Chapter 6: Breast Lumps & Nipple Discharge Assessment

The text outlines the epidemiology of breast complaints, noting that fibroadenomas, fibrocystic changes, and carcinomas represent the three most common findings, with patient age serving as a vital diagnostic pivot point; for instance, fibroadenomas are prevalent in women under thirty, whereas the risk of carcinoma rises significantly after age fifty. The diagnostic reasoning process begins with a focused history that investigates the duration, growth rate, and cyclic nature of the lump, as well as risk factors such as family history, BRCA mutations, and personal history of atypical hyperplasia. The chapter details the evaluation of nipple discharge, distinguishing between physiologic causes like pregnancy or medication-induced hyperprolactinemia (often bilateral and milky) and pathologic causes like intraductal papilloma or ductal ectasia (often unilateral, spontaneous, and serosanguineous or multicolored). A significant portion of the chapter is dedicated to the physical examination, describing inspection techniques for skin dimpling, nipple retraction, and signs of Paget disease, alongside specific palpation methods like the vertical strip pattern to assess the breast tissue and the Tail of Spence. It also covers the assessment of supraclavicular and axillary lymph nodes to detect metastatic disease. Diagnostic strategies are stratified by age and clinical presentation, recommending ultrasonography for differentiating cystic from solid masses in younger women, while diagnostic mammography with tomosynthesis is prioritized for women over thirty or those with palpable masses. The text further explains the role of magnetic resonance imaging for dense tissue or implant evaluation and outlines biopsy techniques including fine-needle aspiration, core needle biopsy, and excisional biopsy. Finally, the chapter provides a detailed differential diagnosis, contrasting the clinical features of benign conditions like lipomas, fat necrosis, and mastitis (including lactational abscesses caused by Staphylococcus aureus) against the presentation of inflammatory breast cancer and male breast disease.