Differential Diagnoses: Breast Lumps & Nipple Discharge

Question 1

Single Breast Mass: Cancer

Answer 1

History: Usually older than 35yo; Unilateral new lump

Physical Findings: Hard, contender, fixed lump; borders irregular or not discrete; can be erythema dimpling; increased vessel patterns; can have nipple discharge

Diagnostic Criteria: Diagnostic mammogram; ultrasound; tissue biopsy

Question 2

Single Breast Mass: Cysts

Answer 2

History: Younger age; Often younger than 35yo; May be single or multiple

Physical Findings: Round or elliptical; soft or fluctuant; mobile

Diagnostic Criteria: Clinical Breast Exam; FNA: Clear aspirate; mammogram; ultrasound: cyst(s)

Question 3

Single Breast Mass: Fibroadenoma

Answer 3

History: Common in adolescents

Physical Findings: Single; Sharply circumscribed; mobile lump

Diagnostic Criteria: Diagnostic mammogram; ultrasound; biopsy

Question 4

Single Breast Mass: Abscess

Answer 4

History: History of mastitis

Physical Findings: Single mass; irregular shape; chronic abscess can be non-tender

Diagnostic Criteria: Incision and drainage with culture

Question 5

Single Breast Mass: Fat Necrosis

Answer 5

History: Can have history of injury at site

Physical Findings: single; fixed, and often irregular tumor

Diagnostic Criteria: biopsy

Question 6

Single Breast Mass: Lipoma

Answer 6

History: Can have others on arms, trunk, buttocks, or back; usually non-tender

Physical Findings: Single tumors; smooth, well-defined; fluctuant consistency

Diagnostic Criteria: Biopsy

Question 7

Single Breast Mass: Tuberculosis

Answer 7

History: History of TB; Positive PPD or CXR; Immunocompromised status

Physical Findings: Single; Irregular shape; Non-tender

Diagnostic Criteria: Biopsy

Question 8

Single Breast Mass: Ruptured Implant

Answer 8

History: History of augmentation; change in size or shape of breast

Physical Findings: Nodule palpated best when patient is sitting

Diagnostic Criteria: Diagnostic mammogram; Ultrasound; MRI

Question 9

Inflammatory Breast Mass: Mastitis and Acute Abscess

Answer 9

History: Primagravida more often than multigravida; > 1week postpartum; breastfeeding; tender nipples

Physical Findings: Red, warm, tender, usually unilateral, one fourth of breast, or one lobule; breast engorgement; fever; nipple discharge: pus

Diagnostic Criteria: Culture positive for S. Aureus, E. coli, or Strep; Elevated WBC

Question 10

Inflammatory Breast Mass: Inflammatory Breast Cancer

Answer 10

History: History of mastitis or inflammatory process of breast

Physical Findings: Entire breast swollen, fever rarely present; axillary lymphadenopathy

Diagnostic Criteria: Biopsy

Question 11

Multiple or Bilateral Breast Lumps: Fibrocystic Breast Changes

Answer 11

History: Multiple breast lumps of both breasts; cyclic changes that worsen at times of menses

Physical Findings: bilateral nodularity; dominant lumps, tender, mobile

Diagnostic Criteria: FNA; US; Mammogram

Question 12

Nipple Discharge: Intraductal Papilloma

Answer 12

History: Bloody nipple discharge; Usual age is 40-50yo

Physical Findings: Unilateral, subareolar

Diagnostic Criteria: Diagnostic mammogram; US; ductogram; maybe MRI

Question 13

Nipple Discharge: Fibrocystic Breast Changes

Answer 13

History: milky nipple discharge; cyclic changes that worsen at time of menses

Physical Findings: spontaneous, clear or milky, bilateral, multi-duct nipple discharge; multiple breast lumps of both breasts

Diagnostic Criteria: mammogram, US, ductogram, maybe MRI

Question 14

Nipple Discharge: Duct Ectasia

Answer 14

History: green nipple discharge

Physical Findings: greenish or brownish nipple discharge

Diagnostic Criteria: diagnostic mammogram, ductogram, maybe MRI

Question 15

Nipple Discharge: Neonatal Discharge (Witch’s Milk)

Answer 15

History: milky discharge 1-2 weeks after delivery

Physical Findings: enlarged breast tissue; milky discharge 1-2 weeks after delivery

Diagnostic Criteria: none

Question 16

Nipple Discharge: Hyperprolactinemia

Answer 16

History: milky or clear nipple discharge; amenorrhea; hx of meds: estrogenic, dopamine blockers/depleters; hypothyroidism; pregnancy; postabortion; nipple stimulators; visual changes

Physical Findings: spontaneous, unilateral or bilateral, multi-duct; clear or milky nipple discharge

Diagnostic Criteria: serum proclactin levels; TSH; MRI if indicated

Question 17

Male Breast Disease: Acute Mastitis

Answer 17

History: hx of clothing rubbing nipple (I.e. jogging); swelling or lump of chest wall; tenderness at site

Physical Findings: red, warm, tender; usually unilateral one fourth of breast, one lobule; breast enlargement; fever; nipple discharge or pus

Diagnostic Criteria: Culture positive for S. Aureus, E. coli, strep; Elevated WBC

Question 18

Male Breast Disease: Cancer

Answer 18

History: Family Hx of Male Breast Cancer; painless lump of chest wall

Physical Findings: induration, retraction of nipple or mass in nipple well; fixed, contender; lymphadenopathy

Diagnostic Criteria: Mammogram, FNA, tissue biopsy