Beware the inframammary crease

Clinical: A 67 year old lady presents with a painless right breast lump that she has noticed in the fold under her breast recently.

Examination reveals only slightly lumpy tissue in the infra-mammary crease area.  A mammogram is reported to show no evidence of malignancy.

Clinical examination in the sitting position is normal, but when the patient is asked to elevate her arms above her head there is obvious deformity of the breast.

An ultrasound examination reveals a solid mass measuring 2cm in diameter and ultrasound guided core biopsy confirms a diagnosis of infiltrating duct carcinoma.

Comment: Approximately 20% of breast cancers are not seen on mammography. Some of these are truly mammogram occult and others cannot be demonstrated for technical reasons.  It can be difficult to image the infra-mammary crease area as the breast cannot be compressed and displaced adequately to include this area on the film.

A thorough clinical examination can facilitate diagnosis. As always with breast examination the patient must be undressed from the waist up and examined in both the sitting and lying position. In this case simple inspection of the breast while elevating the arms draws attention to the area of concern.

Author information: Trevor Smith is a breast and general surgeon and is Director of The Breast Centre Ltd located at Level 2 Ascot Integrated Hospital 90 Greenlane Road Auckland. He is author of the book Breast Care.

Correspondence: Trevor Smith, The Breast Centre Ltd, 90 Greenlane Rd, Remuera, Auckland.

Email breastcentre@xtra.co.nz

Reference:

Sanki A, Spillane A. Diagnostic and treatment challenges of infra-mammary crease breast carcinomas. ANZ J Surg. 2006 Apr;76(4):230-3.