Breast Examination Component What to do/look for and rationale Patient sits up with chest fully exposed Look at nipples for retraction. Cancer, fibrosis and may be normal in some patients. Ask whether this is long standing. Unilateral ulcerations or rashes. Padget’s disease of the breast. Breast asymmetry. May be a normal finding. Ask if this is new or if it has always been the case. Assess for surface, contour, consistency, surface. Look for visible veins. If unilateral -> breast cancer. Skin dimpling and peau d’orange. Advanced breast cancer -> oedematous skin pitting by the sweat gland General inspection Erythema and colour Mastitis Persistent erythematous plaque in nipple area -> contact dermatitis or skin irritation. If asymmetrical or has not responded to treatment -> Paget’s disease of the breast. Ask the patient to raise her arms above her head and then slowly lower them and look for: Tethering of the nipples or the skin in the relative position of the nipples or fixed mass distorting the breast. Look for any obvious masses in the axilla. Ask the patient to rest their hands on the hips and then press hands against the hip. Should accentuates areas of dimpling or fixation. Breast transillumination For cysts and benign tumours such as fibroadenomas Feel for supraclavicular lymph nodes Feel for axillary lymph nodes. Note: Lymph Notes The position of the nodes Consistency Tenderness Fixation Ask the patient to lie flat. Examination can only be performed if the breast tissue is flattened against the chest wall. Ask the patient to place the hand behind the head for palpation of the lateral aspect of the breast and bring the elbow up level with the shoulder for palpation of the medial side of the breast. Perform palpation with the pulps of the middle three fingers parallel to the contour of the breast supporting the breast with the other hand. The total palpation should involve a rectangular area boarded by the clavicle, sternum, midaxillary line and bra line. Do not pinch the breast as that could be mistaken for a tumor. Palpate in four quadrants. Palpation in Laying Flat Position Feel behind the nipple for lumps. Palpation is harder when there are breast implants. Note any breast fluctuance The lump feels soft and squishy -> as if it is filled with water. Cysts Palpation in sitting up position Same as above Position Size, shape and consistency: Hard and irregular nodule -> feature of carcinoma. Firm, smooth and very mobile, regular nodule -> feature of fibroadenoma (especially in young females). Soft, mobile and regular -> benign but may also be metastatic. Evaluation of Tenderness: Breast Lump Suggests inflammatory or cystic lesion. Breast cancer is usually non-tender. Fixation: Mobility is determined by taking the breast between the hands and moving it over the chest wall. Single or multiple lesions present: Multiple nodules suggest benign cystic disease or fibroadenomas. Many normal breasts may have palpable lumps. Non-tender lumps: Cysts Carcinomas Fibrocystic disease. Fibroadenoma -> benign and highly mobile. Tender lumps: Cysts Breast abscess Other Points Fibroadenosis Costal cartilage chondritis Inflammatory breast cancer. Uncommon causes of lumps: Trauma Fat necrosis Other cysts e.g. galactocele Other neoplasms e.g. duct papilloma Granulomatous mastitis -> inflammation mimicking breast cancer. Chest wall -> e.g. lipoma, costal cartilage chondritis -> causes tenderness but NOT lipomas.