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INTRODUCTION

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The most common breast complaints in the ED involve breast pain, breast mass, nipple discharge, infection, or postoperative complications. Approximately 30% of women will present to a physician with a chief complaint related to the breasts.1 Although the problems are rarely emergent except when systemic symptoms such as fever are present, concerns about the potential for breast cancer contribute to patient anxiety.

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PATHOPHYSIOLOGY

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Adult breast is composed of approximately 20% glandular tissue, and the remaining breast volume consists of fat and connective tissue that give the breast its characteristic texture and shape. Glandular lobules drain into lactiferous ducts, which converge and open at the nipple. In nonpendulous breast, the nipple is an important landmark located over the fourth intercostal space.

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Normal breast tissue extends from the sternocostal junction medially to the midaxillary line laterally and from the second to the sixth ribs in the midclavicular line. An axillary tail of breast tissue often extends into the axilla. Blood supply arises from the internal mammary, lateral thoracic, thoracodorsal, and subscapular arteries, whereas venous drainage starts in the subareolar plexus and empties into the intercostals, internal mammary, and axillary veins. Lymphatic drainage of the breast is primarily to the axilla, with a small portion going to internal mammary lymph nodes.

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Cyclic variances in estrogens, progesterone, follicle-stimulating hormone, and luteinizing hormone signal stromal and glandular changes in breast physiology.

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CLINICAL FEATURES

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HISTORY

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Ask the patient about onset of any mass or pain, location of the affected area, and duration of the symptoms. Complaints that vary with menses suggest a benign cause, whereas cancers are often asymptomatic. Radiation of the pain to any other body site is particularly important when a malignancy is suspected. The presence of symptoms in the contralateral breast parenchyma is also more reassuring for a benign diagnosis. Assess the color and consistency of any nipple discharge, although the color of the discharge does not differentiate a benign from a malignant process. Changes that the patient notes on breast self-examination may be significant and should be correlated with the menstrual cycle. Ask about family history, specifically about first-degree relatives with breast cancer and other risk factors (delay of childbearing to after age 30 years, biopsy confirmation of atypical hyperplasia, or history of chest irradiation). However, most women who develop breast cancer have no obvious risk factors beyond the two strongest factors, namely, female gender and age. More than 50% of breast cancers are diagnosed in women ≥65 years of age, and women <30 years of age are diagnosed with <1% of all breast cancers.2

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PHYSICAL EXAMINATION

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The breast examination (Figure 104-1) includes both inspection and palpation. Compare the breasts with the patient sitting upright, and note any breast asymmetry or skin dimpling. Subtle abnormalities in the lower quadrants may be accentuated by having the patient raise her arms above her ...

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