.)

● The definitive diagnosis of a breast mass is made by a breast biopsy, which includes a fine needle aspiration,
core biopsy, or an open biopsy. We prefer a core biopsy that can provide sufficient tissue for differentiation
between invasive and noninvasive cancers as well as provide sufficient tissue for hormone receptor
analysis. (See 'Diagnosis' above and "Breast biopsy".)

● The differential diagnosis of a breast mass includes benign (eg, fibroadenoma, cysts) and malignant (eg,
invasive, noninvasive) tissue. (See 'Differential diagnosis' above.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Physician Insurers Association of America. Breast cancer study, 3rd edition, Physician Insurers Association
of America, Rockville 2002. http://www.neomatrix.com/pdfs/PIAAStudy.pdf (Accessed on January 11, 201
2).
2. Singh H, Sethi S, Raber M, Petersen LA. Errors in cancer diagnosis: current understanding and future
directions. J Clin Oncol 2007; 25:5009.
3. Gandhi TK, Kachalia A, Thomas EJ, et al. Missed and delayed diagnoses in the ambulatory setting: a study
of closed malpractice claims. Ann Intern Med 2006; 145:488.
4. Morrow M. The evaluation of common breast problems. Am Fam Physician 2000; 61:2371.
5. Cady, B, Steele, GD, Morrow, M, et al. Evaluation of Common Breast Problems: A Primer for Primary Care Pro
viders; prepared by the Society of Surgical Oncology and the Commission on Cancer of the American Colleg
e of Surgeons for the Centers for Disease Control and Prevention, Publication no. 633-001/20900, US Depar
 tment of Health and Human Services, 1998. www.utmb.edu/Surgery/clerks/primer.htm (Accessed on Augu
st 08, 2008).
6. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005; 353:275.
7. Morrow M, Wong S, Venta L. The evaluation of breast masses in women younger than forty years of age.
Surgery 1998; 124:634.
8. The palpable breast lump: information and recommendations to assist decision-making when a breast
lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of
Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ 1998; 158 Suppl 3:S3.
9. Rimsten A, Stenkvist B, Johanson H, Lindgren A. The diagnostic accuracy of palpation and fine-needle
biopsy and an evaluation of their combined use in the diagnosis of breast lesions: report on a prospective
study in 1244 women with symptoms. Ann Surg 1975; 182:1.
10. van Dam PA, Van Goethem ML, Kersschot E, et al. Palpable solid breast masses: retrospective single- and
multimodality evaluation of 201 lesions. Radiology 1988; 166:435.
11. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer?
The screening clinical breast examination: should it be done? How? JAMA 1999; 282:1270.
12. Morrow, M. Physical examination of the breast. In: Breast diseases, 3rd edition, Harris, JR, et al (Eds), Lippin
cott, Williams, and Wilkins, Philadelphia 2004. p.29.
13. Saunders KJ, Pilgrim CA, Pennypacker HS. Increased proficiency of search in breast self-examination.
Cancer 1986; 58:2531.
14. Hall DC, Goldstein MK, Stein GH. Progress in manual breast examination. Cancer 1977; 40:364.
15. Moy L, Slanetz PJ, Moore R, et al. Specificity of mammography and US in the evaluation of a palpable
abnormality: retrospective review. Radiology 2002; 225:176.
16. Wang LE, Han CH, Xiong P, et al. Gamma-ray-induced mutagen sensitivity and risk of sporadic breast cancer
in young women: a case-control study. Breast Cancer Res Treat 2012; 132:1147.
17. Orel S. Who should have breast magnetic resonance imaging evaluation? J Clin Oncol 2008; 26:703.
18. Clarke D, Sudhakaran N, Gateley CA. Replace fine needle aspiration cytology with automated core biopsy in
the triple assessment of breast cancer. Ann R Coll Surg Engl 2001; 83:110.
19. Johnson JM, Johnson AK, O'Meara ES, et al. Breast cancer detection with short-interval follow-up
compared with return to annual screening in patients with benign stereotactic or US-guided breast biopsy
results. Radiology 2015; 275:54.
20. Salkowski LR, Fowler AM, Burnside ES, Sisney GA. Utility of 6-month follow-up imaging after a concordant
benign breast biopsy result. Radiology 2011; 258:380.
21. Shaylor SD, Heller SL, Melsaether AN, et al. Short interval follow-up after a benign concordant MR-guided
vacuum assisted breast biopsy--is it worthwhile? Eur Radiol 2014; 24:1176.
22. Klein S. Evaluation of palpable breast masses. Am Fam Physician 2005; 71:1731.
23. Schoonjans JM, Brem RF. Fourteen-gauge ultrasonographically guided large-core needle biopsy of breast
masses. J Ultrasound Med 2001; 20:967.
24. Elmore JG, Barton MB, Moceri VM, et al. Ten-year risk of false positive screening mammograms and clinical
breast examinations. N Engl J Med 1998; 338:1089.
25. de Blacam C, Momoh AO, Colakoglu S, et al. Evaluation of clinical outcomes and aesthetic results after
autologous fat grafting for contour deformities of the reconstructed breast. Plast Reconstr Surg 2011;
128:411e.
 26. Erguvan-Dogan B, Yang WT. Direct injection of paraffin into the breast: mammographic, sonographic, and
MRI features of early complications. AJR Am J Roentgenol 2006; 186:888.
27. Majedah S, Alhabshi I, Salim S. Granulomatous reaction secondary to intramammary silicone injection. BMJ
Case Rep 2013; 2013.
28. Lewin R, Göransson M, Elander A, et al. Risk factors for complications after breast reduction surgery. J
Plast Surg Hand Surg 2014; 48:10.
29. Wagner IJ, Tong WM, Halvorson EG. A classification system for fat necrosis in autologous breast
reconstruction. Ann Plast Surg 2013; 70:553.
30. Meric F, Buchholz TA, Mirza NQ, et al. Long-term complications associated with breast-conservation
surgery and radiotherapy. Ann Surg Oncol 2002; 9:543.
31. Piroth MD, Fischedick K, Wein B, et al. Fat necrosis and parenchymal scarring after breast-conserving
surgery and radiotherapy with an intraoperative electron or fractionated, percutaneous boost: a
retrospective comparison. Breast Cancer 2014; 21:409.

