Clinical Evaluation of the Breast

Patients may present to a physician for a variety of breast complaints, including breast lumps, breast pain,
and nipple discharge. In countries where breast cancer screening is performed routinely, patients will be
sent for follow up of abnormalities detected on imaging. A majority of concerns have benign causes.
However, in sub-Saharan Africa, breast cancer screening is unusual, and presentation, for benign or
malignant conditions, is often delayed, and the likelihood of malignancy is6 higher.

As with all clinical evaluation, evaluation of breast pathology begins with a focused history and physical
exam. Here, we will focus on the important aspects of evaluation of the breast.
History

A focused history should include:

 Evaluation of the specific patient complaint, including duration and onset of the complaint,
changes to the breast or nipple

 Discharge,
 skin retraction,
 new nipple inversion,
 whether unilateral or bilateral),
 cyclical associations,
 any aggravating or relieving factors;

 Past medical, surgical, and family history:

 previous breast disease,

 biopsies or cancer,
 recent breast trauma,
 prior chest radiation,
 other medical conditions or comorbidities,
 previous surgeries, and
 history in first degree relatives of breast disease or malignancies;

 Estrogen exposure and gynecologic history:

→ age at menarche (first menstrual period) and menopause (if applicable),

→ number of pregnancies,
→ breastfeeding history,
→ use of oral contraception or hormone replacement therapies. Estrogen exposure is an
important part of the history because estrogen stimulates breast cells and may stimulate
cancer cells. Thus, higher estrogen exposures over a lifetime increases breast cancer risk.

Physical Examination
High quality physical examination of both breasts and lymph node basins is an essential part of the
workup for any breast complaint. The video below shows this process.
1. Consent and chaperone
2. Inspection for Assymetry,

o General state of the pt…wasting, anemia, jaundice, lymphedema

o swelling,
 o masses,
o Skin changes,
o Nipple changes

In supine: start palpation from asymptomatic breast, palpate against the chest wall using the flat palmar
surface. Start with the normal breast.

Ask the patient to squeeze the nipple for discharge.

Assess for the fixity.
Palpate the LN: axilla, infra and supraclavicular, cervical

PAdditionally, and especially if there is concern for a malignant process with possible metastatic spread,
attention should be paid to:

 General appearance, including evidence of weight loss and cachexia.

  Abdominal exam, including evidence of distension, which could indicate fluid from ascites;
masses; hepatomegaly; and discomfort on palpation.
 Bony examination, including evidence of pain or tenderness to palpation of the spine.
 Cardiopulmonary exam. Any patient in whom surgery may be considered should have an
examination of the heart and lungs.

Imaging Studies
Imaging is very important in the workup of breast pathology as well as in staging of malignant disease.
Here we will briefly look at the types of studies used to image the breasts, though each will be discussed
further in the context of diseases in which it is used.

a. Ultrasonography
Ultrasound is an incredibly important diagnostic modality in the workup of various breast pathologies for
women (and men) of any age and is the imaging modality of choice for breast pathology in women under
the age of 40 or in women of any age with dense breasts. Breast ultrasound is best utilized when it is
targeted at a particular area or lesion of interest as opposed to being used to screen an entire breast or
breasts for possible pathology, which is time consuming and leads to frequent false positive findings.
Ultrasound is also useful for imaging the axilla for lymph node assessment.

Breast ultrasound is non-invasive, easy to learn, and does not carry a risk of radiation. It is user
dependent.

Ultrasound can reliably diagnose some pathologies, such as simple cysts and fibroadenomas, negating the
need for some biopsies.

 Ultrasound findings that favor malignancy include irregular shape, ill-defined margin, solid
tumor, hypoechogenicity, posterior acoustic shadowing (the sound waves cannot pass through),
and tissue distortion.

 Signs that favour a benign lesion include smooth shape, a regular or well-defined margin,
hyperechogenicity, and posterior acoustic enhancement (the sound waves pass through).

The image below shows a 2.5 cm breast mass suspicious for malignancy based on its irregular and ill-
defined shape, solid and heterogeneous composition, and hypoechogenicity.

bb

b. Mammography
+Mammography is a form of breast radiography in which the breast tissue is compressed between two
plates and imaged in two planes, a craniocaudal (CC) view and a mediolateral oblique (MLO) view.
Mammography can be used for screening, where it is used to detect asymptomatic cancers, or diagnosis,
where more images are obtained in order to image a patient with breast symptoms.
Malignancy is indicated by signs like irregularity and spiculation of an area of density and the presence
and patterns of calcifications. Together, the findings on mammography can be incorporated into a risk
assessment tool that gives an overall rating of the likelihood of malignancy. Macrocalcifications can be a
sign of benign ds. This is known as the Breast Imaging-Reporting And Data System, or BI-RADS, and is
widely used to communicate findings on imaging. While it is most commonly used for mammography, it
also applies to ultrasound and MRI of the breast. The categories include:
 BI-RADS 0: incomplete imaging. This means additional imaging or evaluation is needed.
 BI-RADS 1: negative. This means there are no abnormal findings in the imaging.
 BI-RADS 2: benign. This means that the imaging findings carry a 0% risk of malignancy.
 BI-RADS 3: probably benign. This means that the imaging findings carry a risk of malignancy <
2% but short interval follow-up imaging should be performed.
 BI-RADS 4: suspicious abnormality. This means that the imaging findings carry a 2-94% risk of
malignancy. While this category can be further subdivided into low susp. 4A 2-10%, mod susp.
4B10-50 %, and Highly susp.4C 50-94 to better characterize risk, biopsy is recommended.
 BI-RADS 5: highly suggestive of malignancy. This means that the imaging findings carry a >95%
risk of malignancy, and biopsy or other intervention should be done.
 BI-RADS 6: known biopsy-proven malignancy. This is used when imaging is performed
following a biopsy where the result is known to be cancer.

