- Еуромедик, Булевар уметности 29, Београд
Clinical examination of the breast
Прим др Милош Почековац
др Срђан Маринковић
др Милена Радосављевић
A clinical breast examination is a thorough diagnostic procedure that includes history and physical examination. The reason for the clinical examination can be: systematic examination, developmental anomaly, injury, breast pain, breast tumor, wetting from the nipple, enlargement of the lymph nodes in the armpit.
Every physical examination should be preceded by a detailed conversation with the patient, during which the facts necessary for making a correct diagnosis and assessing the prognosis of the disease are learned. The best period for examination is between the seventh and tenth days of the menstrual cycle for women in the reproductive period.
In order to screen for breast diseases, the importance of breast self-examination, followed by clinical breast examination, as well as diagnostic mammography should be emphasized.
ANAMNESIS
The history of the current illness is taken chronologically, from the appearance of the first symptoms and signs to the day of the examination.
When taking data, you should start with a description of the complaints, i.e. observed breast changes and symptoms. If there is a tumor in the breast, the time elapsed from the detection of the tumor to the examination should be found out, compared with the description of the patient, in order to possibly assess the speed and growth and severity of the tumor.
By taking personal history data, it is necessary to find out the conditions or diseases that preceded and may be related to the current condition. Special reference should be made to previous breast diseases or previous breast surgery. At the same time, the goal is to have knowledge about the general condition and specific systems, in order to assess the possible risks of potential surgical treatment.
Known risk factors are of particular importance when breast cancer is suspected. Therefore, information on the presence of malignant breast tumors in close female relatives (mother, paternal or maternal grandmother, sisters, aunts, daughters) should be sought. Information on women’s gynecological anamnesis should be obtained, information on the age of first menstruation, regularity of cycles, pregnancies, childbirth and breastfeeding, taking oral contraceptives and hormonal therapy, hormonal status (menopause or not), etc. should be obtained. When taking hormones for therapeutic purposes, the nature of the hormones, the duration of the intake and the dosage of the medication should be specified.
PHYSICAL EXAMINATION
A physical examination of the breasts includes inspection and palpation.
A complete physical examination of the breasts is performed in an adequately heated room, with respect for the patient’s privacy, while informing the patient about all subsequent steps of the examination, in order to minimize the feeling of discomfort and avoid possible misunderstandings. The patient should be naked to the waist and remove all jewelry that may interfere with the breast examination.
Physical examination of the breasts should be performed in a sitting and lying position.
Inspection
The inspection evaluates the external appearance of the breasts.
Слика 1. Седећи положај са рукама на боковима
Breasts should initially be examined while the person is in a sitting position with arms relaxed by the body, paying attention to:
- Size
- shape,
- symmetry
- deformities,
- skin condition and the presence of excoriations and scars
- the appearance of the areola and indentation of the nipples and/or areola, as well as the presence of discharge from the nipples
- vein drawing.
Then one should change the position by raising both hands above the head with joined palms, placing the palms on the hips while pushing the shoulders forward and finally in a lying position. These maneuvers will accentuate any skin retraction and breast deformities.
The supine position allows the breast tissue to “spill” over the chest wall and reduce the height diameter of the breast tissue, which facilitates examination, especially with voluminous breasts.
Слика 2. Лежећи положај са рукама подигнутим изнад главе
It is necessary to make a comparison of the size and shape of the breasts. If a variation in size is observed, it should be determined when the difference exists. Differences in breast size that are noticed more recently or are rapidly progressing can be a sign of both benign and malignant tumors and require further investigation.
Discreet asymmetry in breast volume is a normal condition, while pronounced asymmetry can be the result of asymmetric growth of normal glandular tissue, the result of surgical intervention or a tumor in the breast that deforms it, but also increases the volume.
Changes in the shape of the breasts and visible deformities, in the absence of previous surgical interventions, are more worrying. Superficial localized tumors can cause bulges, breast contours or skin retraction. Tumors located deep within the breast tissue that involve the preglandular fascia and fibrous Cooper’s septa also cause skin retraction. Although skin retraction is often a sign of breast malignancy, benign breast lesions can also cause so-called false skin retraction. Large cysts and fibroadenomas can displace Cooper’s septa, thus causing visible fixation and distortion of the skin, while a chronic abscess associated with periductal mastitis leads to actual skin attachment, edema, and sometimes a peau d’orange skin appearance. Differential diagnosis, if there is an asymmetric enlargement of the lymph nodes in the armpit, associated with redness of the skin limited to a part of the breast or affecting it as a whole, indicates breast cancer in the evolutionary stage.
Erythema of the skin is another sign of pathological processes of the breast which is verified by inspection. It can be caused by cellulitis or an abscess, and inflammatory breast cancer should be considered as a differential diagnosis, which differs from inflammatory breast processes by the absence of elevated temperature and skin tension.
