The most common breast complaints in the ED involve breast pain, breast
mass, nipple discharge, infection, or postoperative complications. Although
the problems are rarely emergent except when systemic symptoms such
as fever are present, concern for the potential of breast cancer may
contribute to increased patient anxiety.
Few data are available regarding the incidence of emergency presentations
of general breast disorders. Approximately one in every three to four
women in the U.S. sees a physician with a chief complaint relating to
the breasts.1 Current epidemiology of the emergency
presentation of breast problems has not been recently reported in
the U.S.2 In Spain, complaints secondary to breast
cancer account for approximately 15% of all oncologic emergency
visits, or 5% of total emergency visits.3 Women in
the U.S. have a 12% lifetime risk of developing breast
cancer.2 In 2008, the incidence of all breast cancers
exceeded 182,000 new cases, with an estimated 40,480 deaths attributable
to breast cancer. Although the acuity of the breast complaints may
be low, the prevalence of presenting breast disorders can be quite
Normal breast tissue is a circular mass of glandular tissue located
on the anterior chest wall and extending from the sternocostal junction medially
to the midaxillary line laterally and from the second to the sixth
ribs in the midclavicular line. Sensory innervation is dermatomal in
distribution, whereas the arterial supply to the breast arises from the
internal mammary, lateral thoracic, thoracodorsal, and subscapular
arteries. Lymphatic drainage of the breast is primarily to the axilla, with
a small portion going to internal mammary lymph nodes. Lymph flow
is not regionally distributed; lymphatic drainage to either the
axilla or the internal mammary chain can originate in any quadrant
of the breast.
Stromal and lobular tissues continue to develop until approximately
25 years of age. Adult breast is composed of approximately 20% ductal
tissue, and the remaining breast volume consists of fat and connective
tissue that give the breast its characteristic texture and shape.
Cyclic variances in estrogens, progesterone, follicle-stimulating
hormone, and luteinizing hormone signal stromal and glandular changes
in breast physiology. For example, rising levels of circulating
progesterone and a small peak in estrogen levels result in interlobular
edema and cause the breast swelling, engorgement, and tenderness
associated with the premenstrual phase. Breast tissue volume and
tenderness are at a minimum 5 to 7 days after menstruation due to
the relative lack of progesterone, which allows for a more comfortable
breast examination. The rapid decline in estrogen and progesterone
levels at the onset of menstruation leads to ductal involution.
At menopause, glandular tissue is lost secondary to the gradual
loss of estrogen and progesterone synthesis. The resulting postmenopausal
breast consists predominantly of prepectoral fat, connective tissue,
mammary ducts, and minimal lobular elements.
The history taking and examination should be as private, comfortable, and
reassuring as ...