What to do when What to do when examination of breast is examination of breast is

next !next !

If the patient is If the patient is female and you female and you doctor are a male, doctor are a male, ALWAYS LOOK ALWAYS LOOK FOR A FEMALE FOR A FEMALE CHAPERONE!!!!CHAPERONE!!!!

Be sure to ask if the Be sure to ask if the patient has examined patient has examined her breasts lately, her breasts lately, how often?, any how often?, any discomfort, pain or discomfort, pain or lumps?, any lumps?, any discharge from the discharge from the nipples?nipples?

Important!!!Important!!!

Male breasts and female Male breasts and female

breasts in human beings breasts in human beings

develop from the same develop from the same

embryological tissues. In embryological tissues. In

females at puberty sex females at puberty sex

hormones, mainly estrogens, hormones, mainly estrogens,

promote breast development. promote breast development.

In males this does not happen. In males this does not happen.

As a result, breasts become As a result, breasts become

more prominent in adult more prominent in adult

females than in males.females than in males. FIGURE 1 OBTAINED FROM SITE: WWW.WIIKIPEDA.COM. SEARCH: BREAST CANCER

Common Breast Types Common Breast Types (shapes)(shapes)

i.i. Perfect BreastsPerfect Breasts - The perfect breast shape is quite a - The perfect breast shape is quite a

rarity. In both medicine and esthetics, the perfect breast rarity. In both medicine and esthetics, the perfect breast

shape is the one in which the nipple points outwards, shape is the one in which the nipple points outwards,

parallel to the ground. There should be no sag and the parallel to the ground. There should be no sag and the

breast should be supple and well-toned. breast should be supple and well-toned.

ii.ii. Swooping BreastsSwooping Breasts - This shape is the one in which the - This shape is the one in which the

breast slightly bends inwards above the areola. There is breast slightly bends inwards above the areola. There is

no sag however. Due to the bending of the breast, the no sag however. Due to the bending of the breast, the

nipple points upwards, inclined to the vertical. nipple points upwards, inclined to the vertical.

iii.iii. Saggy or Ptotic breastsSaggy or Ptotic breasts - Saggy breasts are commonly - Saggy breasts are commonly

found in women as their age advances. These breasts found in women as their age advances. These breasts

droop downwards, causing the nipple to be pointed droop downwards, causing the nipple to be pointed

downwards too. Saggy breasts may have more or little downwards too. Saggy breasts may have more or little

volume, depending on the amount of fat tissues in them. volume, depending on the amount of fat tissues in them.

iv.iv. Small BreastsSmall Breasts - Small breasts are breasts that have very - Small breasts are breasts that have very

little volume of fatty tissue in them. Small breasts also have little volume of fatty tissue in them. Small breasts also have

small nipples and areolas. There is very little substance small nipples and areolas. There is very little substance

between the nipples and the pectoral muscles.between the nipples and the pectoral muscles.

v.v. Tubular or Constricted BreastsTubular or Constricted Breasts - These are actually - These are actually

a defective breast shape which may be cause due to a defective breast shape which may be cause due to

hernia in the breast tissue. They are visible as tubular hernia in the breast tissue. They are visible as tubular

or narrow cylindrical in shape, with very small nipples or narrow cylindrical in shape, with very small nipples

and areolas. Their base is also small, and the two and areolas. Their base is also small, and the two

breasts may be far apart. breasts may be far apart.

vi.vi. Augmented BreastsAugmented Breasts - These are a severe condition - These are a severe condition

of tubular breasts. There are visible anomalies in the of tubular breasts. There are visible anomalies in the

shape of the breasts.shape of the breasts.

vii.vii. Pectus carinatum or Pigeon BreastsPectus carinatum or Pigeon Breasts - These - These

are severely deformed breasts which lie almost are severely deformed breasts which lie almost

flat on the chest. They do not look like breasts flat on the chest. They do not look like breasts

at all. These are caused due to a congenital at all. These are caused due to a congenital

defect.defect.

Breast General Breast General InformationInformation

It is found within the 2It is found within the 2ndnd

and 7and 7thth rib. It stems rib. It stems

from the sternal edge to from the sternal edge to

the anterior axillary line.the anterior axillary line.

