Examination of the breasts

Examination of the breastsThe common breast complaints in females are discovery of a lump (benign or malignant), pain (mastalgia) and nipple discharge. In males, the most common ailment is unilateral or bilateral hypertrophy (gynaecomastia), which may be idiopathic (postpubertal), drug induced or sec­ondary to certain disorders, e.g. liver disease.

Undoubtedly the most important presentation is & pal­pable lump, in view of the frequency of breast carcinoma, which now affects 1 in 12 females in western countries. Breast pain is a very common complaint and may be either diffuse and cyclical, with pain and tenderness before and during menstrual periods (cyclical pronounced mastal­gia), or localized to a specific area with or without a pal­pable lesion at this site (trigger-point mastalgia). Nipple discharge may occur alone or in association with other symptoms (e.g. lump or pain). The nature and colour of the discharge vary but when blood-stained, nipple dis­charge signifies the presence of a duct papilloma or car­cinoma. The examination of the breasts should always include palpation of the neck and both axillae for lymph node enlargement.

Inspection of the breasts

This necessitates removal of clothing to the waist and therefore requires privacy, the presence of a nurse. Inspection is carried out in two postures.

The breasts are initially inspected with the women sit­ting up straight and the arms by the side facing the doctor. At this stage one is assessing size, contour of breast mounds, surface abnormalities and the state, direction of the nipples. A certain amount of disparity in breast size is quite common and normal, but the nipples should point in the same direction. Inversion of the nipples is fre­quently encountered and may be normal or due to benign disease (usually bilateral retraction) or an underlying can­cer (unilateral retraction). The skin over a breast abscess is red, shiny and oedematous. However, a similar appear­ance is encountered in patients with inflammatory breast cancer (mastitis carcinosa). The thickening of the skin in these patients is due to oedema secondary to cutaneous lymphatic permeation, the pitted appearance simulating orange skin — hence the term peau d’orange. The women is then asked to lift her upper arms above her head. This manoeuvre normally results in uplifting of the breasts with diminished protrusion of the nipples, although the surface contour of the breast mounds should remain smooth and convex. Dimpling or localized depres­sion or obvious inversion of the nipple is indicative of an underlying malignant mass that is causing tethering of the superficial tissues.

Palpation of the breast

The unaffected breast is palpated first. The patient during an examination of the breasts must be comfortable in the sitting or semirecumbent position, with her elbows resting on the couch and the arms on her flanks. Palpation of the breast is carried out with the flat of the hand gently compressing the breast tissue against the chest wall. It starts in the areolar region and covers, in a systematic manner, the entire breast, including the axillary tail. If a lump is found, its position is noted but the general palpation is continued to determine whether any other lumps are present. Normal breast tissue feels soft and smooth. However, in many adult females, the breasts have a nodular lumpy consistency and the distinction between normal and abnormal may be difficult and requires considerable expe­rience. Pathological diffuse thickening maybe localized or generalized.

Palpation of an identified breast lump

If a lump is identified during the general palpation, the following information is essential: tenderness, position, size, consistency, margins, mobility and involvement of adjacent structures and tissues. A breast abscess is exquis­itely tender. Tenderness is also encountered in mammary duct ectasia, Mondor’s disease (thrombophlebitis of the subcutaneous breast veins) and traumatic fat necrosis of the breast.

In terms of precise location of a lump, the breast is divided into the areolar region and four quadrants: upper inner, upper outer, lower outer, lower inner. The size of the lump is best measured by callipers in two directions. Size is one of the variables used in the staging of cancer of the breast. Breast cancer feels firm to hard, is not tender and has indistinct margins. In contrast, benign lesions (fibroadenomas, breast cysts) are firm, smooth and always mobile. Fibroadenoma is very mobile and tends to slip away from the examining finger and for this reason has been described as a ‘breast mouse’. The mobility of a lump is tested in relation to both the overlying skin, the underlying pectoralis major fascia and muscle. Tethering or fixation of the lump to the underlying pectoral muscles is determined after the women is asked to contract the ipsilateral pectoralis major muscle by pressing on her hips with her hand. Involvement of the superficial breast tissue varies from tethering, such that the skin and subadjacent breast parenchyma cannot be rolled over the mass, to actual involvement with puckering of the skin, ulceration and fungation.

Palpation of the axillae and neck

Examination of the breasts is incomplete without careful palpation of both axillae and neck for palpable lymph nodes, which could represent metastatic disease. Palpa­tion of the axilla is carried out from in front of the women, who is either in the semirecumbent or sitting position. The patient’s upper arm is supported on the examiner’s arm during the palpation, which must be car­ried out in an orderly fashion, starting at the apex of the axillae followed by the medial (chest) wall, anterior wall (pectoral muscles) and posterior wall (over the subscapularis muscle). If palpable lymph nodes are present, their number and mobility or otherwise are noted.

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