Clinical Examination of Breast

Property of Department of Surgery, Faculty of Medicine, University of Zagazig, Egypt

1. Clinical Examination of Breast

2. ANATOMY OF BREAST SHAPE AND SIZE :considerable individual variation BASE : V ertically - from 2nd to 6th rib in midclavicular line H orizontally - from the midline of the sternum almost to the midaxillary line superolaterally- extends as the axillary tail of spence through the foramen of langer

3. THE AREOLA : pigmented circular area of skin around the base of the nipple. It contains a number of subcutaneous glands which enlarge during pregnancy and are called tubercles of Montgomery. THE NIPPLE : cylindrical or conical structure projecting from the center of the areola. It contains subcutaneous network of smooth muscle cells and elastic fibers.

4. BREAST GLANDS Each breast has 8 to 10 sections ( lobes ) Inside each lobe are many smaller structures called lobules At the end of each lobule are tiny sacs ( bulbs )

5. ARTERIAL SUPPLY It is supplied by: Lateral thoracic branch of 2nd part of axillary artery Medial mammary branches of internal thoracic artery Superior thoracic branch of axillary artery Lateral branches of 2nd,3rd,4th posterior intercostal arteries

6. VENOUS DRAINAGE Circular venous plexus deep to the areola at the base of the nipple. From this plexus two sets of veins are formed : 1.superficial set- ends in internal thoracic vein 2.deep set - ends in internal thoracic , axillary and post intercostal veins

7. LYMPHATIC DRAINAGE 5 Groups: ANTERIOR (PECTORAL) SET : Situated along the lateral thoracic vein under the ant axillary fold,they lie mainly on the 3rd rib POSTERIOR (SCAPULAR) SET: Lies on the post axillary fold in relation to the subscapular vessels LATERAL (AXILLARY VEIN) SET: Along the upper part of humerus in relation to the axillary vein CENTRAL SET : Situated in the fat of the upper Axilla . APICAL or INFRACLAVICULAR SET: Lie deep to the clavipectoral fascia along the axillary vesels

8. History 1- Personal history Age sex

9. History 2 - Present history: Lump

10. Pain Painless lump Painful lump - Cyst - Carcinoma - Fibroadenosis (chronic mastitis) - Fibroadenoma - Fat necrosis - Cyst - Breast abscess - Fibroadenosis Periductal mastitis Carcinoma (rare)

11. Discharge from nipple Serous Early pregnancy fibroadenosis Milky Late pregnancy Lactation Puberty prolactinoma Yellow, brown, green fibroadenosis

12. Thick and creamy Ductectasia Purulent Retroareolar abscess Breast abscess TB Bloody Intraductal ca Intraductal papilloma Paget’s disease

13. Fever Retraction of nipple Trauma

14. History Swelling elsewhere Similar episodes Smoking Alcoholism Diet habits(high fat diet) Breast feeding Drug intake

15. History - CA risk factors Age : older History : family Radiation exposure Menstrual history: Early menarche Late menopause and late pregnancy

16. Metastasis - Recent backache, Bone ache - General malaise, weight loss - Nodules in the skin - Jaundice - Mental changes - Dyspnea , pleuritic pain

17. common causes of a benign breast mass Fibrocystic disease: the most common breast mass in women. Fat necrosis Abscess Cyst Others : - Intraductal papilloma - Ductal / lobular Hyperplasia - Ductectasia - Lipoma - Granulomatous mastitis

18. Thank you

19. Pt removes upper body clothing Expose/ inspect the opposite side so can compare for asymmetry . Expose

20. Ask pt. if Tenderness before start touching them. Warm your hands Tenderness

21. Introduce yourself to the patient Ask Permission to perform the examination Assure privacy ask for chaperone to be present Explain what you want to do Expose the patient adequately Position the patient correctly If sores visible,wear gloves .

22. Methods of Inspection Sitting position,arms at sides Arms overhead

23. Arms pressing on hips Leaning forward

24. Inspection Position : Sitting with arms by side Symmetry Any mass Skin Ulcer

25. skin Skin retraction Dimpling

26. skin Redness Peau d'orange (ca) Veins: congestion mastitis Inflammatory ca

27. Nipples Nipple number, position Inversion retraction; (fibrosis, CA, normal) Slit like

28. Nipples Red, bleeding (Paget's dz of nipple). Discharge

29. Ask patient to raise arms and place hands behind head Change in a mass's relative position. Nipple or skin tethering

30. Inspect whole skin Raise the breast to inspect the undermined skin.

31. Inspect the axilla Examine axilla while pt's arms are raised; axillary tail axillary LNs any mass, ulcer Edema,nodules Cancer en cuirase

32. Pt. pushes hands on hips. Look for: • Dimpling. • Fixation. Large breasts: pt. leans forward Hands on knees Ask patient to put hands on hips and push inwards flexes pectorals Again look for contour of breast

33. Palpation - Use fingerpads of middle 3 fingers -Palpation should not elicit pain -Consistency is highly variable

34. Sitting position First examine sitting Examine ‘normal’ side first Place hand behind head One quadrant at a time

35. Supine position Spreads the breast more evenly across chest Examine lying down Use one or two hands to elicit lumps If felt define lump with fingertips

36. Press breast against chest wall Rolling fingers in small, circular motions. Press lightly for superficial layers Medium pressure for middle layer Firmer pressure for deepest layers Start at sternoclavicular junction. Move in overlapping vertical strips until all 4 breast quadrants are covered.

37. Evaluation of Breast Mass Characteristics Location Size Shape Number Consistency Definition Mobility Tenderness Erythema Dimpling or retraction Lymphadenopathy

38. Comparison of Breast Lumps Benign Breast Disease Multiple or single Rubbery texture Mobile / slippery Regular borders Tenderness (cyclic) No retraction May increase/decrease in size rapidly Cancer Unilateral Firm texture Fixed firmly Irregular border Usually painless Usually retraction Grows constantly

39. Palpate: Nipples Finally palpate nipple Palpate around areola. Palpate depression under nipple. Gently press nipple between thumb index finger; Discharge .

40. Examination of Axilla

41. palpate the axilla Support patient’s arm Palpate tail between fingers and thumb. Palpate axillary lymph nodes Supraclavicular nodes. Palpable lymph nodes less than 1 cm in diameter usually are clinically insignificant

42. Pectoral group Central and apical

43. Posterior group

44. supraclavicular infraclavicular

45. BREAST SELF EXAM GOAL: Early detection IN PREPARATION FOR TEACHING: Assess: knowledge base , motivation fears and concerns family history risk factors TEACHING: Use show and tell; use finger pads EXAM: monthly, day 5-7 of menstrual cycle; after menopause same day each month Use in conjunction with mammography & CBE

46. Breast Self Exam - Step 1 Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Here's what you should lookfor: Breasts that are their usual size, shape, and color. Breasts that are evenly shaped without visible distortion or swelling. If you see any of the following changes, bring them to your doctor's attention: Dimpling, puckering, or bulging of the skin. A nipple that has changed position or become inverted (pushed inward instead of sticking out). Redness, soreness, rash, or swelling

47. Breast Self Exam - Step 2 and 3 Raise your arms and look for the same changes. While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

48. Breast Self Exam - Step 4 Feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage

49. Breast Self Exam - Step 5 Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

50. GYNECOMASTIA

51. Mondor ’ s disease: thrombophlebitis

52. Phylloides tumor