Clinically is composed of Clinically is composed of

the Nipple Areolar the Nipple Areolar

Complex and the Complex and the

Glandular Portion.Glandular Portion.

Nipple Areolar Complex Nipple Areolar Complex and Glandular Portionand Glandular Portion

NAC is pigmented and NAC is pigmented and

hairless. It should be hairless. It should be

normally at the middle normally at the middle

of the aspect of the arm of the aspect of the arm

and, why is this and, why is this

important? important? Because it Because it

helps in the criteria of helps in the criteria of

ptosis of the breast.ptosis of the breast.

Glandular Portion is Glandular Portion is

composed of: 15 to composed of: 15 to

25 lobes that divide 25 lobes that divide

into 50 -75 lobules.into 50 -75 lobules.

Tail of the breast Tail of the breast

extends into the extends into the

axilla, and is thicker axilla, and is thicker

than other areas.than other areas.

QuadrantsQuadrants

Breast is divided Breast is divided

into quadrants.into quadrants.

Upper-Outer Upper-Outer

quadrant has the quadrant has the

greatest mass.greatest mass.

UOQ is the site of UOQ is the site of

about half of all about half of all

breast cancers.breast cancers.

Techniques of Techniques of ExaminationExamination

InspectionInspection

PalpationPalpation

REMEMBER THE FOUR DIFFERENT SITES

InspectionInspection

Inspect the breasts and nipples Inspect the breasts and nipples

with the patient in the sitting with the patient in the sitting

position and undressed to the position and undressed to the

waist. waist.

Inspect the movement of breast Inspect the movement of breast

tissue in four views:tissue in four views: Arms at sidesArms at sides Arms over headArms over head Arms pressed against hipsArms pressed against hips Leaning forwardLeaning forward

InspectionInspection

In the Breasts inspect:In the Breasts inspect:

SizeSize

ShapeShape

SymmetrySymmetry

Skin appearance (color, thickening)Skin appearance (color, thickening)

Contour (dimpling, masses, flattening)Contour (dimpling, masses, flattening)

InspectionInspection

In the Nipples inspect:In the Nipples inspect:

Size.Size.

Shape.Shape.

Direction (inverted, flat).Direction (inverted, flat).

Discharge or bleeding.Discharge or bleeding.

Inspection of AxillaeInspection of Axillae

The inspection of the axillae is performed The inspection of the axillae is performed

with the arms raised over the head with the arms raised over the head

preferably in a sitting position but can be preferably in a sitting position but can be

done laying down.done laying down.

In the axillae inspect:In the axillae inspect:

SkinSkin

• Rash, unusual pigmentation, infectionRash, unusual pigmentation, infection

• LumpsLumps

Inspection of Male Inspection of Male BreastBreast

In male breast inspect: In male breast inspect:

• SizeSize

• SymmetrySymmetry

• Skin appearanceSkin appearance

Inspect the nipple and Inspect the nipple and

areola for nodules and areola for nodules and

ulcerations.ulcerations.

PalpationPalpation

The breast palpation: The breast palpation:

Best performed when the breast tissue is flattened. The patient Best performed when the breast tissue is flattened. The patient

should be in a supine position. should be in a supine position.

Palpate a rectangular area. It is important to be systematic. Palpate a rectangular area. It is important to be systematic.

Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the

fingers slightly flexed. Although a circular or wedge pattern can fingers slightly flexed. Although a circular or wedge pattern can

be used, the vertical strip pattern is currently the best validated be used, the vertical strip pattern is currently the best validated

technique for detecting breast masses. technique for detecting breast masses.

Palpate in small, concentric circles at each examining point, if Palpate in small, concentric circles at each examining point, if

possible applying light, medium, and deep pressure.possible applying light, medium, and deep pressure.

Examination the lateral Examination the lateral portion of the breast:portion of the breast:

Ask the patient to roll onto the opposite Ask the patient to roll onto the opposite

hip, placing her hand on her forehead but hip, placing her hand on her forehead but

keeping the shoulders pressed against the keeping the shoulders pressed against the

bed or examining table. This flattens the bed or examining table. This flattens the

lateral breast tissue. lateral breast tissue.

