Detection of a palpable breast mass, solid or cystic, is of great concern to patients and may prompt an emergency department visit. The emergency physician should examine the patient systematically, as described above, and determine whether a true mass exists. The normal glandular breast tissue has a nodular consistency. Both the upper outer quadrant of the breast and the inframammary ridge have increased nodularity. When a nodularity is persistent throughout the menstrual cycle, it may well be a true mass and may represent a number of entities, including cyst, fibroadenoma, fibrocystic change, or carcinoma. Usually, a patient with a breast malignancy presents with a solitary mass in the upper outer quadrant. Poorly defined masses or thickenings may also be cancer. The breast may be indurated, with thickened skin and nipple retraction. A serosanguineous nipple discharge may be present.
The patient should always be referred for mammography and evaluation by a specialist, even if a mass cannot be detected on examination.
Aspiration of solid or cystic breast masses is best left to a specialist or a provider of continuity of care. A necrotizing breast carcinoma may present identically to abscess, and some authors recommend biopsy of the abscess wall at the time of abscess drainage,9 a procedure clearly beyond the scope of emergency medicine practice. Some authors recommend that the same person who performs the fine-needle aspiration procedure be the evaluating cytopathologist, 18 especially since the feel of the lesion (e.g., the rubbery consistency of a fibroadenoma, the gritty consistency of a malignancy, or the resistant nature of a fibrocystic lesion) has diagnostic importance. In addition, nuances in technique are best left to the specialists (e.g., obtaining a dermal specimen when inflammatory disease of the breast is suspected). The consensus statement of a National Cancer Institute conference has identified the specific indications and training and credentialing recommendations for fine-needle aspiration of breast masses.19
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