BREAST CANCER: SIGN SYMPTOMS CLINICAL EXAMINATION OF BREAST AND AXILLA

1. “CLINICAL PRESENTATION OF BREAST CANCER
AND EXAMNATION OF BREAST & AXILLA”
Made by: Dr. Isha Jaiswal
Moderator: Dr.Madhup
Rastogi
Date : 22 January 2014

2. “The chances of finding a treatable
BREAST CANCER makes the full
examination of breast a
necessary feature of general
examination of every woman”

3. 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

4. CLINICAL FEATURES
OF BREAST CANCER

5. What symptoms signal a problem with
the breasts?Breast lump
 Pain
 Nipple discharge
Retraction of nipple
Swelling in axilla
Neck swelling
Loss of weight
Loss of appetite
 Bony tenderness
Abdominal distension
Abdominal mass
disturbed cognitive function

6. 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 %)

7. Assessing the Breasts
 Obtain a breast history.
 Perform a breast physical
assessment.
Differentiate between normal
and abnormal findings.

8. History taking &
clinical examination

9. CHIEF COMPLAINS

10. 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

11. 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
history
Site: anywhere including
axillary tail but mc in upper
outer quadrant

12. 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. breast
May become painful in advance
stages
Skeletal pain due to bony mets.
Neuronal pain due to brachial
plexus involvement
Site
onset,
severity, nature
radiation of pain

13. Discharge from
nipple
Benign diseases Malignant diseases
Milk: galactocele or
mammary fistula
Pus: mammary abscess
Serous:fibroadenosis
Greenish: duct ectasia
Blood: duct papilloma or
carcinoma
Pus: inflammatory
carcinoma
Enquire about:
onset ,
nature,
 colour
, odour of
discharge

14. Changes in nipples:
Retraction of nipple Inversion of nipple

15. Retraction of nipple: differentiating
from nipple inversion
a retracted nipple appears
flat & broad
An inverted nipple can be
pulled out

16. 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

17. LYMPHADENOPATHY

18. Symptoms related to distant
metastases :
Localizing
neurologic signs
,Altered cognitive
function.
Breathing
difficulties
Abdominal
distension
,Jaundice
 Bone pain

19. PERSONAL, PAST & FAMILY
HISTORY

20. 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

21. 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

22. Examination
of breast
SBE:Self
breast
examination
CBE: Clinical
breast
examination

23. 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

24. 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

25. 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

26. Clinical breast examination
Inspection: Palpation
Lymph node examination
Examination to rule out metastasis
expose up to waist
 maintain privacy

27. Inspection: various positions & their
importance

28. Sitting, arms at sides of body:
Most common position for
examination of breast
Advantages:
Gives information regarding
Symmetry of breast
Skin & nipple changes
 level of nipples,
 breast lump
 aids in palpation of axilla & scf
Disadvantages: makes the breast
look pendulous and bulky

29. 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

30. Arms pressing on hips
• This maneuver taut
the pectoral
muscles. Helps to
see the fixity of lump
to underlying
muscles and chest
wall.

31. Arms overhead
Arms raised straight
above head makes
the lump or dimple
more marked.

32. Leaning forward position
Gives information regarding retraction of
nipple if any
When pt bend forwards the breast fall away,
any failure of one nipple to fall away from
chest indicate abnormal fibrosis behind nipple

33. ON INSPECTION OF BREAST..
Look for:
breast :Position, Size & shape
puckering, dimpling, retraction of skin over breast
Swelling, ulcer,fungation,nodules over breast
Nipples: presence, position ,number, size & shape,
prominence, flattened or retracted,
Look at surface of nipple for cracks, fissure or eczema
Nipple discharge

34. ON INSPECTION OF BREAST..
Areola: color, size,
surface, montgomery’s
tubercles
Skin over breast:
color ,texture, engorged
veins, Peau d’ orange

35. On inspection…
Note the retraction of left nipple due to presence of
carcinoma in upper outer quadrant ;swelling seen

36. Fungated carcinoma in breast with axillary
lymphadenopathy
On inspection..

37. 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.