Begin palpation in the axilla, moving in a Begin palpation in the axilla, moving in a

straight line down to the bra line, then straight line down to the bra line, then

move the fingers medially and palpate in move the fingers medially and palpate in

a vertical strip up the chest to the clavicle. a vertical strip up the chest to the clavicle.

Continue in vertical overlapping strips Continue in vertical overlapping strips

until you reach the nipple, then reposition until you reach the nipple, then reposition

the patient to flatten the medial portion of the patient to flatten the medial portion of

the breast.the breast.

Examination of the medial Examination of the medial portion of the breastportion of the breast

Ask the patient to lie with her shoulders flat Ask the patient to lie with her shoulders flat

against the bed or examining table, placing her against the bed or examining table, placing her

hand at her neck and lifting up her elbow until it is hand at her neck and lifting up her elbow until it is

even with her shoulder. even with her shoulder.

Palpate in a straight line down from the nipple to Palpate in a straight line down from the nipple to

the bra line, then back to the clavicle, continuing the bra line, then back to the clavicle, continuing

in vertical overlapping strips to the midsternum.in vertical overlapping strips to the midsternum.

Examine the breast tissue Examine the breast tissue carefully for:carefully for:

Consistency of the tissues.Consistency of the tissues.

Tenderness, as in premenstrual fullness.Tenderness, as in premenstrual fullness.

Nodules:Nodules: LocationLocation SizeSize ShapeShape ConsistencyConsistency DelimitationDelimitation TendernessTenderness MobilityMobility

Palpate each nipple, noting Palpate each nipple, noting

its elasticity.its elasticity.

Palpation of the male breast

Palpate the areola and breast tissue for nodules. Palpate the areola and breast tissue for nodules.

If the breast appears enlarged, distinguish If the breast appears enlarged, distinguish

between the soft fatty enlargement of obesity between the soft fatty enlargement of obesity

and the firm disc of glandular enlargement, called and the firm disc of glandular enlargement, called

gynecomastia.gynecomastia.

A hard, irregular, eccentric, or ulcerating nodule A hard, irregular, eccentric, or ulcerating nodule

is not gynecomastia and suggests breast cancer.is not gynecomastia and suggests breast cancer.

GynecomastiaGynecomastia

Development of Development of

abnormally large abnormally large

mammary glands in mammary glands in

males resulting in males resulting in

breast enlargement, breast enlargement,

which can sometimes which can sometimes

cause secretion of milk.cause secretion of milk.

Palpating the Axillae Palpating the Axillae

Ask the patient to relax with the left or Ask the patient to relax with the left or

right arm down. right arm down.

Cup together the fingers of your right Cup together the fingers of your right

hand and reach as high as you can hand and reach as high as you can

toward the apex of the axilla.toward the apex of the axilla.

Your fingers should lie directly behind Your fingers should lie directly behind

the pectoral muscles, pointing toward the pectoral muscles, pointing toward

the midclavicle. the midclavicle.

Now press your fingers in toward the Now press your fingers in toward the

chest wall and slide them downward, chest wall and slide them downward,

trying to feel the central nodes against trying to feel the central nodes against

the chest wall.the chest wall.

If the central nodes feel large, hard, or tender, If the central nodes feel large, hard, or tender,

or if there is a suspicious lesion in the drainage or if there is a suspicious lesion in the drainage

areas for the axillary nodes, feel for the other areas for the axillary nodes, feel for the other

groups of axillary lymph nodes:groups of axillary lymph nodes:

Pectoral nodes - grasp the anterior axillary fold Pectoral nodes - grasp the anterior axillary fold

between your thumb and fingers, and with your between your thumb and fingers, and with your

fingers palpate inside the border of the pectoral fingers palpate inside the border of the pectoral

muscle.muscle.

Lateral nodes - from high in the axilla, feel Lateral nodes - from high in the axilla, feel

along the upper humerus.along the upper humerus.

Subscapular nodes - step behind the patient Subscapular nodes - step behind the patient

and with your fingers feel inside the muscle of and with your fingers feel inside the muscle of

the posterior axillary fold.the posterior axillary fold.

Also, feel for infraclavicular nodes and Also, feel for infraclavicular nodes and

reexamine the supraclavicular nodes.reexamine the supraclavicular nodes.

