014 breast examination

! To detect the breast problems at the earliest stage.

! To differentiate between benign and malignant breast problems.

! To assess the extent of disease (stage of disease).

! To plan effective management & follow up.

! To document the data for audit.

! To counsel the patient and her attendants adequately.

! To learn the skills of examination.

OBJECTIVES

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

Physical Examination

of breasts

Triple assessment - I

CLINICAL BREAST EXAMINATION (CBE) Muhammad Shuja Tahir, FRCS (EdIn), FCPS Pak (Hon)

TRIPLE ASSESSMENTIt is a combination of three modalities of assessment performed to confirm the diagnosis and status of breast disease specially carcinoma of breast. It includes following different modalities to assess the disease process;

! Clinical data. (Clinical History and examination findings)

! Imaging# Ultrasound examination# Mammography# Magnetic resonance imaging.

! Cyto-histological examination. (FNAC / CORE / Excision Biopsy).

The diagnostic sensitivity of triple assessment ranges from 85-95%. It covers all the medico-legal aspects of the diagnosis and treatment of breast malignancy.

The reasons for breast examination training of the students is to learn to detect mass in the breast and to

1improve the clinical skills .

The objective of clinical breast examination is to

SURGERY - CLINICAL EXAMINATION SYSTEM 196

CLINICAL BREAST EXAMINATION (CBE) 02

differentiate normal physiological nodularity or change in size of breast with duration.from discrete breast mass. If a discrete mass is ! Menstrual cycle and its disturbances.detected, its evaluation is mandatory in all ! Age of menarche.cases to exclude breast cancer. It is guided by ! Number of pregnanciesclinical findings, age of patients and her ! History of lactation.

2personal risk staus . A careful clinical ! Relevant family history both in first and examination is an essential part of breast second degree relatives.screening in order to reduce false negative ! History of contraceptive pill intake.

3! History of hormone replacement therapy restuls . A standardized system to describe

with its duration.clinical breast examination (CBE) aler ts physician to an increased risk of delayed

4 EXPOSURE & POSITIONSdiagnosis of breast cancer .Breasts are examined in the examination room with privacy but always in the presence of a PHYSICAL EXAMINATION OF BREASTnurse or a female attendant. The room It is the first part of triple assessment. It may be temperature should be comfortable. The light conducted by the doctor (clinical breast should be adequate and patient should be examination) or by the patient herself (breast completely exposed above the umbilicus.self examination).

ALWAYS EXAMINE BOTH BREASTSPREPARATION! In lying patient.The patient is dressed in hospital gown and ! In sitting patient.settled in the examination room. The examining ! In sitting patient with hands abducted (over doctor introduces him/herself to the patient and

head).checks the identity of the patient. Then he/she ! In sitting patient with hand pressing over explains plan of clinical examination to the

the hips.patient in a language clearly understandable by ! In leaning (dependent) position.the patient.The patient stands away from the table and rests her hands on the table leaving her breasts hang SPECIAL INTERVIEWfreely. Certain information such as; age of menarche,

menstrual history of patient, obstetric history, All the findings are recorded on the diagram.history of lactation and breast feeding, history

of breast cancer and other malignancies in the family is very carefully noted. History of hormonal intake for contraception or as replacement therapy.

Following specific questions are asked before examination is started;! Complaints of lump, nipple discharge, pain



INSPECTIONBoth sides are examined simultaneously.

NIPPLESLook for;! Shape of the nipple.! Discharge from the nipple

(its amount and color)! Retraction of the nipple

(Whether recent or old)(Unilateral or bilateral)

! Cracks & fissures! Eczema

(Whether recent or old)(Unilateral or bilateral)

! Color of the skin

AREOLALook for;! Color of the skin.! Skin pigmentation or de pigmentation.! Lumps.! Surrounding area.

BREAST PROPERLook for;! Size of the breast.! Shape of the breast.! Color of the skin.! Symmetry of breast.! Visible veins.! Scars.! Signs of inflammation.! Lumps.! Peau-de-orange.! Fungating Mass.! Ulceration.

PALPATIONPatient is asked to point out the site of lesion. Sitting patient with hands abducted



Normal breast is palpated first.

SUPERFICIAL PALPATIONWhole of the breast should be palpated with the flat of hand gently. It makes the lump or tender areas obvious.

DEEP PALPATION (PRECISE PALPATION)The precise palpation of the lump can be performed between thumb and fingers. The palpation is performed systematically to avoid missing lump in any part of the breast.

Feel the;! Nipples.! Areola.! Breast proper.Skin temperature is felt over and around the breast. Tenderness and point of maximum tenderness is noted.

All observations are marked on the diagram.

Note the following points as well;

SITEExact site in relation to the quadrants of the breast is recorded as;



Peau-de-orange appearance(Breast carcinoma)

Ulceration (Carcinoma Breast)

Feeling the nipples

!

! Lower outer quadrant.! Upper inner quadrant.! Lower inner quadrant.! Axillary tail.

Nipple and areolar lesions are noted. Side of the breast (Right or Left) is always mentioned.

SIZEExact size of the lump is measured and noted in centimeters in two dimensions. It is measured measurement is performed of the largest with help of a caliper. Measurement with the diameter with the caliper. It is essential for the measuring tape is not correct in case of proper staging of the disease. The speed of rounded, oval and irregular lumps. The increase in size is mentioned in the history.

Upper outer quadrant.



Deep (precise) palpation for the lump

SHAPEIt should be drawn in the diagram of the breast.

CONSISTENCYThe lump is palpated between thumb and the index finger and the consistency is recorded as;

Soft (similar to touch of cheek).Cystic (similar to touch of water filled balloon).Firm (similar to touch of tip of nose).Hard (similar to touch of forehead).