Inspection of warts includes symmetry, retraction, and changes in skin appearance. Retraction of the nipple or areola raises a high suspicion of an infiltrative process in the central quadrant of the breast. Ulcerations, raspberry skin of the nipple, increased flaking can be signs of Paget’s disease.
Asymmetry in the venous pattern can be a sign of pathological vascularization of a malignant tumor, but it should not be confused with a congenital capillary hemangioma of the breast skin. Inflammation with thrombosis of the superficial vein in the skin of the breast, which usually spreads to the chest wall, is called Mondor’s disease.
After the inspection, the breasts are palpated.
Palpation
While the patient is sitting, the axillary lymph nodes should be palpated. When examining the axilla, the doctor leans on the patient’s shoulder with the same hand and holds the forearm, thus relaxing the fascia and chest muscles, and performs palpation with the opposite hand (picture 3). This examination begins with the palpation of cervical nodes on the anterior side of the sternocleidomastoid muscle. By palpating downwards, the supraclavicular fossa should be examined with the tips of the fingers with gentle pressure towards the neck muscles and behind the collarbone (picture 4).
Слика 3.
Преглед пазушне јаме у седећем положају
Преглед пазушне јаме у седећем положају
Слика 4.
Преглед наткључне јаме у седећем положају
Преглед наткључне јаме у седећем положају
Then the subclavian nodes should be examined by gentle pressure under the clavicle towards the deltopectoral groove. It continues by palpating the lymph nodes high in the armpit, because in this way the lymph nodes are pushed downwards and their easier palpation is enabled. Palpation is performed with back-and-forth movements several times from the top of the axilla down. The armpit should also be palpated in the lying position (picture 5).
Слика 5.
Преглед пазушне јаме у лежећем положају
If lymph nodes are palpable, their size and consistency should be described, as well as whether they are single, multiple or fused. It should be noted whether they are mobile or fixed. Based on this information, the doctor should assess whether the lymph nodes are clinically suspicious. Lymph nodes verified in the armpit smaller than 1 cm, soft and mobile are generally not clinically significant. Palpable enlarged supraclavicular lymph nodes require further investigation.
Then the breast tissue is palpated, so that the opposite, conditionally healthy breast should always be palpated first. The patient should stand up, because such a position allows a complete examination of the breast, including its axillary extension and circumference. Palpation is performed with a hand placed on the breast with at least two-thirds of the fingers placed on the breast tissue, while the opposite hand gently holds the breast or rests on the chest. In this way, it is possible to determine the third dimension of a possible tumor.
Слика 6.
Преглед дојки у седећем положају
Слика 7.
Преглед дојки у лежећем положају
Then the position of the patient should be changed to lying down with the arms raised above the head (fig. 7). The doctor can use different movements when palpating the breast, such as movements in the form of concentric circles or spirals, then in the pattern of wires on a bicycle wheel, or up and down movements in the form of vertical strips. The breast is palpated from the clavicle to the rib cage, as well as from the mid-axillary line to the sternum. The doctor should use two-thirds of the second, third and fourth fingers and palpate with kneading movements, without squeezing. The degree of pressure on the breast tissue should vary, but should not cause discomfort. Particular attention should be paid to the upper outer quadrant and breast tissue behind the areola and nipple, as this is the most common localization of cancer.
The surgeon should verify the consistency of the breast tissue. Fibroglandular tissue of the breast is not always equally distributed, which can cause confusion, it is most often concentrated in the upper outer quadrant, sometimes it can extend into the axilla, therefore the findings should always be compared with the opposite breast. There may be a lack of tissue beneath the areola, leaving a ridge of normal parenchyma that may be mistaken for infiltration. The same can be interpreted as defects under the scars.
The areola is palpated starting from the edge and sliding towards the center with light movements. The nipple is palpated by gentle squeezing to determine if there is any discharge, as well as if there is a tumor mass below the areola-nipple complex.
Слика 7.
Палпација ареоле и брадавице
If the existence of tumefaction is determined by palpation, it is necessary to determine the limitation of the change, consistency, character of the edges, mobility, fixation to the skin or pectoral muscles, describe the size and location (quadrant, position compared to the clock hand and distance from the edge of the areola). This is necessary so that after 4-6 months at the follow-up examination, the surgeon can make a comparison.
Literature
1.Jay R.Harris. Diseases of the breast 5E. Philadelphia, PA: Walters Kluwer Health: 2014.
2. Michael Sabel. Essentials of breast surgery 1E. Philadelphia, PA: Mosby: 2009.
3. Robert Mensel, David Webster, Helen Sweetland. Benign disorders and diseases of the breast 3E. Saunders ltd.:2009.
4. Miloš Počekovac i saradnici. Fibroadenomi i ciste dojke. Naučna KMD d.o.o.: 2018.
5. Dragoslav Stevović i saradnici. Hirurgija za studente i lekare. Beograd: Savremena administracija: 2000.