Breast Examination

Introduction

• Wash hands

• Introduce yourself

• Confirm patient details – name / DOB

• Explain the examination

• Gain consent

• Ask the patient to sit at first, then at approx 30˚ with the hand of the side you are examining behind the patients head

• Adequate exposure - ensure the patient is covered up when the examination is not taking place

• Chaperone is essential for this examination - the examiner can act as the chaperone during the examination

• Check understanding with the patient, ask if they have any questions

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General Inspection

• Patient : age, cachexia

• Look with patient sitting and with the patients hands behind their head

• Look for: asymmetry, local swelling, skin changes (erythema, dimpling, peau d’orange, scars), nipple changes (Paget’s disease of the breast , inversion)

Breast:

• Size

• Symmetry

• Shape

• Skin colour

• Lumps

• Skin tethering

Don't forget to palpate the axillary tail!

Palpation techniques

Nipple:

• Everted/flat/inverted

• Cracking

• Bleeding - may indicate malignancy

• Scale – may indicate Eczema or Paget’s disease

• Retraction - congenital / underlying tumour / ductal ectasia

• Yellow / green discharge  – suggestive of infection

Areola:

• Abnormal reddening (erythema) - infection / superficial malignancy

• Thickening

• Puckering - may indicate an underlying malignant mass

• Peau d’orange (cutaneous oedema) – inflammatory breast cancer

Peau d'orange

Paget's disease of the breast

In 4 positions:

• Arms relaxed

• Hands rested on hips and forwards

• Hands actively pressed into hips (tenses pectorals)

• Hands behind head (to expose whole breast and accentuate dimpling)

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Breast examination

• Also lift the breast to look in the submammary fold.

• Feel with patient lying

• Position patient at 30 degrees. The patient’s hand on the side of the breast being examined should be placed behind the patient’s head.

• Check pain first and start on normal side.

• Examine using both hands, massaging the breast with your hand flat to the skin. Use the whole of all 4 fingers.

• Move your hands in step-wise increments around breast in a systematic manor (e.g. a spiral motion from outside in).

• Examine the axillary tail between your first two fingers and thumb.

• Describe any lump (SSSCCCTTT): Site, Size, Shape, Consistency, Contours, Colour, Tenderness, Temperature, (Transillumination)

• Ask the patient to gently massage each nipple to attempt to express any discharge.

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Lymph nodes

• Put on gloves. Lymph nodes are palpated while lying first, then while sitting.

• Axillary lymph nodes: e.g. to examine the right: ask the patient to hold your right biceps while you support the weight of their right arm at their elbow with your right hand. Now place your left arm over your right and place your left hand into the axilla. Now palpate the apical, lateral, medial, anterior and posterior lymph node groups by pressing the soft tissues (hard) and rolling them over the underlying harder tissues.

• Supraclavicular/Infraclavicular lymph nodes: feel with your fingertips pressed into the supraclavicular fossae from the front.

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Summary

• Thank patient and cover them

• Summarise and suggest further investigations you would do after a full history

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Triple assessment:

• Examination

• Imaging (ultrasound if <35y or mammogram if >35y)

• Tissue sampling

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Questions:

1. Suggest 3 further investigations following an abnormal breast exam?

2. Give 3 differential diagnoses for a breast lump?

3. How would you describe a breast lump?

4. What are the 2 main types of breast cancer?

5. What is Peau d'orange?

6. Name one 'side effect' of a mastectomy with total axillary lymph node clearance

7. What 4 locations does breast cancer most commonly spread to?

8. What is Paget's disease?