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Breast Examination

 

Examination of the breast is one of the least taught examinations. However breast lumps in females is a very common presentation in general practice. Understandably there is much anxiety surrounding breast cancer, however, breast cysts and fibroadenomas are far more common.

The breast examination, along with the all important history, is the first part of the 'Triple Assessment' (see Diagram 1):

1) Clinical history and examination

2) Imaging (Mammogram or USS)

3) Cytology/Histology (FNA or core biopsy)

 

1. Preparation

 

Before you start, remember ICEPAP:

  • Introduce yourself
  • Consent, including chaperone (explain that a person will be in the room)
  • Exposure; ask the patient to undress from the waist up including the bra, and put on a surgical gown
  • Position; sit on edge of couch with arms by the side)
  • Alcohol handgel
  • Pain; ask if they are in any pain, and start the examination most distal to the site of pain to relax the patient and gain their trust

 

2. Inspection

 

Ask the patient to lower their gown to their waist. The patient can be stood or sat on the edge of the couch with their arms in the anatomical position. Inspect the breasts from the front and the sides.

 

BREASTS:

  • Size - important to note for surgical treatment options (would a wide lump excision be cosmetically acceptable if the lump was Xcm's?)
  • Symmetry - it is normal to have some asymmetry of the breasts. Ask the patient if this is new.
  • Contour - any obvious lumps or dimpling
  • Scars - any previous breast surgery. Black dots on the skin may be a sign of radiotherapy.
  • Dimpling/tethering of skin - think of the cancerous lump pulling the tissue towards itself
  • Ulceration - consider Paget's disease if the areola is red, thickened and ulcerated
  • Peau d'orange - orange-peel-looking skin overlying a carcinoma. This is due to the cancer blocking the lymphatic drainage resulting in oedema.

 

     

     

    NIPPLES:

    • Number - any additional nipples along the mammary line? (see Figure 1) 
    • Symmetry
    • Everted, flat or inverted. Inverted nipples can be normal.
    • Scale - eczema or Paget's disease
    • Nipple discharge - bloody discharge suggests neoplasia, particularly if it is from a single duct.

     

      MANOEUVERS:

      Now ask the patient to place their hands on their hips and press down (Figure 2). This tightens the suspensory ligaments making it easier to see any abnormalities in the contour of the breast.

      Finally ask the patient to cross their arms behind their head (Figure 3). This allows you to inspect the axilla for any skin dimpling or lumps.

       

      3. Palpation

       

      Ask the patient to lie supine on the couch with their hands by their sides. (When palpating the patient's upper outer quadrant of the right breast ask the patient to place their right hand behind their head - it's easier to palpate!)

      Ask the patient again if they are in any pain so you can start away from that site.

      Clinically the breast is divided into four quadrants: upper outer, upper inner, lower outer and lower inner. The percentage of all breast cancers found in each quadrant varies from 45% in the upper outer qudrant to only 5% in the lower inner quadrant (see Figure 4).

       

       

      BREASTS:

      Palpate the asymptomatic breast first. Everybodys breasts feel different, therefore by starting with the asymptomatic breast you can get a feel for the normal texture for that particular individual.

      With your hand flat use your 2nd, 3rd and 4th fingers held together to palpate the breast in small circular motions. Two techniques are most commonly used to move over the breast: a spiral pattern and a two column pattern.

      The technique that I use is the spiral (Figure 5). I use the spiral rather than the vertical column method because I feel more confident that I have felt all areas of the breast. Whichever method you choose don't forget to palpate the tail of Spence.

       

       

      If you feel a lump, modify '4 Students, 3 Teachers around the CAMPFIRE'

      • Site - describe the location of the lump as a position on a clockface i.e. 'A firm mass is felt at 2 o'clock'.  
      • Size
      • Shape
      • Surface/ Overlying skin
      • Tenderness
      • Consistency
      • Appearance of patient
      • Mobility and attachment

       

        1. If you are unable to move the skin over the lump it implies fixation.
        2. Wrinkling on extremities of movement implies tethering.
        3. Fibroadenomas (benign breast lumps) are also known as 'chasing mice', as these move around as you try to feel them.

         

          • Regional lymph nodes
          • Edge

           

           

          NIPPLES:

          If the patient mentioned nipple discharge in their history, ask them to squeeze their nipple for a sample of the discharge.

           

          AXILLA:

          With the patient still lying supine hold the patients left elbow from below with your left hand (right with right). Ask the patient to relax their arm. Lift their arm up and palpate for any lumps and the axillary lymph nodes: anterior, posterior, central, lateral and apical (see Figure 6). Describe any lumps as above.

          N.B. The centre and outer quadrants of the breast drain to the axillary lymph nodes, so if a lump is found in this part of the breast extra care should be given to palpation of the axilla. The inner part of the breast drains into the internal mammary nodes which are deep, thus impalpable.

           

           

          Finally ...

          Cover up the patient with the gown and thank them!

          Record your findings and produce your differential diagnoses. Remember that the most common breast lumps are cysts, which are benign. See Table 1 for the characteristic findings of malignant and benign lumps.

           

          4. To complete the examination

           

          Further examinations/tests you can do:

          • Examine the infraclavicular and supraclavicular lymph nodes
          • Examine the common sites of metastasis:
          1. Palpate the liver - hepatomegaly
          2. Percuss the lung bases - dull
          3. Percuss the spine - tender
          4. Examine the skin
          5. Examine the CNS

           

            • Imaging - according to NICE guidelines a mammogram or USS depending on the patient's age (and therefore breast tissue density), should be performed if there is a moderate to high risk of breast cancer. USS is preferred for patients aged <35, whereas mammograms are recommended for patients >35 years of age
            • Fine needle aspiration or core biopsy

             

              Bibliography

               

              • Burkitt HG, Quick CRG. Essential Surgery: Problems, Diagnosis and Management. 3rd ed. London: Elsevier Ltd; 2002
              • Douglas G ed., Nicol F ed., Robertson C ed. Macleod's Clinical Examination. 12th ed. London: Elsevier; 2009
              • Epstein O, Perkin GD, de Bono DP, Cookson J. Clinical Examination. 2nd ed. London: Mosby; 1997
              • Kumar P ed., Clark M ed. Kumar and Clark's Clinical Medicine. 7th ed. London: Elsevier; 2009
              • NICE. Improving Outcomes in Breast Cancer - Manual Update, CSGBC. London; 2002 (last updated 2010).

               

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