BREAST

EXAMINATION
TUTORIAL
OUTLINE
• Introduction
• Review basic anatomy of the breast
• Indications
• Clinical breast exam
• Investigations of breast disease
• Differentials
• Prevention
• Self breast exam
ANATOMY
• The breast is located on the anterior thoracic wall and extends from
the lateral border of the sternum to the mid-axillary line horizontally
and spans between the 2nd and 6th costal cartilages.
• It lies superficial to the pectoralis major and serratus anterior
muscles.
• It is considered to be composed of 2 regions; the circular body
( nipple, areola and fat tissue) and axillary tail
INTRODUCTION
ANATOMY

 Most breast feel ‘lumpy’ on palpation

due to: glandular tissue, fibrous tissue,
supporting ligaments & fat
 The Nipple extends outwards from the
areola.
 Nerves, blood vessels & lymphatic
structures contained within the
breasts
 Lymphatic drainage provides the
primary pathway for the spread of
cancer
 Often unequal in size (Left often larger)
 Change in size during maturation,
pregnancy & menstrual cycle
INDICATIONS
• Every 3 years between menarche & 40 years.
• Annually from 40 years onwards.
• Complaints of;
Breast pain, Nipple Discharges, Skin changes, Gross changes in size or
shape, Lumps.
• History of swelling in the axillary region.
• Any other feature that cause concern to the patient, warrants a
physical examination.
Risk of abnormality being detected increases with age & risk factors.
Control Breast Examination discovered a small amount of cancers
missed by mammography.
HISTORY.

• Biodata.
• History of lump(pain ,duration, size, progression, pain ulcer, number,
associated symptoms such as fever).
• History of nipple discharge( amount, colour, smell, type, number of openings.
• Personal history(menstrual history, age of menarche or menopause, first birth,
breast feeding).
• Family history( any similar illness or cancer of the GIT or ovaries)
• Metastatic symptoms (anorexia, weight loss, bone pain, hemoptysis, jaundice).
• History of ulcers.
CLINICAL EXAMINATION
A- PREPARATION
• Introduce yourself to patient
• Washed and warm hands
• Explain procedure and obtain the patients consent.
• Equipment required : Powder/Lotion (may enhance ease of palpatory
breast examination), Gloves (for axillary region as often damp), Pillow.
• Sufficient light
• Male doctor must have a female chaperone present.
• The patient should be allowed to undress to the waist behind a screen and
then asked to lie on a couch tilted at 30 degrees and cover themselves
with a blanket before you approach
CLINICAL EXAMINATION…
B- PATIENTS POSITION
Breast is examined in different positions to elicit
different clinical features.
Different positions are-
• Sitting position with arms by the side
• 45° semi-recumbent position is very much
convenient.
• Sitting position with leaning forward
• Sitting position with arms over the waist
• Sitting position with arms rising above the shoulder
to see fixity to chest wall and changes in nipple.
• Lying down position for self-examination
CLINICAL EXAMINATION…
C- GENERAL EXAMINATION
JACCOLD specific for the breast
• Jaundice
• Anemia
• Oedema
• Lymphadenopathy
• Nutritional status
D- LOCAL EXAMINATION
(1) INSPECTION

the inspection is done with the arms

in three positions;
• Arms relaxed at the sides
• Arms raised above the head
(nipple deviations and skin
changes)
• Hands pressing at the waist
(highlight under lying
abnormalities )
Other positions; sitting and leaning
forward to determine fixity of the
breasts.
.
D- LOCAL EXAMINATION…
• The patient should be lying comfortably with her hands by her side.
• Ask patients permission and then turn down blanket.