Palpating the Axillae Palpating the Axillae

VIDEO 1 VIDEO 1

VIDEO 2VIDEO 2

There are four main There are four main groups of problems. groups of problems.

CongenitalCongenital

Imflammatory/ Imflammatory/ InfectiousInfectious

TumoralTumoral

TraumaticTraumatic

Adolescent Breast Adolescent Breast ProblemsProblems

Asymmetric growth is the rule rather than the Asymmetric growth is the rule rather than the

exception.exception.

Mammary hypertrophy: Mammary hypertrophy:

Postpone surgical intervention until all growth has Postpone surgical intervention until all growth has

occurred.occurred.

The majority of the breast masses are 100% benign The majority of the breast masses are 100% benign

and surgery or FNA is almost never warranted, and surgery or FNA is almost never warranted,

(disturbs breast architecture and may be disfiguring).(disturbs breast architecture and may be disfiguring).

Palpable Masses of the Palpable Masses of the BreastBreast

15 – 25 years of age: 15 – 25 years of age:

FibroadenomasFibroadenomas

25 – 50 years of age:25 – 50 years of age:

CystsCysts

Fibrocystic ChangesFibrocystic Changes

CancerCancer

50 and over: 50 and over:

CancerCancer

If pregnancy or If pregnancy or

lactation is present: lactation is present:

adenomas, cysts, adenomas, cysts,

mastitis and cancer.mastitis and cancer.

Clinical Notes: if the patient is a 18 years old girl, it 99% fibroadenoma, but if the patient is 57 years old, with multiple masses, then is usually a fibrocystic disease but do not exclude CA.

Supernumerary Breasts: Supernumerary Breasts: CongenitalCongenital

Relatively commonRelatively common

Found along “milk Found along “milk

line”line”

Most identified during Most identified during

pregnancy/lactationpregnancy/lactation

Most common in axillaMost common in axilla

Not dangerousNot dangerous

Supernumerary Nipples: Supernumerary Nipples: CongenitalCongenital

More common than More common than

supernumerary breasts, but supernumerary breasts, but

is more commonly seen in is more commonly seen in

males than females.males than females.

Found along milk line.Found along milk line.

May darken during May darken during

pregnancy.pregnancy.

Not dangerous.Not dangerous.

Inverted Nipples: Inverted Nipples: CongenitalCongenital

Often will evert with Often will evert with

stimulation.stimulation.

Mostly a cosmetic issue.Mostly a cosmetic issue.

Successful Successful

breastfeeding is usually breastfeeding is usually

possible.possible.

Pregnancy ChangesPregnancy Changes

1st TM: Tender breasts and nipples1st TM: Tender breasts and nipples 2nd TM: Non-tender breasts enlarge2nd TM: Non-tender breasts enlarge 2nd-3rd TM: Steady darkening of nipples 2nd-3rd TM: Steady darkening of nipples

and prominent Montgomery’s glandsand prominent Montgomery’s glands

Puerperal MastitisPuerperal Mastitis

Rapid onset of red, Rapid onset of red,

hot, swollen, tender hot, swollen, tender

breastbreast

High feverHigh fever

Abscess needs Abscess needs

drainagedrainage

Keep breast-feedingKeep breast-feeding

Nipple LacerationNipple Laceration

Usually at breast feeding by staphylococcus infection into the ducts. Enlargement Usually at breast feeding by staphylococcus infection into the ducts. Enlargement

of breast may occur by galactosyl. May be similar to peau d’ orange, how to of breast may occur by galactosyl. May be similar to peau d’ orange, how to

know? If the patient with antibiotics does not get better in 10 days, think of CA.know? If the patient with antibiotics does not get better in 10 days, think of CA.

Keep clean and dry.Keep clean and dry.

Stop breast feeding that side and allow to heal.Stop breast feeding that side and allow to heal.

Antibiotics usually not necessary.Antibiotics usually not necessary.

Cyclic Breast PainCyclic Breast Pain

Worst just before menses.Worst just before menses.

Thick, tender, nodular breasts.Thick, tender, nodular breasts.

Not dangerous but bothersome.Not dangerous but bothersome.

