What are the key components of a history and physical exam for a patient presenting with a suspected fibroadenoma (benign breast tumor)?

History and Physical Examination for Suspected Fibroadenoma

Begin with a complete medical history followed by a thorough clinical breast examination (CBE) performed with the patient in both upright and supine positions, including systematic palpation of the entire breast and all regional nodal basins. 1

Key History Components

Breast-Specific History Elements

• Age of patient – fibroadenomas typically occur in women under 40 years, with giant fibroadenomas more common in those under 20 2, 3
• Duration and growth rate of the mass – rapid growth raises concern for phyllodes tumor 4, 5
• Symptoms associated with the mass – pain, skin changes, or nipple discharge 1
• Family history of breast cancer (age at diagnosis, bilaterality), ovarian cancer, and other malignancies 1
• History of prior breast biopsies or breast disease 1
• Menstrual history – date of last menstrual period, possibility of pregnancy, hormone use 1
• History of prior therapeutic chest irradiation 1

General Medical History

• Overall health status and comorbidities that may affect management decisions 1
• History of collagen vascular disease (relevant for potential radiation therapy considerations) 1

Physical Examination Technique

Inspection

• Examine breasts with patient upright and supine 1
• Position patient to elicit subtle shape or contour changes in the breast 1
• Assess for skin changes including peau d'orange, erythema, nipple excoriation, scaling/eczema, or ulceration 1, 3
• Evaluate nipple appearance for discharge, eczema, or distortion 1

Palpation

• Palpate entire breast systematically in both upright and supine positions 1
• Include all nodal basins: axillary, supraclavicular, and internal mammary nodes 1

Characteristics to Document for the Mass

Typical fibroadenoma features on palpation:

• Smooth, rubbery texture 2
• Mobile (moves freely within breast tissue) 2, 5
• Well-defined, discrete margins 1
• Round or oval shape 1

Concerning features requiring further evaluation:

• Immobile or fixed mass – suggests phyllodes tumor or malignancy 5
• Poorly circumscribed or indistinct borders – associated with non-fibroadenoma pathology 1, 5
• Firm or hard consistency – may indicate malignancy 1
• Size greater than 2-2.5 cm – increases likelihood of phyllodes tumor 4, 5
• Asymmetric thickening compared to contralateral breast 1
• Skin or fascial attachment with dimpling or nipple retraction 1

Specific Measurements to Record

• Tumor size (measured in centimeters) and precise location if palpable 1
• Ratio of breast size to tumor size 1
• Axillary node status including size and mobility 1
• Presence of supraclavicular nodes 1
• Appearance of contralateral breast and axilla 1

Critical Clinical Pearls

Physical examination alone cannot reliably distinguish fibroadenoma from other masses – in one study, only 58% of palpable cysts were correctly identified by examination, and experienced surgeons agreed on biopsy need in only 73% of proven malignancies 1. Therefore, imaging evaluation is necessary in almost all cases to characterize any palpable breast lesion 1.

Never allow negative imaging to overrule a highly suspicious physical finding – any highly suspicious breast mass detected by palpation should undergo biopsy unless exceptional clinical circumstances exist 1.

Patient anxiety about the mass is a valid indication for excision even when imaging suggests benign fibroadenoma 4.