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
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