What to do when examination of breast is next !

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

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

Important!!!


Male breasts and female breasts in human beings develop from the same embryological tissues. In females at puberty sex hormones, mainly estrogens, promote breast development. In males this does not happen. As a result, breasts become more prominent in adult females than in males.

FIGURE 1 OBTAINED FROM SITE: WWW.WIIKIPEDA.COM. SEARCH: BREAST CANCER

Common Breast Types (shapes)

i.

Perfect Breasts - The perfect breast shape is quite a rarity. In both medicine and esthetics, the perfect breast shape is the one in which the nipple points outwards, parallel to the ground. There should be no sag and the breast should be supple and well-toned. well-

ii.

Swooping Breasts - This shape is the one in which the breast slightly bends inwards above the areola. There is no sag however. Due to the bending of the breast, the nipple points upwards, inclined to the vertical.

iii.

Saggy or Ptotic breasts - Saggy breasts are commonly found in women as their age advances. These breasts droop downwards, causing the nipple to be pointed downwards too. Saggy breasts may have more or little volume, depending on the amount of fat tissues in them.

iv.

Small Breasts - Small breasts are breasts that have very little volume of fatty tissue in them. Small breasts also have small nipples and areolas. There is very little substance between the nipples and the pectoral muscles.

v.

Tubular or Constricted Breasts - These are actually a defective breast shape which may be cause due to hernia in the breast tissue. They are visible as tubular or narrow cylindrical in shape, with very small nipples and areolas. Their base is also small, and the two breasts may be far apart.

vi.

Augmented Breasts - These are a severe condition of tubular breasts. There are visible anomalies in the shape of the breasts.

vii.

Pectus carinatum or Pigeon Breasts - These are severely deformed breasts which lie almost flat on the chest. They do not look like breasts at all. These are caused due to a congenital defect.

Breast General Information



It is found within the 2nd and 7th rib. It stems from the sternal edge to the anterior axillary line.

Clinically is composed of the Nipple Areolar Complex and the Glandular Portion.

Nipple Areolar Complex and Glandular Portion



NAC is pigmented and hairless. It should be normally at the middle of the aspect of the arm and, why is this important? Because it helps in the criteria of ptosis of the breast.

Glandular Portion is composed of: 15 to 25 lobes that divide into 50 -75 lobules.

Tail of the breast extends into the axilla, axilla, and is thicker than other areas.

Quadrants


Breast is divided into quadrants.

UpperUpper-Outer quadrant has the greatest mass.

UOQ is the site of about half of all breast cancers.

Techniques of Examination


Inspection Palpation

REMEMBER THE FOUR DIFFERENT SITES

Inspection


Inspect the breasts and nipples with the patient in the sitting position and undressed to the waist.

Inspect the movement of breast tissue in four views:

   

Arms at sides Arms over head Arms pressed against hips Leaning forward

Inspection


In the Breasts inspect:

    

Size Shape Symmetry Skin appearance (color, thickening) Contour (dimpling, masses, flattening)

Inspection

In the Nipples inspect:

   

Size. Shape. Direction (inverted, flat). Discharge or bleeding.

Inspection of Axillae


The inspection of the axillae is performed with the arms raised over the head preferably in a sitting position but can be done laying down.

In the axillae inspect:



Skin

Rash, unusual pigmentation, infection Lumps

Inspection of Male Breast



In male breast inspect:

Size Symmetry Skin appearance

Inspect the nipple and areola for nodules and ulcerations.

Palpation


The breast palpation:



Best performed when the breast tissue is flattened. The patient should be in a supine position.

 

Palpate a rectangular area. It is important to be systematic. Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed. Although a circular or wedge pattern can be used, the vertical strip pattern is currently the best validated technique for detecting breast masses.

Palpate in small, concentric circles at each examining point, if possible applying light, medium, and deep pressure.

Examination the lateral portion of the breast:



Ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue.

Begin palpation in the axilla, moving in a axilla, straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle.

Continue in vertical overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast.

Examination of the medial portion of the breast



Ask the patient to lie with her shoulders flat against the bed or examining table, placing her hand at her neck and lifting up her elbow until it is even with her shoulder.

Palpate in a straight line down from the nipple to the bra line, then back to the clavicle, continuing in vertical overlapping strips to the midsternum. midsternum.

Examine the breast tissue carefully for:

  

Consistency of the tissues. Tenderness, as in premenstrual fullness. Nodules:

      

Location Size Shape Consistency Delimitation Tenderness Mobility

Palpate each nipple, noting its elasticity.

Palpation of the male breast



Palpate the areola and breast tissue for nodules. If the breast appears enlarged, distinguish between the soft fatty enlargement of obesity and the firm disc of glandular enlargement, called gynecomastia. gynecomastia.

A hard, irregular, eccentric, or ulcerating nodule is not gynecomastia and suggests breast cancer.