Rx: OCPs (cyclic or continuous).Rx: OCPs (cyclic or continuous).

Rx: Danazol (extreme cases).Rx: Danazol (extreme cases).

Reduce caffeine? Vitamin E?Reduce caffeine? Vitamin E?

Non-Cyclic Breast PainNon-Cyclic Breast Pain

Often due to trauma (breast Often due to trauma (breast

or chest wall).or chest wall).

May be due to muscle strain.May be due to muscle strain.

May be due to increased May be due to increased

levels of estrogen.levels of estrogen.

Usually not due to cancer.Usually not due to cancer.

Examine and refer if cause is Examine and refer if cause is

not obvious.not obvious.

Nipple DischargeNipple Discharge

Normal nipple discharge is Normal nipple discharge is

clear, milky or green-tinged.clear, milky or green-tinged.

If bloody, needs surgical If bloody, needs surgical

evaluation.evaluation.

If it stains the inside of the If it stains the inside of the

bra each day, that is bra each day, that is

galactorrhea and will need galactorrhea and will need

thyroid and pituitary thyroid and pituitary

evaluation.evaluation.

Fat NecrosisFat Necrosis

Tender, thickened, bruised Tender, thickened, bruised

area of breast.area of breast.

Follows traumaFollows trauma

Benign.Benign.

Resolves spontaneously Resolves spontaneously

over weeks to months.over weeks to months.

Atypical cases should have Atypical cases should have

FNA.FNA.

Breast CystBreast Cyst

Smooth, unilateral mass.Smooth, unilateral mass.

Feels like a cyst.Feels like a cyst.

Infrequently associated Infrequently associated

with malignancy.with malignancy.

Aspirate.Aspirate.

Watch for reforming of Watch for reforming of

cyst.cyst.

Recurring cysts are more Recurring cysts are more

worrisome.worrisome.

Paget’s DiseasePaget’s Disease

Crusty, flaking lesion.Crusty, flaking lesion.

Gradual onset over Gradual onset over

months or years.months or years.

Associated with Associated with

underlying breast underlying breast

malignancy.malignancy.

Diagnosis confirmed by Diagnosis confirmed by

needle biopsy.needle biopsy.

Breast MassBreast Mass

Dominant massDominant mass UnilateralUnilateral Persists through Persists through

the menstrual the menstrual cyclecycle

Usually biopsied Usually biopsied (FNA or excisional)(FNA or excisional)

Can wait weeks Can wait weeks but not monthsbut not months

FibroadenomaFibroadenoma

CommonCommon

BenignBenign

Solid, rubbery, non-tenderSolid, rubbery, non-tender

Round or ovalRound or oval

Rarely grow > 2-3 cmRarely grow > 2-3 cm

FNA or excisional BxFNA or excisional Bx

Observe in adolescentsObserve in adolescents

Breast Cancer

30% of all cancers in women.

Treatment is successful in ¾.

Rare before age 25.

Steadily increasing frequency

with increasing age.

Affects 1/9 women reaching age

90.

In males, only 1% is affected.

Breast Cancer Breast Cancer Risk FactorsRisk Factors

Strong family history.Strong family history.

Menopause after age 55.Menopause after age 55.

No term pregnancy prior to age 35.No term pregnancy prior to age 35.

Most (80%) of breast cancer occurs in women Most (80%) of breast cancer occurs in women

not at increased risk.not at increased risk.

Question, how do you examine a person with Question, how do you examine a person with

breast implants?breast implants?

BibliographyBibliography

Bickley, Lynn. Quick Head To Toe Examination. Bickley, Lynn. Quick Head To Toe Examination.

Breast And Axilla. Lippincott Williams And Breast And Axilla. Lippincott Williams And

Wilkins. 2007Wilkins. 2007

Bates. Guide To Physical Examination And Bates. Guide To Physical Examination And

History Taking. Breast And Axilla. Lippincott History Taking. Breast And Axilla. Lippincott

Williams And Wilkins, 5Williams And Wilkins, 5thth Edition. 2007. Edition. 2007.

Moore, Dalley. Clinical Oriented Anatomy, 2Moore, Dalley. Clinical Oriented Anatomy, 2ndnd

Edition. Lww. 2005Edition. Lww. 2005