“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