Gynecomastia


Development of abnormally large mammary glands in males resulting in breast enlargement, which can sometimes cause secretion of milk.

Palpating the Axillae



Ask the patient to relax with the left or right arm down.

Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla. axilla.

Your fingers should lie directly behind the pectoral muscles, pointing toward the midclavicle. midclavicle.

Now press your fingers in toward the chest wall and slide them downward, trying to feel the central nodes against the chest wall.

Palpating the Axillae

If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in the drainage areas for the axillary nodes, feel for the other groups of axillary lymph nodes:


Pectoral nodes - grasp the anterior axillary fold between your thumb and fingers, and with your fingers palpate inside the border of the pectoral muscle.

Lateral nodes - from high in the axilla, feel along axilla, the upper humerus. humerus.

Subscapular nodes - step behind the patient and with your fingers feel inside the muscle of the posterior axillary fold.

Also, feel for infraclavicular nodes and reexamine the supraclavicular nodes.

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There are four main groups of problems.



Congenital Imflammatory/ Imflammatory/ Infectious Tumoral Traumatic

Adolescent Breast Problems

 

Asymmetric growth is the rule rather than the exception. exception. Mammary hypertrophy:


Postpone surgical intervention until all growth has occurred.

The majority of the breast masses are 100% benign and 100% surgery or FNA is almost never warranted, (disturbs breast architecture and may be disfiguring).

Palpable Masses of the Breast



15


25 years of age:
Fibroadenomas

50 and over:


Cancer

25
  

50 years of age:
Cysts Fibrocystic Changes Cancer

If pregnancy or lactation is present:



adenomas, cysts, 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: Congenital

  

Relatively common Found along milk line Most identified during pregnancy/lactation

 

Most common in axilla Not dangerous

Supernumerary Nipples: Congenital



More common than supernumerary breasts, but is more commonly seen in males than females.

 

Found along milk line. May darken during pregnancy.

Not dangerous.

Inverted Nipples: Congenital



Often will evert with stimulation.

 

Mostly a cosmetic issue. Successful breastfeeding is usually possible.

Pregnancy Changes

  

1st TM: Tender breasts and nipples 2nd TM: Non-tender breasts enlarge Non2nd2nd-3rd TM: Steady darkening of nipples and prominent Montgomery s glands

Puerperal Mastitis


Rapid onset of red, hot, swollen, tender breast High fever Abscess needs drainage Keep breast-feeding breast-

 

Nipple Laceration

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

Keep clean and dry. Stop breast feeding that side and allow to heal. Antibiotics usually not necessary.

Cyclic Breast Pain

     

Worst just before menses. Thick, tender, nodular breasts. Not dangerous but bothersome. Rx: OCPs (cyclic or continuous). continuous). Rx: Danazol (extreme cases). cases). Reduce caffeine? Vitamin E?

NonNon-Cyclic Breast Pain



Often due to trauma (breast or chest wall). wall).

 

May be due to muscle strain. May be due to increased levels of estrogen.

 

Usually not due to cancer. Examine and refer if cause is not obvious.

Nipple Discharge


Normal nipple discharge is clear, milky or green-tinged. green-tinged.

If bloody, needs surgical evaluation.

If it stains the inside of the bra each day, that is galactorrhea and will need thyroid and pituitary evaluation.

Fat Necrosis


Tender, thickened, bruised area of breast.

  

Follows trauma Benign. Resolves spontaneously over weeks to months.

Atypical cases should have FNA.

Breast Cyst
  

Smooth, unilateral mass. Feels like a cyst. Infrequently associated with malignancy.

  

Aspirate. Watch for reforming of cyst. Recurring cysts are more worrisome.

Paget s Disease
 

Crusty, flaking lesion. Gradual onset over months or years.

Associated with underlying breast malignancy.

Diagnosis confirmed by needle biopsy.

Breast Mass
    

Dominant mass Unilateral Persists through the menstrual cycle Usually biopsied (FNA or excisional) excisional) Can wait weeks but not months

Fibroadenoma
      

Common Benign Solid, rubbery, non-tender nonRound or oval Rarely grow > 2-3 cm 2FNA or excisional Bx Observe in adolescents

Breast Cancer


30% of all cancers in women. Treatment is successful in . 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 Risk Factors

   

Strong family history. Menopause after age 55. No term pregnancy prior to age 35. Most (80%) of breast cancer occurs in women not at increased risk. risk.

Question, how do you examine a person with breast implants?

Bibliography


Bickley, Bickley, Lynn. Quick Head To Toe Examination. Breast And Axilla. Lippincott Williams And Wilkins. 2007 Axilla.

Bates. Guide To Physical Examination And History Taking. Breast And Axilla. Lippincott Williams And Axilla. Wilkins, 5th Edition. 2007.

Moore, Dalley. Clinical Oriented Anatomy, 2nd Edition. Dalley. Lww. Lww. 2005