“CLINICAL PRESENTATION OF BREAST CANCER AND
EXAMNATION OF BREAST & AXILLA”
Made by: Dr. Isha JaiswalModerator: Dr.Madhup
RastogiDate : 22 January 2014
“The chances of finding a treatable BREAST CANCER makes the full examination of breast a necessary feature of general examination of every woman”
At the end of the presentation we are likely to have a deeper insight
into the following questions:
What symptoms arouse the suspicion of breast cancer in a female
what are the clinical signs suggestive of breast malignancy
How to differentiate between a benign & malignant breast lump
The importance of history n examinations in diagnosing a breast cancer
The role of self breast examination
CLINICAL FEATURES OF BREAST CANCER
What symptoms signal a problem with the breasts?
Breast lump Pain Nipple dischargeRetraction of nippleSwelling in axillaNeck swellingLoss of weightLoss of appetite Bony tendernessAbdominal distensionAbdominal massdisturbed cognitive function
Percentage wise…. Painless lump (67%) Pain (5 %)Nipple (deviation, retraction, destroyed) (4 %)Nipple discharge (2 %)Skin retraction (1 %)Axillary mass ( 1%)Swelling of arm (1 %)
Assessing the Breasts
Obtain a breast history. Perform a breast physical
assessment.Differentiate between normal and abnormal findings.
History taking &clinical examination
CHIEF COMPLAINS
Breast Lump: m.c mode of presentation
enquire about : onset, duration, rate of growth, change in size
with menstruation. history of trauma: may lead to hematoma ,fat
necrosis or simply attract attention towards a preexisting lump.
Associated with pain or other signs of inflammation
On the basis of history …
Benign lump Malignant lump
Slow growth & long history Site: anywhere but m.c in lower half of breast
rapid growth & short historySite: anywhere including axillary tail but mc in upper outer quadrant
Pain: enquire about
Benign breast diseases
Carcinoma breast
Acute pain: mastitis
Throbbing pain: breast abscess
Cyclical pain: fibroa denosis
Painless to begin with except inflammatory ca. breastMay become painful in advance stagesSkeletal pain due to bony mets.Neuronal pain due to brachial plexus involvement
Siteonset,
severity, nature
radiation of pain
Discharge from nipple
Benign diseases Malignant diseases
Milk: galactocele or mammary fistula
Pus: mammary abscessSerous:fibroadenosis
Greenish: duct ectasia
Blood: duct papilloma or carcinoma
Pus: inflammatory carcinoma
Enquire about: onset ,nature, colour, odour of discharge
Changes in nipples:
Retraction of nipple Inversion of nipple
Retraction of nipple: differentiating from nipple inversion
a retracted nipple appears flat & broad
An inverted nipple can be pulled out
destruction of nipple:
Nipples may be destroyed in PAGETS DISEASE due to erosion
Nipples may be destroyed by fungating breast carcinoma.
deviation of nipple:
In fibroadenoma: nipples move away from the lump
In carcinoma breast: nipples move towards the lump
LYMPHADENOPATHY
Symptoms related to distant metastases :
Localizing neurologic signs ,Altered cognitive function.
Breathing difficulties
Abdominal distension ,Jaundice
Bone pain
PERSONAL, PAST & FAMILY HISTORY
What can the personal history tell you….enquire about the following risk factor
Gender: female (1% males)
Race: more common in whites
Age: increases as a woman gets older.
Relative : (mother or sister)
Menstrual history :early menarche.late menopause
Childbirth: first child After the age of 30 or having no children at all
Pregnancy and breastfeeding are protective against breast cancer
Obesity
Diet: Fat
Alcohol
Lack of Physical Activity ; Stress
Radiation Exposure
History of cancer: breast, uterus, cervix, ovary
Hormones: estrogens in Hormone replacement therapy & Birth control pills
> 70% have no risk factors
Examination of breast
SBE:Self breast
examination
CBE: Clinical breast
examination
Breast Self Examination (BSE)
• Every women visiting an oncology opd should be motivated & educated about self breast examination.
• Monthly exam of the breasts and underarm area
• May discover any changes early
• Begin at age 20, continue monthly
When to do BSE
• Menstruating women- 5 to 7 days after the beginning of
their period• Menopausal women - same date each month• Pregnant women – same date each month• Perform BSE at least once a month
Clinical Breast Examination
• Performed by doctor or trained practitioner
• Annually for women over 40yrs
• At least every 3 years for women between 20 and 40 yrs
• More frequent examination for high risk patients
Clinical breast examination
Inspection: Palpation
Lymph node examinationExamination to rule out metastasis
expose up to waist maintain privacy
Inspection: various positions & their importance
Sitting, arms at sides of body:
Most common position for examination of breastAdvantages:
Gives information regardingSymmetry of breastSkin & nipple changes level of nipples, breast lump aids in palpation of axilla & scf
Disadvantages: makes the breast look pendulous and bulky
Recumbent position
2nd most common position for examination of breast
Advantages: to palpate the breast against chest wall
Palpate the lump see its mobility check for fixity with chest wall
Disadvantages: Flatten the breast Breast fall sideways
Arms pressing on hips
• This maneuver taut the pectoral muscles. Helps to see the fixity of lump to underlying muscles and chest wall.
