Breast Examination and Diseases.

1. BREAST
EXAMINATION
P R E S E N T E D BY :
M A R I YA M S H A K I L

2. • OBJECTIVES:
•History taking of breast disease
• Breast Examination
• Recording and investigations
• Benign and malignant breast diseases
• Differential diagnosis

3. HISTORY TAKING OF BREAST DISEASE
• 1-Age :
• * Less than 30 years. * Older than 50 years
• 2- Residence:
• 3- Lump :
• * Duration since lump first noted * Consistency of lump presence * Change in
size * Location * Shape * Rate of growth * Associated with menses, discharge,
nipple retraction, tenderness ,dimpling and tender lymph nodes.
• 4- Pain :
• * Site ,Onset ,duration ,intermittent?* Character of pain * Associated with
menses -timing and severity * Associated symptoms -lump or any discharge
Contributing factors -trauma ,strenuous activity * Radiation – does the pain
move anywhere else? * Exacerbating / Relieving factors – does anything
the pain worse or better?

4. • 5- Nipple discharge :
• * Color * Unilateral or bilateral * Any associate mass
• * 6- recent nipple inversion:
• 7-eczema ,dimpling ,ulceration:
• 8-evidence of systemic disease:
• Past medical history:
• Relevant obstetric/gynecological history:
• * Age at menarche/menopause:
• Parity:
• * Age at first pregnancy
• * Did they breastfeed?
• * Use of hormonal replacement therapy or oral contraceptive pill
• Relevant past medical history:

5. • :* Recent breast trauma – fat necrosis
• * Previous breast disease – malignant or benign?
• * Any other previous malignancies?
• * Other significant medical problems?
• Surgical history:
• – breast surgery / other surgery
• Family history:
• Family history of breast disease in the family.

6. BREAST EXAMINATION

7. RECOMMENDATION
• A L L W O M E N O F AG E 2 0 A N D O L D E R
P E R F O R M B S E O N A M O N T H LY B A S I S
• A L L W O M E N O F AG E 2 9 TO 3 9
S H O U L D H AV E C L I N I C A L
E X A M I N AT I O N E V E R Y 0 3 Y E A R S .
• A L L W O M E N AG E S 4 0 A N D O L D E R
H AV E R E G U L A R ( E V E R Y 0 1 TO 0 2
Y E A R S ) M A M M O G R A M S .

8. GENERAL:
• All examiners should normally be chaperoned
• The texture of normal breast tissue varies from smooth
to granular, also varies with menstrual cycle and
during pregnancy.
• Nodularity and tenderness often increases towards the
end of the cycle and during menstruation
• Always examine both the breast and compare the two

10. INSPECTION:
• The patient should be fully
undressed to the waist, with
upper body raised 45 degree
to the legs.
• BREAST:
• Size
• Symmetry
• Shape
• Skin color
• Lumps
• Skin tethering
• Prominent veins and edema with
dimpling like (peau d’orange)
• Nipples:
• Everted , flat, or inverted (recent or
longstanding)
• Cracking or eczema
• Gross deviation of the nipple
• Bleeding or discharge
• Areola : observe for
• Abnormal reddening
• thickening

11. INSPECTION:
• Ask the patient to raise her arms
above her head (important for
examination of axilla and axillary
tail)
• Ask the patient to place hands on
hips and apply downward pressure.
• Inspect the breast while patient is
lying flat.
• Inspect the axilla , arms and
supraclavicular fossa.( Grossly
enlarged LNS/ veins/ edema) may
be visible.
• Healthy women may have some

12. BREAST PALPATION:
• Patient lies on the the couch , lying flat with pillow
behind the head.
• Arms by her side or behind her head.
• Palpate with the flat of the finger using middle
three fingers.
• Either begin with the normal side or feel both the
breast together.
• Get on level with the patient.
• Use rotatory motion to gently press the breast
tissue against the chest wall.
• Palpate the axillary tail which lies on the anterior
axillary tail.
• LUMP : site , size, shape, surface ,edge, and
consistency. Bi-manual examination controlling
movement of the lump with one hand and feeling
with the other.

14. BREAST PALPATION:
• Examine the breast systematically , covering the whole
cone of the breast tissue using one of the following 03
methods
• 1. zigzag 2. concentric. 3.cricular
• A systemic methodological exam, covering all four
quadrants, axillary tail, areola and nipple.
• With large breast use one hand to steady the breast.

15. SYSTEM OF THE BREAST PALPATION
1/ZIGZAG
• The examiner zigzags up
and down
• Preferred method for self
examination
• Advantage: Breast tissue
remains in contact with the
chest wall during palpation.

16. SYSTEMS OF THE BREAST
PALAPATION 2/ CIRCULAR
• Breast tissue is examined
using a circular approach
• The examiner starts at
periphery and ends at the
areola and nipple.

17. SYSTEMS OF THE BREAST
EXAMINATION 3/RADIAL
• The examiner divides the
breast in series of
segments
• The quadrants are
examined methodically,
from periphery towards
nipple
• The examiner traces a
pattern similar to a clock.

18. THE AXILLA:
• To examine the axillary
tail, ask the patient to
rest her arms above her
head
• Feel the tail between
thumb and fingers(
extends from the upper
outer quadrant towards
axilla).