Topic 804 Version 22.0

GRAPHICS

Risk and protective factors for developing breast cancer

Risk group
 
Low risk High risk Relative risk

Risk factors

Deleterious BRCA1/BRCA2 genes Negative Positive 3.0 to 7.0

Mother or sister with breast cancer No Yes 2.6

Age 30 to 34 70 to 74 18.0

Age at menarche >14 <12 1.5

Age at first birth <20 >30 1.9 to 3.5

Age at menopause <45 >55 2.0

Use of contraceptive pills Never Past/current use 1.07 to 1.2

Hormone replacement therapy (estrogen + progestin) Never Current 1.2

Alcohol None Two to five drinks/day 1.4

Breast density on mammography (percents) 0 ≥75 1.8 to 6.0

Bone density Lowest quartile Highest quartile 2.7 to 3.5

History of a benign breast biopsy No Yes 1.7

History of atypical hyperplasia on biopsy No Yes 3.7

Protective factors

Breast feeding (months) ≥16 0 0.73

Parity ≥5 0 0.71

Recreational exercise Yes No 0.70

2
Postmenopause body mass index (kg/m ) <22.9 >30.7 0.63

Oophorectomy before age 35 years Yes No 0.3

Aspirin ≥Once/week for ≥6 months Nonusers 0.79

Adapted from: Clemons M, Goss P. Estrogen and the risk of breast cancer. N Engl J Med 2001; 344:276.

Graphic 64508 Version 3.0

Breast exam

A. The breast exam is started with the patient in a seated position with her arms relaxed. Breast inspection is
aided by patient positioning. The patient is asked to raise her arms over her head so the lower part of the
breasts can be inspected for asymmetry, skin changes, and nipple inversion or retraction. The patient then
puts her hands on her hips and presses in to contract the pectoral muscles so that any other areas of
retraction can be visualized.
B. The regional lymph node exam is completed while the patient is still in the sitting position and includes
the cervical, supraclavicular, infraclavicular, and axillary nodal basins.
C. A bimanual examination of the breasts can be performed while the patient is still in the sitting position.
This is especially useful for women with large pendulous breasts.
D. The breast exam is completed with the patient in a supine position with the ipsilateral arm raised above
her head. The area examined should extend from the clavicle superiorly to the rib cage inferiorly and from
the sternum medially to the mid-axillary line laterally. A systematic approach ensures that the entire breast is
examined. This can be accomplished with either concentric circles, a radial approach, or vertical strips,
referred to as the "lawnmower" method.

Graphic 61035 Version 2.0

Contributor Disclosures
Michael S Sabel, MD Nothing to disclose Anees B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C) Nothing
to disclose Wenliang Chen, MD, PhD Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.

Conflict of interest policy