Arms overhead
Arms raised straight above head makes the lump or dimple more marked.
Leaning forward positionGives information regarding retraction of nipple if anyWhen pt bend forwards the breast fall away, any failure of one nipple to fall away from chest indicate abnormal fibrosis behind nipple
ON INSPECTION OF BREAST..
Look for:
breast :Position, Size & shape puckering, dimpling, retraction of skin over breastSwelling, ulcer,fungation,nodules over breast
Nipples: presence, position ,number, size & shape, prominence, flattened or retracted,Look at surface of nipple for cracks, fissure or eczemaNipple discharge
ON INSPECTION OF BREAST..
Areola: color, size, surface, montgomery’s tubercles
Skin over breast: color ,texture, engorged veins, Peau d’ orange
On inspection…
Note the retraction of left nipple due to presence of carcinoma in upper outer quadrant ;swelling seen
Fungated carcinoma in breast with axillary lymphadenopathy
On inspection..
PALPATION: sitting position
Confirm the diagnosis of inspection..Palpate the normal breast first.Then the affected side is palpated
keeping in mind the findings of normal breast & compairing them
The four quadrants should be palpated systematically.
Palpation :supine position
palpate a rectangular area extending vertically: from clavicle to the inframammary fold laterally:from the midsternal line to the posterior
axillary line finally into the axilla for the tail of the breast.
• Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers flat. It is important to be systematic.
Technique of palpation• Palpate the breasts using one of the three different patterns• circular or clockwise,• wedge, • vertical strip.
Levels of palpation Vary the level
of pressureLIGHT –
superficial MEDIUM –
mid-level tissue
Deep – to the ribs
Palpation :Supine with shoulder support,Vertical Strip Method PreferredUse pads of fingers of dominant hand
CIRCULAR METHOD
Bimanual palpation
PALPATION FOR THE NIPPLES
PALPATION FOR THE NIPPLES: press the areola to see any discharge
Bloody discharge is seen in papilloma & breast carcinoma
PALPATION FOR THE LUMPECTOMY OR MASTECTOMY SITE
• Mastectomy or lumpectomy scar
• Lymphedema• Signs of inflammation
What if we find a lump in the breast?
• Look for-Local temperatureTendernesquadrant location NumberSize & shapeSurface &MarginConsistency:cystic.firm,
hard,stony hardfluctuation
Look for mobility or fixity of lump-
Fixity to skinFixity to breast tissueFixity to pectoral
fascia &mucleFixity to chest wall
Fixity to skin can be tested in following ways:
--move the tumor side to side or up down:if the tumor is fixed it may result in dimpling or tethering of skin--skin is not able to slide over tumor.--skin over the tumor cannot be pinched up.--peau d’orangebecome more prominent
Difference between tethered & fixed breast lump
TETHERED FIXED
Means malignant ds has spread to fine fibrous septathat pass from
breast to skin
Means there is direct & continuous infiltration of
skin by tumor
Test for fixity of breast lump to pectoralis muscle
Pt. is asked to pres her hips.
This taut the pectoralis ms.
Now the lump is moved in the direction of fibers of pectoralis major ms. & then at right angle
Compare the range of mobillity
Feel the ant fold of axila to see that ms. Is taut.
Any restriction in mobility indicates fixation to pectoral fascia & muscle
If the lump is fixed there will be no movement along the line of ms. Fiber but slight movement at right angle
Fixity to breast tissue
• Hold the breast tissue in one hand & gently move the tumor with other hand.
• Asses the mobility of tumor.
FIROADENOMA CARCINOMA BREAST
MobileAlso called as breast mouse
Fixed to breastCannot be moved
fixity to chest wall
• If the tumor is fixed irrespective of contraction of any muscle: it is fixed to chest wall
Motwakil. A. H. MoneerGezira 2005
BENIGN MALIGNANTSize Frequently small Larger
Consistency Firm, rubbery mass
Hard
Pain (tenderness)
Frequently painful Painless ( in 85%)
Surface Regular Irregular
Immobility (Fixity)
Nil Possible
Skin dimpling Nil Present
Nipple retraction
Nil Present
Bloody discharge
Nil Present
Motwakil. A. H. MoneerGezira 2005
what about the Characteristics of Discharge?