Position yourself in front of patient and note:

o Size of each and compare,
o Symmetry,
o Skin ( Color, texture, engorged veins, dimpling/puckering, peau
d’orange,, ulceration, fungation.)
o Masses.
o Nipples (size, shape, discharge, position, number, surface, retraction).
o Areolar (color, size surface).
INSPECTION…
Observe the nipples noting:
o Shape (everted, flat or inverted), Is
this normal for patient?
o Color ( darker after first
pregnancy)
o Symmetry, Is this normal for
patient
o Discharge

 Ask the patient if any possible

problems noted are normal for
that patient.
(2) PALPATION Maneuvers
Examine breast parts differently:
Circular part: Nipple, Areolar, Fat tissue
Axilla part: Smooth, palpable and non
palpable nodes
SPOKES OF THE WHEEL

CONCENTRIC
PALPATION…
• Maintain contact with the tissue at all times as you move around the
breast to avoid missing even the smallest area.
• Examine each breast in a systematic fashion from the clavicle to 6th rib
and sternal border to anterior axillary line.
• Examine the axillary tail by following it out from the upper outer
quadrant into the axilla using the same technique.
• If the breast is particularly large or pendulous you should use one
hand to steady the breast on its lower while palpating with the other.
• Discharge; express any discharge by pressing firmly on the breast
tissue.
• Dimpling; consolidate the breast tissue by mounting
LUMP PALPATION…
• If you find a lump you should note the following;
o SITE( which quadrant)
o SIZE,
o SHAPE,
o SURFACE,
o TEXTURE,
o TENDERNESS,
o TEMPERATURE
o MOBILITY.
Lymph Node Palpation:
 Lymph Node Palpation:
 Stand or sit in front of patient and use the fingers of
your right hand to examine the patient’s left axilla and
your left hand to examine the right side except for the
lateral and posterior groups which are palpated with
the same hand.
 Support and abduct the patient’s arm with your spare
hand.
 Palpate the medial, anterior, lateral, posterior and
apical aspects of the axilla in sequence
 Palpate each supraclavicular fossa in turn using the
pulps of your index and middle fingers.
 Note the presence and site of any lump found and
assess for Size, Shape, Surface, Mobility, Tenderness
and Temperature.
 Cover the patient with the blanket.
 Reassure and thank the patient then leave them to
dress or ask the female nurse to help them if necessary.
FINDINGS
TYPES OF NODULES AND MASSES
Benign masses are:
• Firm, rubbery mass
• Frequently painful
• Regular margins
• Not fixed to skin or chest wall, mobile
• No skin dimpling
• No nipple retraction
• No bloody discharge

TYPES OF DISCHARGES
Malignant discharge;
Unilateral, spontaneous, one duct or
orifice, bloody, serosanguineous, or serous
Benign discharge;
Bilateral, spontaneous or induced, Multiple
duct orifices.
 INVESTIGATIONS
• Mammography.
X-rays of the breast. Defines a lump.
Mammograms are also recommended for screening to find early cancer in age>35yrs.
• Ultrasound.
Done to evaluate a breast lump. (women less than 35 years; ↑breast density)
Tells whether a mass fluid (cystic) or solid. Can be used to guide a biopsy or fluid
aspiration
• FNAC/FNAB or incisional/excisional biopsy.
The only way to diagnose breast cancer with certainty is to biopsy the tissue in
question.
Diagnostic investigations…
• Blood - before mastectomy
• Hb , group & cross match. Book at least 2 units
• Bleeding profile; BT, CT, INR
• CBC with WBC diff. it may be an infection
• LFTs - ALP & γGT

• Imaging – USS can – to asses the breast mass

Differentials of Cancer of the Breast:
• Fibroadenosis
• Mastitis
• Traumatic fat necrosis
• Antibioma
• Tuberculosis of breast
• Galactocele
• Bloodgood cyst
• Mondor’s disease
• Filariasis breast
• Cystosarcoma phylloides
 PREVENTION
 Main risks for Ca breast are sex, age & genes.
 Regular screening is recommended for early detection for complete cure,which
includes BSE, CBE & mammography.
 For menstruating women the best time for examination is immediately after MP’s.
 For women who are not menstruating or whose periods are extremely irregular,
picking a certain date each month seems to work best.
 Clinical breast examination:
by doctor every 3yrs from 20 yrs, yearly >40 yrs.
 Mammograms every 1-2 yrs from 30 yrs.
 For high risk women it should be more regular.
 Weight reduction & reduced alcohol decrease the risk of breast cancer slightly.
 Preventive mastectomy for high risk persons.
 Removal of ovaries also reduces the risk
 Preventive anti-hormonal drugs
SELF EXAMINATION
• Similar technique
• inspection is done
before a mirror
• Paplation is done in a
supine position
• Lymph nodes should
not be palpable
• The flat of the middle
fingers should be used