SURFACEFLUCTUATION

It is felt and recorded whether smooth or It is tested carefully. The lump is fixed between

nodular.two fingers of one hand and it is pressed with the index finger of the opposite hand. The lift up

MARGINSof the stationary finger is felt. The fluctuation is

Margins of the lump are felt. These can be;tested in two planes at right angles to each other. It is positive in cystic (fluid filled) lesions.

Diffuse (Not clearly demarcated)Clearly demarcatedRegularIrregular

MOBILITY / FIXITYFixity or mobility in relation to overlying skin orunderlying structures is examined. The skin is lifted up between thumb and the index finger. The skin is rolled over the lump in all directions. It clears the fixity or mobility of the skin. The lumps present in the skin become obvious as well.

The patient is asked to push against both iliac crests. This puts the pectoralis major muscles TRANSILLUMINATIONinto contraction on both sides. The lump is It is performed in the dark room with a powerful moved over the fixed and contracted (Hard) pencil torch. Fluid filled lumps (Cysts) become pectoralis major muscles in all directions. It obvious showing (red glowing areas) trans-clearly shows the freely mobile or fixed nature of illumination test positive.the lump.



group of glands which is involved in disease process at the earliest.

LEVEL-IIThese glands are next group to be involved and these are present posterior to pectoralis minor muscle.

LEVEL-IIIThese glands are present supero-medial to the pectoralis minor muscle. These are the last OTHER FEATURES FOR EXAMINATIONones to get involved and show worse outcome Jaundice, pallor and edema especially of upper of the disease process.limbs is noted. Complete examination of liver,

lungs and spine is performed to search of CLINICAL STAGING OF THE CARCINOMAdistant metastasis. The assessment of breast BREAST(TNM)lump after physical examination is described as T TUMORbelow; N LYMPH GLANDSM METASTASIS

T STAGES

T-xPrimary tumor cannot be assessed.(Post operative patients who were not staged

REGIONAL LYMPH GLANDS initially).All of the regional lymph glands draining the breast are carefully examined and recorded. All T-isgroups of axillary lymph glands, infra-clavicular Carcinoma in situ. Incidental finding showing lymph glands supra-clavicular lymph glands are presence of malignant cells without invasion of palpated and observations are noted. basement membrane.

EXAMINATION OF GLANDS DURING T-0SURGERY

No palpable primary tumor. It is an incidental The lymph glands are specially explored and felt

finding. Malignant cells are present in the biopsy during axillary exploration. These are examined

specimen and basement membrane has been histologically according the level of their site

just invaded.such as;

It is a next step in progress of malignancy to carcinoma in situ.

LEVEL-IThese are the lymph glands present infro lateral to the pectoralis minor muscle. These are the



T-1 N-2Tumor size 2 cm or less. Fixed ipsilateral axillary lymph glands.No fixity.No nipple retraction. N-3T-2 Palpable supra clavicular lymph glands mobile Tumor size 2-5 cm. or fixed. Edema of the arm.

Involvement of ipsilateral internal mammary glands.T-3

Tumor size 5-10 cm. M STAGES

M-0T-4No metastasis.Tumor size more than 10 cm.

Any size with infiltration or ulceration of the skin.M-1Tumor fixed to the chest wall.

Peau-de-orange appearance of the skin. Distant metastasis including skin involvement outside the breast. Opposite breast involvement.

Involvement of the lymph nodes of the opposite axilla and supra clavicular lymph glands. Other distant metastasis.

STAGE I(T0, T1,N0, M0)This includes growths confined to the breast.

Tumor less than 2 cm diameter in size. No nodal involvement.No distant metastasis.N STAGES

N-x The tumor should not be adherent to the pectoral Axillary node cannot be assessed. muscles or chest wall.

N-0 STAGE IINo palpable axillary lymph glands. (T0, T1 OR T2 and N1, M0)

Tumor size less than 5 cm in diameter but there are affected mobile lymph glands in the axilla of N-1the same side. Palpable but mobile ipsilateral axillary lymph Tumor size 5 cms without lymph node involve-glands.ment.



No distant metastasis. Distant metastasis either lymph borne or blood False negative results of clinical examination are borne. about 25-30%. Involvement of opposite breast.

STAGE III The patients is covered and allowed to change (T0, T1, T2, T3, T4, N2 and M0) the end of completion of examination after the All breast cancers of any size. Skin involvement examining doctor leaves the rooms.or peau-de-orange present in larger areas than the tumor itself but these are limited to the COUNSELINGbreast. The patient is informed about the disease status Tumor fixed to pectoral muscles but not to the as assessed clinically. chest wall.

Plan of investigations and possible modes of Axillary lymph nodes, internal mammary node treatment are informed. and Supra clavicular nodes are involved. Edema of the arm may be present. Necessary documentation and appointments

are made and recorded. Whole of this STAGE IV information is also sent to the referring doctor.(Any T or any N with M1)Skin involvement extending outside the breast.



REFERENCES1. Madam Ak, Aliabadi-Wahle S, Balbom 3. Park BW; Kim SI; Kim MH; Kim EK; Park SH;

Posner M, Beech DJ. Education of medical Lee KS: Clinical examination (CBE) for students in ceinicae breast examination screening of a symptomatic women. The during surgical clerkship. Am J Surg 2002 importance of CBE for breast cancer Dec; 184(6): 637-40, discussion 641. detection. Yonsei Med J. (Korea 2000 Jun:

41 (3):312-8.2. Freund KM. Rationale and technique of

clinical breast examination. Medscape 4. Goodson WH; Moorl DH: Overall clinical women health 2000 No; 5(6):E2. breast examination as a factor in

diagnosis of breast cancer. Arch Surg 2002 Oct; 137 (10): 1152-6.

014 breast examination

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