While non-invasive, mammography is somewhat uncomfortable. It also requires a specially trained

radiologist to read the images and exposes the patient to radiation. It is not sensitive enough in women
with dense breasts, as dense breast tissue can mask malignancy. Most women under the age of 40 have
not had enough fatty replacement of breast tissue for appropriate sensitivity and thus, mammography is
not of utility in younger patients. Further, it is not widely available in many sub-Saharan African
countries and may be expensive in some places.

The images below show how a mammogram is performed, and a mammogram showing a small
malignancy,

c. MRI
+MRI of the breast has gained popularity recently due to its high sensitivity for breast pathology. Indeed,
it is the most sensitive imaging modality for breast tissue and diagnosis of breast cancer. Its high
sensitivity has led to high false positive rates, especially for benign proliferative breast lesions, which
will be discussed later. While its use continues to evolve, it is currently used in a variety of preoperative
situations, to assess response to neoadjuvant chemotherapy, to attempt detection of a primary breast
cancer in a patient who presents with axillary lymphadenopathy and an undetectable primary
tumor, in young women who are high-risk due genetically (BRCA1 or BRCA2), and in women
with previous surgery and scarring that make other modalities less sensitive.

Unfortunately, it is expensive and not widely available in many sub-Saharan African countries, which
limits its usefulness to the surgeon here.
 d. CT/bone scintigraphy/PET(CT)
+When patients are asymptomatic but at high risk for metastatic spread or have signs or symptoms of
metastasis, a staging workup is performed. While this will be discussed further in the section on breast
cancer, the main imaging modalities used are CT, bone scintigraphy, and PET(CT), reflecting the major
organs of metastatic spread of breast cancer, liver, lungs, bone, and brain.

Laboratory Evaluations and Biopsy Techniques

Beyond routine serum laboratory evaluations that are performed for a variety of conditions, such as CBC
and electrolyte concentrations, there is little role for blood work for specific breast pathologies. When
there is concern for metastatic spread of breast cancer, either in an asymptomatic patient who is high risk
or in a patient with signs and symptoms, liver function tests and alkaline phosphatase, which may help to
identify metastasis to liver and bone, are recommended.

In any patient where there is concern about the possibility of breast malignancy or an unclear diagnosis,
pathologic evaluation is necessary. This requires biopsy of the lesion in question. A full discussion of
types of tissue biopsies is discussed in the Oncology module, however this will focus on features
pertinent to workup of breast pathology. When a lesion is not palpable, it should be performed using
imaging for localization and guidance. This may use ultrasound, which can be done in an outpatient
clinic, or mammography, which is known as a stereotactic biopsy and must be done by a radiologist with
the necessary equipment. When the lesion is palpable, imaging may be used but does not have to be.
Options include:

 Core needle biopsy (CNB), vacuume assisted core biopsy(large caliber needle)
o CNB is the preferred method of biopsy for breast lesions. This is because it allows the
cells to be seen within the tissue architecture. Thus, the specimen can be used to determine
the involvement of neurovascular tissue components and the presence or absence of
invasion. The specimen can also be used to determine the presence or absence of hormone
receptors on the cancer cells, such as estrogen (ER), progesterone (PR), and human
epidermal growth factor receptor 2 (HER2).
o There is a possibility of sampling error (about 20% of patients with atypical ductal
hyperplasia on core biopsy have invasive cancer found on pathology of excised lesion),
however, CNB is much more sensitive and specific than FNA.
o Vacuum-assisted devices can be used to increase tissue obtained while not requiring
multiple skin insertions. These devices are similar to a core biopsy device but use a
vacuum to draw the tissue into the chamber where a rotating cutting device cuts several
pieces of tissue.
 Fine needle aspiration (FNA)
o FNA only extracts cellular material, so can give diagnosis of breast cancer but cannot give
information on the malignant cells relative to the tissue architecture, meaning it cannot be
used to determine whether or not a cancer is invasive. It also cannot be used to assess for
hormone receptors in the breast tissue.
o Requires pathologist trained in cytology for analysis of the sample.
o Can be used to confirm metastasis in lymph nodes.
 Excisional biopsy 
o With excisional biopsy, the entirety of the lesion is removed. While once the biopsy
method of choice, this method is now reserved for situations when the pathology on core
biopsy does not match the imaging findings, known as discordant results or for situations
when the pathology on core has a significant risk of harboring or having associated cancer,
 such as with radial scar or atypical ductal hyperplasia. These situations will be discussed in
later sections.

Knowledge Check
Check your recall and understanding of the information presented above by answering the following
questions.
Which of the following is the most sensitive imaging modality for detection of primary breast cancer?

Ultrasound
Mammogram
MRI scan
CT scan
Which is the preferred biopsy method for breast masses?

Fine needle aspirate

Core needle biopsy
Excisional biopsy
Punch biopsy
An imaging finding that is categorized as BIRADS 3 indicates what?

The finding is benign

The finding is probably benign
The finding carries a low suspicion for malignancy
The finding carries a moderate suspicion for malignancy