Benign Malignant
Bilateral Unilateral
Spontaneous or induced
Spontaneous
Multiple duct orifices One duct orifice
Thick green or yellow, induced and bilateral (duct ectasia)
Bloody, serosanguineous, or serous
Features of malignant mass
• Hard• Painless• Irregular• Possibly fixed to
skin or chest wall• Skin dimpling• Nipple retraction• Bloody discharge• Peu d orange
Peau d’ orange: classic sign of carcinoma breast
This is due to blockage of subcuticular lymphatic's with edema of skin which deepens the mouth of sweat gland & hair follicles giving an orange peel appearance
Brawny edema of arm due to extensive neoplastic infiltration of axillary Lymph node
Examination of arms & thorax“Cancer en cuirasse”
• Multiple cancerous nodules and thicken infiltrate skin like a coat of armor may be seen in the arm & thoracic wall
Inflammatory carcinoma breast
Breast cancer presenting with unilateral enlargement of the nipple in a middle aged woman
Breast lump. Note the breast lump with inverted, elevated nipple. Note also the prominent blood
vessels suggesting neo-angiogenesis
Paget’s disease: Ulcerated nipple in a middle aged woman
Old woman with prominent axillary involvement as well as right breast swelling. There is increase in size of the areola and edema of the nipple areola complex
Lymph node examination
• Very important for the staging & prognosis of breast cancer
• Done in sitting position.• The axillary & cervical group of lymph
nodes are palpated
Lymph Node Examination
• abnormal nodes, described in terms of
location size discrete or matted
togethermobile or fixed consistency (soft, hard,
firm) tenderness
Characters of L.N enlargement in malignancy
Slowly progressive,firm, Multiple nodes
involved, stuck together & to underlying
structures, not tender.
Axillary LN examination
• Axillary lymph node groups
• Pectoral group• Brachial group• Subscapular group• Central group• Apical group
PECTORAL NODES
Method of palpationThe pt arm is elevated & using the right hand for left side the fingers insinuated behind pectoralis majorThe arm is now lowered and made to rest on clinicians forearm (this relaxes P.MINOR)With pulp of finger palpate l.n ,the palm faces forward.The thumb of same hand pushes the pectoralis major backwards from front (facilitates palpation)
Location; situated just behind the anterior axillary fold along the lateral thoracic vein.
• Arm is adducted & allowed to rest comfortably on clinician’s forearm
• The thumb pushes the p.major ms.backwards.palm should look forward.
BRACHIAL GROUPLocation: It lies on lateral wall of axilla in relation to axillary vein.
Method of palpation: left hand is used for left sideIt is felt with palm directed laterally against upper hand of humerus.
SUB-SCAPULAR NODES:Location: lies on posterior axillary fold in relation to subscapular vessels.
Method of palpation:stand behind the pt.Hold the antero-internal surface of post axillary fold with one handWhile with other hand pt.arm is semi lifted
SUBSCAPULAR NODES
• The nodes are palpated along antero-internal surface of post. axillary fold with palm of examining hand looking backwards
CENTRAL NODES• Method of palpation:• Pt. right central nodes
examined with left hand.• Pt.arm abducted & forearm
rest on clinicians forearm• Clinician passes his
extended fingers right up to apex of axilla directing palm towards lat.thoracic wall
• Other hand of clinician placed on shoulder.
• Palpation carried by sliding fingers against chest wall.
APICAL NODES
Method of Palpation: same as central group nodes but fingers
are pushed further up If the lymph nodes are very much enlarged
they may push themselves through the clavi-pectoral fascia& the pectoralis major ms just below clavicle
Palpation of SUPRACLAVICULAR L.N
the clinician stands behind the patient & dips the finger down behind the middle of clavicle.
Two sides are palpated simultaneously & compared
Passive elevation of shoulders would relax the muscles of neck &facilitate palpation
Always flex the neck of pt. for better palpation
Palpation of supra clavicular node
GENERAL EXAMINATION
Look for signs of liver secondaries: hepatomegaly Ascitis with jaundiceTenderness in right hypochondrium
Per abdomen examination
Examination of liverin carcinoma r breast
Note-size of tumor,-complete replacement of breast tissue,-nipple retraction and deviation,-edema and ulceration of overlying skin.
Note further the abdominal swelling which was due to liver metastases and ascites
young to middle aged woman with advanced breast cancer.
EXAMINATION OF BONES FOR SKELETAL METASTASIS: evaluation of site of bone pain
NEUROLOGICAL EXAMINATION FOR BRAIN METASTASIS
RECTAL & VAGINAL EXAMINATION TO DETECT KRUKENBERG’S TUMOUR OF OVARY (which occur by trans celomic spread or lymphatic spread)
GENERAL EXAMINATION: to determine metastasis
AUSCULTATION OFLUNG FOR PULMONARY METASTASIS
Thank you