3/3/23, 11:48 AM Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass - UpToDate

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Clinical manifestations, differential diagnosis, and

clinical evaluation 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: Feb 2023. | This topic last updated: Aug 20, 2021.

INTRODUCTION

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'.)

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, differential diagnosis, and clinical evaluation of women with a
palpable breast mass are reviewed here. Breast imaging and breast biopsy are discussed in
detail separately. (See "Diagnostic evaluation of suspected breast cancer" and "Breast
biopsy".)

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 diseases".)

● (See "Breast pain".)

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● (See "Nipple discharge".)

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

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

CLINICAL MANIFESTATIONS

A breast mass can be discovered by the patient incidentally or on routine examination by a

patient or clinician. It is often discovered after a breast examination prompted by other
symptoms (eg, pain, nipple discharge) or trauma [4,5].

On the physical examination, the palpable breast mass can be obvious or subtle; the density
can be soft, firm, or hard; it can be mobile or fixed to the chest wall or skin; and it can be
tender or nontender [6]. The mass may have well-defined or nondiscrete margins and be
associated with clinical findings including ecchymosis, erythema, peau d'orange, or skin
dimpling; nipple discharge; or nipple retraction. Often the mass has no associated clinical
findings. (See 'Physical examination' below.)

Multiple epidemiologic studies around the world have reported that breast cancer occurs
more frequently in the upper outer quadrant than any other part of the breast. In a National
Cancer Database (NCDB) study of over 2 million women diagnosed with breast cancer
between 2004 and 2015, 39.5 percent had cancer in the upper outer quadrant [7]. Smaller
studies reported breast cancer in the upper outer quadrant in 36 to 62 percent of patients
[7]. Although this is most likely secondary to the upper outer quadrant having more breast
tissue [8], there may be differences in genomic instability in this area [9].

DIFFERENTIAL DIAGNOSIS

The differential diagnosis of a palpable breast mass includes benign and malignant
etiologies. Palpable breast masses are very common in women, and most palpable masses
are benign [4,10,11]. 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 [12].

Benign — 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 can be found elsewhere. (See "Overview of benign breast diseases".)

● 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

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mass is firm and often mobile. A fibroadenoma may be solitary, multiple, or bilateral.
(See "Overview of benign breast diseases", section on '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 and may be bilateral, unilateral, or focal. The breast tissue, particularly in the
upper outer quadrant, may increase in size prior to the onset of menses, then return to
baseline after the onset of the menstrual flow. On clinical examination, the breast
tissue frequently is nodular. (See "Breast pain", section on 'Cyclical breast pain'.)

● 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 [13], paraffin, or
silicone [14,15]; an operative procedure such as breast reductive surgery [16] or
autologous breast reconstruction [17]; and radiation therapy [18,19] to the breast. Fat
necrosis from trauma is generally associated with skin ecchymosis. Fat necrosis can
often be clinically and even radiographically difficult to distinguish from a malignant
mass. (See "Overview of benign breast diseases", 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 is
left untreated or 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 and noninvasive cancers. The following types of masses are among the most
common malignant breast masses palpated. Further review of the pathology of breast
cancer is discussed separately. (See "Clinical features, diagnosis, and staging of newly

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diagnosed breast cancer", section on 'Differential diagnosis' and "Pathology of breast

cancer".)

● The most common breast cancer is an infiltrating ductal breast carcinoma [11]. 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. Infiltrating lobular carcinoma often presents as a prominent
diffuse thickening of the breast rather than as a discrete mass. There are also variants
of the invasive ductal carcinomas that can be detected as a palpable mass. (See
"Clinical features, diagnosis, and staging of newly diagnosed breast cancer", section on
'Differential diagnosis'.)

● Rarely, noninvasive cancers (ductal carcinoma in situ [DCIS]) with or without

microinvasion can develop into a palpable breast mass. (See "Breast ductal carcinoma
in situ: Epidemiology, clinical manifestations, and diagnosis".)

CLINICAL EVALUATION

The clinical evaluation of a palpable breast mass begins with a complete history and physical
examination, as described below [4,5]. Although some radiographically identified masses
may not be palpable, the same clinical evaluation also applies.

History — The history should include a full review of medical and surgical illnesses,
medications, and allergies and an assessment of risk factors for breast cancer, such as a
detailed family history. 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].

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. (See "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".)

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● 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' above.)

● 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 diseases", section on 'Nonproliferative lesions' and "Breast
cysts: Clinical manifestations, diagnosis, and management".)

● 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 diseases", section on 'Fat necrosis'.)

