From the Guidelines
To assess the breast for masses, perform a systematic examination using both visual inspection and palpation, as this approach ensures thorough examination and increases the likelihood of detecting abnormalities that may require further evaluation. When assessing the breast for masses, it is essential to begin with a visual inspection, looking for asymmetry, skin changes, nipple retraction, or visible masses, as recommended by 1. The patient should sit with her hands pushing tightly on her hips to contract the pectoralis major muscles and enhance identification of asymmetries. The visual inspection should assess symmetry in breast shape or contour and skin changes, particularly any skin erythema, retraction, or dimpling, and nipple changes, as outlined in the BREAST acronym, which signifies Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, and Tender breast 1.
Palpation
Then, have the patient lie supine with the arm on the examined side raised above the head. Use the pads of your fingers to palpate the entire breast tissue in a consistent pattern (vertical strips, concentric circles, or wedges) from the collarbone to the inframammary fold and from the sternum to the axilla, applying three levels of pressure (light, medium, and deep) to detect masses at different depths, as suggested by 1. Pay special attention to the upper outer quadrant, where most breast cancers occur. Examine the axillary lymph nodes by having the patient relax their arm while you palpate the axilla. Finally, gently compress the nipple to check for discharge. Document any findings, including the location, size, shape, consistency, mobility, tenderness, and skin changes associated with any masses.
Imaging Evaluation
According to 1, a thorough imaging workup of a palpable mass should be completed prior to biopsy, and diagnostic mammography or DBT is the initial imaging modality of choice for evaluating a clinically detected palpable breast mass in a woman aged 40 years or older. For women younger than age 30 years, breast US is the initial imaging modality of choice, while for women aged 30 to 39 years, either US or diagnostic mammography or DBT can be used for initial evaluation, as recommended by 1. Correlation between imaging and the palpable area of concern is essential, and any highly suspicious breast mass detected by imaging or palpation should be biopsied, irrespective of imaging or palpable findings, as stated in 1 and 1.
Key Points
- Perform a systematic examination using both visual inspection and palpation
- Begin with visual inspection, looking for asymmetry, skin changes, nipple retraction, or visible masses
- Use a consistent pattern for palpation, applying three levels of pressure
- Pay special attention to the upper outer quadrant
- Examine the axillary lymph nodes and check for nipple discharge
- Document all findings, including location, size, shape, consistency, mobility, tenderness, and skin changes
- Correlate imaging with palpable findings and biopsy any highly suspicious masses.
From the Research
Assessing the Breast for Masses
To assess the breast for masses, several methods can be employed, including clinical breast examination, mammography, ultrasound, and biopsy.
- Clinical Breast Examination: This is the first step in evaluating a breast mass, where a healthcare professional examines the breast to identify any palpable masses or abnormalities 2.
- Imaging Techniques:
- Mammography: It is the initial imaging modality of choice for women aged 40 years and above with a clinically detected breast mass 3.
- Ultrasound: It is typically used for initial evaluation in women under 30 years, pregnant, or lactating. For women between 30 to 39 years, either ultrasound or diagnostic mammography may be used 3.
- MRI: It is rarely indicated for evaluating a clinically detected breast mass 3.
- Biopsy: It is indicated for masses with suspicious features. Short-term follow-up is a reasonable alternative to biopsy for solid masses with probably benign features suggesting fibroadenoma 3.
- Combination of Mammography and Ultrasound: Studies have shown that combining mammography with ultrasound can detect more breast cancer cases than mammography alone, especially in women with dense breasts 4, 5, 6.
- Accuracy of Ultrasound and Mammography: Ultrasound has been found to have higher sensitivity than mammography, especially in women under 50 years and those with dense breasts 5. However, mammography has higher specificity, particularly in women over 50 years 5.
Key Considerations
- Correlation between imaging and clinical findings is essential for accurate diagnosis 3.
- The choice of imaging modality depends on the patient's age, breast density, and clinical presentation 3, 4, 5, 6.
- Supplemental ultrasound can improve cancer detection in screening, but it may also increase recall and biopsy rates 4, 6.