Breast Examination

Background Info

Presentations of Breast Disease

• Lump
• Pain – Rare in breast cancer
• Asymmetry – Change in breast size – particularly related to the menstrual cycle
• Change in breast feature
• Change in Nipple
• May present to clinic due to strong FH of breast disease

Breast lumps

Examination

• Get a CHAPERONE!
• Careful of your terminology – try to use phrases like ‘I will examine the left breast now’ and not things like ‘I will have a feel of the breast now’

Explanation

Inspection

• Peau d’orange – ‘orange peel skin’ – part of the skin of the breast may have a texture like orange peel. This is often a sign of cancer.
• Tethering – a dimple in the skin often indicates an underlying mass (usually cancer) pulling on the skin
• Rash / redness

Any visible lumps
Check symmetry

• Breasts are not usually completely symmetrical. If there is a gross abnormality, you can always ask the patient when she first noticed, and if it has been there very long.

Now ask the patient to put her hands on her hips and squeeze inwards – this tenses the pectoral muscles, and can bring out any lumps or abnormalities
Now ask the patient to put her hands behind her head –similar to the above, can allow you to see lumps and other abnormalities that may not have been visible before. Also allows you to look into the axilla.

Any other abnormalities

• Don’t forget to look right along the tail of the breast up into the axilla.
• Don’t forget to look under the breast. You may need to life up the breast to see properly into the skin fold underneath

Palpation

• You should have a system. Some doctors will divide the breast into quadrants, and check each quadrant individually, but a better way is to image the breast like a clockface and move round clockwise. You can then also note any abnormalities by their relation to the clockface, e.g.: ‘A 1-2cm, hard lump, tethered to the skin at 4’o’clock in the left breast.’
• Technique – you should NOT your fingertips or your palms, instead, use the ‘pad’ of your fingers, basically, the part of the finger under the middle phalange, and the DIP. Use several finger at once, and start at the outside of the breast and move inwards toward the nipple.
• If you find a lump, continue the rest of the examination of the particular breast, and then come back to it at the end, and fully analyse it then. Norma breast tissue can be a bit lumpy, especially in the ‘tail’ of the breast (12 to 3 o’clock region). Some doctors describe it as like feeling for a marble in a bag of rice!
• Remember to feel behind the nipple – tell the patient what you are about to do before you do it!
• Repeat for the other breast
• Some doctors then recommend you repeat the examination with the patient sitting. Different position can expose lumps that you didn’t previously feel.

Lymph node exam

• Support the weight of the woman’s arm, with your own, and ask her to relax.
• It may feel uncomfortable, but shouldn’t be painful
• Not palpate for lymph nodes in the axilla. Make sure you feel all the four sides of the axilla
• Palpable lymph nodes can again be normal – e.g. with general arm trauma / cuts / bruises, but in these cases, the inflamed nodes should subside within a couple of months. They may of course also be a sign of breast pathology (e.g. cancer)

Presenting findings

• Size
• Location
• Shape
• Surface
• Texture
• Mobility

Triple assessment and grading of the lump

• Examination
• Fine need aspiration (Cytology)
• Imaging (can be Mammography – if patient >35 , USS if patient <35, or MRI if USS/mammogram is not definitaive)
• Any patient referred to hospital for a breast problem will have a triple assessment to try to find the underlying cause.

Examination

• E1 – Normal (no lump)
• E2 – Benign lump
• E3 – A lump
• E4 – A suspicious lump
• E5 – Probable cancer

Cytology

• C1 – inadequate sample
• C2 –Benign
• C3 – Atypical features, but still likely benign
• C4 –Atypical features, probably malignant
• C5 –Malignant

Imaging (<35 USS [breast tissue too dense for mamm.], >35 Mammogram)

• M1 / U1 – Normal
• M2 / U2 –benign
• M3 / U3 –Probably benign
• M4 / U4 –Probably malignant
• M5 / U5 –Malignant

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