Risk factors for 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 both breasts and the nodal
basins of the neck, chest wall, and both axillae and is part of a complete physical
examination ( figure 1) [4,20,21].

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.

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● 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. This allows relaxation of the latissimus and pectoralis muscles for ease in
palpating high into the axilla. 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 [20-22]. 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 [20,23]. One hand stabilizes the breast while the other hand is used to
perform the examination [21].

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

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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 nipple or from the
radial edge of the areola can be used to document location of the mass.

Timing of examination — In premenopausal patients, 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. However, the evaluation of a
clinically suspicious mass should not be influenced by the phase of the menstrual cycle.

Accuracy of 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
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 clinician-
detected masses (n = 121) [24].

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. 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
are not perfect. In one report, from a study of symptomatic women, experienced examiners
who diagnosed "definite cancer" on palpation were correct in 93 percent of cases [25]. In
another series, the physical examination had a positive predictive value of 73 percent and a
negative predictive value of 87 percent [26].

DIAGNOSTIC EVALUATION

Imaging options include diagnostic mammography, including tomosynthesis where

available, and targeted breast ultrasound, the choice of which depends on patient age and
the degree of clinical/radiologic suspicion. There is little role for advanced imaging
modalities such as breast magnetic resonance imaging. (See "Diagnostic evaluation of
suspected breast cancer", section on 'Our approaches'.)

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The diagnosis of a benign or malignant breast mass is confirmed by a breast biopsy. 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 diseases" and "Clinical
features, diagnosis, and staging of newly diagnosed breast cancer", section on 'Pathology'.)

FOLLOW-UP OF BENIGN BREAST MASS

The appropriate interval of follow-up for patients with benign biopsy is controversial and
depends on the histology. Although various intervals (four or six months) have been
proposed, no evidence-based guidelines are available to aid this decision [27].

For patients with a benign biopsy, we suggest repeating clinical examination and imaging
every six months for two years, and if stable, patients may return to routine screening after
that. Biopsy-proven benign masses that change clinically or radiographically, such as
increasing in size on follow-up examinations, should be reevaluated and excised.

Whether a short follow-up interval is necessary has been questioned [28,29]. 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) [27]. A total of 17,631 biopsies with benign findings
were identified. Similar cancer detection rates were found 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".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Evaluation of breast
problems".)

INFORMATION FOR PATIENTS

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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 email 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 topic (see "Patient education: Common breast problems (The Basics)")

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

SUMMARY AND RECOMMENDATIONS

● Clinical manifestations – A breast mass can be discovered by the patient incidentally

or on routine examination by a patient or clinician. It is often discovered after a breast
examination prompted by other symptoms (eg, pain, nipple discharge) or trauma. The
characteristics of the mass to be evaluated include density (such as soft, hard, or firm),
skin changes, nipple-areolar changes, and/or fixation to the chest wall. (See 'Clinical
manifestations' above.)

● Differential diagnosis – The differential diagnosis of a palpable breast mass includes

benign (eg, fibroadenoma, cysts) and malignant (eg, invasive and noninvasive cancer)
etiologies. Although most palpable breast masses are benign, especially in young
women, it is crucial to exclude breast cancer in a woman of any age. (See 'Differential
diagnosis' above.)

● Clinical evaluation – A systematic history including risk factors for breast cancer and
physical examination are performed for every woman who presents with a new breast
mass, whether it is palpable or only recognized radiographically. (See 'Clinical
evaluation' above.)

● Imaging – Because physical examination alone is usually insufficient to distinguish

between a benign mass and a malignancy, diagnostic evaluation including radiographic
imaging and, frequently, a breast biopsy is required. Breast imaging and breast biopsy

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are discussed in other topics. (See "Diagnostic evaluation of suspected breast cancer"
and "Breast biopsy".)

● Follow-up after benign biopsy – For patients with a benign breast biopsy, we suggest
repeating clinical examination and imaging every six months for two years, and if
stable, patients may return to routine screening after that. Biopsy-proven benign
masses that change clinically or radiographically, such as increasing in size on follow-up
examinations, should be reevaluated and excised. (See 'Follow-up of benign breast
mass' above.)

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REFERENCES

1. Singh H, Sethi S, Raber M, Petersen LA. Errors in cancer diagnosis: current

understanding and future directions. J Clin Oncol 2007; 25:5009.
2. 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.
3. Aaronson EL, Quinn GR, Wong CI, et al. Missed diagnosis of cancer in primary care:
Insights from malpractice claims data. J Healthc Risk Manag 2019; 39:19.
4. Morrow M. The evaluation of common breast problems. Am Fam Physician 2000;
61:2371.

5. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005; 353:275.
6. 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.
7. Sisti A, Huayllani MT, Boczar D, et al. Breast cancer in women: a descriptive analysis of
the national cancer database. Acta Biomed 2020; 91:332.
8. Chen JH, Liao F, Zhang Y, et al. 3D MRI for Quantitative Analysis of Quadrant Percent
Breast Density: Correlation with Quadrant Location of Breast Cancer. Acad Radiol 2017;
24:811.

9. Ellsworth DL, Ellsworth RE, Love B, et al. Outer breast quadrants demonstrate increased
levels of genomic instability. Ann Surg Oncol 2004; 11:861.
10. Klein S. Evaluation of palpable breast masses. Am Fam Physician 2005; 71:1731.

11. Schoonjans JM, Brem RF. Fourteen-gauge ultrasonographically guided large-core needle
biopsy of breast masses. J Ultrasound Med 2001; 20:967.

https://www.uptodate.com/contents/clinical-manifestations-differential-diagnosis-and-clinical-evaluation-of-a-palpable-breast-mass/print?search… 10/17
3/3/23, 11:48 AM Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass - UpToDate

12. 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.
13. 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.
14. 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.
15. Majedah S, Alhabshi I, Salim S. Granulomatous reaction secondary to intramammary
silicone injection. BMJ Case Rep 2013; 2013.
16. Lewin R, Göransson M, Elander A, et al. Risk factors for complications after breast
reduction surgery. J Plast Surg Hand Surg 2014; 48:10.

17. Wagner IJ, Tong WM, Halvorson EG. A classification system for fat necrosis in
autologous breast reconstruction. Ann Plast Surg 2013; 70:553.
18. Meric F, Buchholz TA, Mirza NQ, et al. Long-term complications associated with breast-
conservation surgery and radiotherapy. Ann Surg Oncol 2002; 9:543.

19. 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.

20. 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.

21. Morrow M. Physical examination of the breast. In: Diseases of the Breast, 5th edition, Ha
rris JR, Lippman ME, Morrow M, Osbourne CK (Eds), Lippincott Williams & Wilkins, Philad
elphia 2014. p.25.

22. Saunders KJ, Pilgrim CA, Pennypacker HS. Increased proficiency of search in breast self-
examination. Cancer 1986; 58:2531.

23. Hall DC, Goldstein MK, Stein GH. Progress in manual breast examination. Cancer 1977;
40:364.

24. Morrow M, Wong S, Venta L. The evaluation of breast masses in women younger than
forty years of age. Surgery 1998; 124:634.

25. 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.

https://www.uptodate.com/contents/clinical-manifestations-differential-diagnosis-and-clinical-evaluation-of-a-palpable-breast-mass/print?search… 11/17
3/3/23, 11:48 AM Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass - UpToDate

26. 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.

27. 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.
28. 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.

29. 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.
Topic 804 Version 25.0

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GRAPHICS

Risk and protective factors for developing breast cancer

Risk group
 
Relative
Low risk High risk
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 1.07 to 1.2

use

Hormone replacement Never Current 1.2

therapy (estrogen + progestin)

Alcohol None 2 to 1.4

5 drinks/day

Breast density on mammography 0 ≥75 1.8 to 6.0

(percents)

Bone density Lowest quartile Highest 2.7 to 3.5

quartile

History of a benign breast biopsy No Yes 1.7

History of atypical hyperplasia on No Yes 3.7

biopsy

Protective factors

Breast feeding (months) ≥16 0 0.73

Parity ≥5 0 0.71

Recreational exercise Yes No 0.70

Postmenopause body mass index <22.9 >30.7 0.63

(kg/m 2 )

Oophorectomy before age 35 years Yes No 0.3

Aspirin ≥Once/week for ≥6 Nonusers 0.79

months

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

Graphic 64508 Version 4.0

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Breast examination

(A) The breast examination 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.

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(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 examination 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
midaxillary 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 4.0

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Contributor Disclosures
Michael S Sabel, MD No relevant financial relationship(s) with ineligible companies to disclose. Anees
B Chagpar, MD, MSc, MA, MPH, MBA, FACS, FRCS(C) Consultant/Advisory Boards: Athenex [Breast
cancer]; Guardant Health [Breast cancer]; Lumicell [Breast cancer]; Novartis [Breast cancer]; Protean
BioDiagnostics [Breast cancer]; Puma Diagnostics [Breast cancer]; Sanofi-Aventis [Breast cancer].
Speaker's Bureau: Merck [Breast cancer]. All of the relevant financial relationships listed have been
mitigated. Wenliang Chen, MD, PhD No relevant financial relationship(s) with ineligible companies 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

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