Palpable tumour
If, upon palpation of the breasts (by either the woman herself or an examiner), a tumour is detected, it is of utmost importance to establish whether this tumour is benign or malignant. To assess the nature of the tumour, it is important to possess a sound understanding of the relative value of each diagnostic finding (history-taking, physical examination, mammography, ultrasound and cytology).
A physical-diagnostic examination alone is not sufficient to distinguish with certainty between malignant or benign breast disease.
It should be combined with the history-taking and any further diagnostic examinations to establish the nature of the tumour. Palpation of a tumour can provide information about the following aspects: location, size, consistency, shape, surface, relationship with the tumour surroundings (skin and subcutaneous tissue) and tenderness. A tumour that is significantly adhered to the surrounding tissue is probably malignant. A very firm consistency and irregular surface can also indicate malignancy.
On the other hand, a smooth, round or oval tumour that is free from the skin and subcutaneous tissue is often benign, particularly if the size of the tumour varies with the menstrual cycle. Tenderness accompanied by local redness is suggestive of localised inflammation.
Finally, the age of the woman also plays a role. Malignant breast tumours are rare under the age of 30. Above 50 years of age, the risk that a palpable tumour is malignant increases.
Palpation of a tumour must be carried out carefully. There is a risk of haematogenous and/or lymphatic dissemination as the result of overzealous palpation.
If a palpable tumour is detected, it is essential to find out whether there are distant metastases present.
Nipple discharge
Spontaneous discharge from the nipple should be examined further if it consists of bloody or serous fluid. Colourless or white fluid is almost always benign and represents normal discharge from mammary gland tissue, such as the large volumes secreted post-partum. Bilateral discharge is often hormonally determined. Unilateral bloody or serous discharge may be based on an intraductal papilloma or a ductal carcinoma in situ. Usually, however, a benign papilloma is involved.
A cytological examination can be carried out on fluid from the nipple to detect the presence of tumour cells. If a malignancy is suspected, invasive examination is essential.
Mastalgia
(= pain in one or both breasts)
Whether the pain varies during the course of the menstrual cycle is important. If this is the case, it will often be accompanied by a taut and heavy feeling in the breasts. These symptoms indicate mastopathy. If the pain is accompanied by a palpable tumour, this tumour should be examined further. It has been found that pain provides no information about whether or not a co-existing tumour is malignant.
Following blunt trauma to the breast, there may be pain as the result of a contusion.
If the pain is accompanied by local redness, there may be mastitis or a breast abscess. This is rare outside the puerperium period.
Nipple and skin defects
Retractions of the skin or nipple that have developed recently are suggestive of an underlying malignancy. Formation of fibrous tissue can cause the suspensory ligaments of Cooper to shrink. This causes traction of the skin and dimpling becomes visible which justifies further examination.
‘Peau d’orange’ (orange peel skin) is caused by oedema of the skin due to blockage of the lymphatic ducts, often as the result of the tumour cells located there. The skin takes on the appearance of a miniature crater landscape, like the peel of an orange. The effect is often more visible when the skin is pinched together slightly.
Any recent skin flaking and redness around the nipple is suspect for Paget’s carcinoma of the nipple.
Changes to breast skin can, of course, also be part of a generalised skin condition (eczema, psoriasis, acne, etc.).