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ESSENTIALS OF DIAGNOSIS

ESSENTIALS OF DIAGNOSIS

  • Classified as cyclical, noncyclical, or extramammary.

  • Abnormal physical examination findings, such as a breast mass or skin abnormalities, should prompt radiographic imaging.

GENERAL CONSIDERATIONS

Breast pain, also known as mastalgia, is a common condition and affects up to 70% of women during their lifetime. Mastalgia is classified as cyclical, noncyclical, or extramammary. Cyclical mastalgia is the most common type of breast pain and is characterized by discomfort that is most prominent during the luteal phase of ovulation, improving with menses. Noncyclical mastalgia has no relationship to the menstrual cycle and is more common among women in their fourth or fifth decades of life. Causes of noncyclical mastalgia include duct ectasia, mastitis, large breast size (with stretching of Cooper ligaments), medications, pregnancy, thoracic vein thrombophlebitis, trauma, or prior breast surgery. Although uncommon, advanced breast cancer, invasive lobular carcinoma, and anaplastic carcinoma of the breast may also present with mastalgia. Extramammary mastalgia is caused by pain that is referred from other anatomic locations, including the chest wall, heart, gallbladder, or spine.

CLINICAL FINDINGS

A. Symptoms and Signs

Cyclical mastalgia is typically diffuse, bilateral, and associated with either the menstrual cycle or cyclically administered hormonal therapies such as contraceptives or menopausal hormone therapy. Conversely, noncyclical mastalgia, which may be constant or intermittent, is variable in location and can involve one or both breasts. Chest wall pain, a frequent cause of extramammary mastalgia, typically causes unilateral, burning pain that may be either localized or diffuse.

A careful physical examination is essential in all women who report breast pain. Extramammary causes of mastalgia, such as inflammation of the pectoralis major muscle or costochondral junction, can usually be diagnosed through careful palpation. Mondor disease, which is caused by superficial thrombophlebitis of the lateral thoracic vein, is associated with a red, tender, palpable cord.

B. Imaging

An ultrasound, mammogram, or both should be obtained in women who have a palpable breast mass or in whom Mondor disease is suspected since this diagnosis may be associated with breast cancer.

Additionally, imaging should be considered for women who experience noncyclical, unilateral, or localized mastalgia that is not clearly associated with a specific diagnosis, particularly when pain is progressive. According to the American College of Radiology Appropriateness Criteria, ultrasound is the preferred imaging modality for women under the age of 30 years because it is more accurate than mammography in this age group. Mammography and ultrasonography should be performed in women over the age of 40 years, and use of both imaging modalities should also be considered in selected patients aged 30–39 years.

Women who are up to date on routine screening mammography, who present with cyclical or nonfocal bilateral breast pain, and who have normal physical examination ...

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