38. 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.

39. • Use the finger pads of the 2nd, 3rd, and
4th fingers, keeping the fingers flat. It is
important to be systematic.

40. Technique of palpation
• Palpate the breasts using one of the three different patterns
• circular or clockwise,
• wedge,
• vertical strip.

41. Levels of palpation
Vary the level
of pressure
LIGHT –
superficial
MEDIUM –
mid-level
tissue
Deep – to
the ribs

42. Palpation :Supine with shoulder support,
Vertical Strip Method Preferred
Use pads of fingers of dominant hand

43. CIRCULAR METHOD

44. Bimanual palpation

45. PALPATION FOR THE NIPPLES

46. PALPATION FOR THE NIPPLES: press
the areola to see any discharge
Bloody
discharge is
seen in
papilloma &
breast
carcinoma

47. PALPATION FOR THE LUMPECTOMY OR MASTECTOMY
SITE
• Mastectomy or
lumpectomy scar
• Lymphedema
• Signs of inflammation

48. What if we find a lump in the
breast?
• Look for-
Local temperature
Tendernes
quadrant location
Number
Size & shape
Surface &Margin
Consistency:cystic.firm,
hard,stony hard
fluctuation
Look for mobility or
fixity of lump-
Fixity to skin
Fixity to breast tissue
Fixity to pectoral
fascia &mucle
Fixity to chest wall

49. 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’orange
become more prominent

50. 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

51. 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

52. 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

53. 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
Mobile
Also called as
breast mouse
Fixed to breast
Cannot be moved

54. fixity to chest wall
• If the tumor is fixed irrespective of contraction
of any muscle: it is fixed to chest wall

55. Gezira 2005 Motwakil. A. H. Moneer
Frequently small Larger
Firm, rubbery
mass
Hard
Frequently painful Painless ( in
85%)
Regular Irregular
Nil Possible
Nil Present
Nil Present
Nil Present

56. Gezira 2005 Motwakil. A. H. Moneer
what about the Characteristics
of Discharge?

57. Features of malignant mass
• Hard
• Painless
• Irregular
• Possibly fixed to
skin or chest wall
• Skin dimpling
• Nipple retraction
• Bloody discharge
• Peu d orange

58. 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

59. Brawny edema of arm due to extensive
neoplastic infiltration of axillary Lymph node

60. 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

61. Inflammatory carcinoma breast

62. Breast cancer presenting with unilateral
enlargement of the nipple in a middle aged woman

63. Breast lump. Note the breast lump with inverted,
elevated nipple. Note also the prominent blood
vessels suggesting neo-angiogenesis

64. Paget’s disease: Ulcerated nipple in a middle aged
woman

65. 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

66. 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

67. Lymph Node Examination
• abnormal nodes,
described in terms of
location
size
discrete or matted
together
mobile 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.

68. Axillary LN examination
• Axillary lymph node groups
• Pectoral group
• Brachial group
• Subscapular group
• Central group
• Apical group

69. PECTORAL NODES
Method of palpation
The pt arm is elevated & using the right hand for left
side the fingers insinuated behind pectoralis major
The 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.

70. • Arm is adducted & allowed to rest comfortably on
clinician’s forearm
• The thumb pushes the p.major ms.backwards.palm
should look forward.

71. BRACHIAL GROUP
Location: It lies on lateral
wall of axilla in relation to
axillary vein.
Method of palpation:
left hand is used for left
side
It is felt with palm
directed laterally against
upper hand of humerus.

72. 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 hand
While with other hand pt.arm
is semi lifted

73. SUBSCAPULAR NODES
• The nodes are
palpated along
antero-internal
surface of post.
axillary fold with palm
of examining hand
looking backwards

74. 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.

75. 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

76. 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

77. Palpation of supra clavicular
node

79. GENERAL EXAMINATION
Look for signs of liver
secondaries:
 hepatomegaly
Ascitis with jaundice
Tenderness in right
hypochondrium
Per abdomen
examination
Examination of liver
in carcinoma r breast

80. 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.

81. 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

82. Thank you