19. NIPPLE AND AREOLA:
• To examine the nipple; hold
the areola between thumb
and fingers.
• Gently compress, attempting
to express discharge.
• Note color of any discharge,
send for cytology.
• Cover the patient .

20. EXAMINATION OF AXILLA:
• Stand on the patients right side.
• Patients arm is raised and supported.
• Take hold of right elbow with your right hand
and let her forearm rest on your right
forearm.
• Place your left hand flat against the chest wall
and feel for any glands by sweeping tips of
your fingers to catch the glands against the
chest wall.
• Slightly cupped hands are then inserted into
the apex of the axilla ( push firmly).
• To examine the left axilla, move around to the
left axilla hold her left elbow with your left
hand and use your right hand to feel the
axilla.
• Palpate the clavicular fossa and the neck.
• Note No, size and consistence of any glands

21. GENERAL EXAMINATION:
• Check the arms for swelling or any
neurological/vascular abnormalities.
• Palpate the abdomen, look for hepatomegaly/ascites.
• Examine the lumber spine for pain or restricted
movements.

22. RECORDING AND INVESTIGATIONS:
• Identify which quadrant and which breast. (Right upper outer
quadrant)
• Best to record graphically.
• TRIPLE ASSESMENT:
• women with suspected cancer receive triple assessment,
which consists of
• 1. HISTORY AND EXAMINATION
• 2. MAMMOGRAPHY/ ULTRASOUND SCAN.
• 3. CYTOLOGY(FNA) OR HISTOLOGY(BIOPSY).

23. THE NIPPLE:
–NIPPLE RETRACTION:
–SIMPLE NIPPLE INVERSION:
• Retraction occurring during puberty
• Bilateral
• Of unknown etiology.
• May cause infection during breast feeding.
• RECENT RETRACTION OF THE NIPPLE: Is of considerable
significance.
• SLIT LIKE RETRACTION: may be caused by ductal ectasia
and chronic pre ductal mastitis.
• CIRCUMFERENTIAL RETRACTION: with or without lump
indicate carcinoma.

25. • CRACKED NIPPLE: May occur during lactation. It should be rested for 24-48 hrs.
• PAPILLOMA OF THE NIPPLE: should be excised with a tiny disc of skin or the base
maybe tied to a ligature and the papilloma will fall off.
• RETENTION CYST OF GLAND OF MONTGOMERY: These glands, situated in the areola,
secrete sebum.
• If blocked can cause sebaceous cysts.
• ECZEMA: Rare, often bilateral. Treated with 0.5 per cent hydrocortisone.
• PAGETS’S DISEASE: Occurs due to malignant
cells in in the subdermal layer.
• Usually associated with carcinoma.
• Should be differentiated from eczema.
• Nipple is eroded slowly and eventually disap-
pears.

26. DISCHARGE FROM THE NIPPLE:
• DISCHARGE FROM THE
SURFACE:
• Paget’s disease
• Eczema, psoriasis
• Discharge from a single duct:
Blood stained
• Intraduct pailoma
• Intraduct carcinoma
Serous stained
• Fibrocystic disease
• Duct ectasia
• DISCHARGE FROM MORE THAN
ONE DUCT:
BLOOD STAINED: CARCINOMA
BLACK OR GREEN: DUCT ECTESIA
PURULENT: INFECTIONS
SEROUS: FIBROCYSTIC DISEASE
MILK: LACTATION

27. CONGENITAL DISEASES OF THE
BREAST:
•Amazia: congenital absence of the breast.
• It is associated with absence of the sternal potion of the
pectoralis major(POLAND’S SYNDROME)
• More common in males.
•POLYMAZIA: Accessory breasts
•Most commonly occur in axilla, groin
and buttock.

28. • MASTITIS OF INFANTS: Milky secretion on the 3rd
or 4th day of life, if the breast is slightly pressed
down.
• It is physiological.
• Caused by stimulation of fetal breast
by prolactin due to drop in maternal
oestrogen.
• TRUE MASTITIS: Relatively uncommon
caused by staph aureus.

29. •Diffuse Hypertrophy:
•The breast attain enormous dimensions.
•In early puberty or 1st trimester of pregnancy.
•Rarely unilateral
•Due to the alteration of the normal sensitivity of
the breast to oestrogen.
•Treatment: Anti-oestrogens or reduction
mammoplasty.

30. INJURIES OF THE
BREAST:
• H E M ATO M A : G I V E S R I S E TO A L U M P
• T R A U M AT I C FAT N E C R O S I S : M AY B E A C U T E O R
C H R O N I C , U S U A L LY O C C U R S I N S TO U T M I D D L E A G E D
W O M E N .
• F O L LO W I N G A B L O W.
• P R E S E N T S A S A PA I N L E S S L U M P.
• M AY M I M I C A C A R C I N O M A .
• D X : B I O P S Y ( H I S TO R Y O F T R A U M A I S N OT
D I A G N O S T I C )

31. ACUTE AND SUBACUTE
INFLAMMATION OF THE BREAST
• BACTERIAL MASTITIS: Most common variety
• Associated with lactation.
• Caused by S.aurues (mostly staphylococcus
present in the infants nasopharynx)
• PRESENTATION: Classical signs of acute inflam-
mation
• Early on presents as cellulitis later an abscess
will form.
TREATMENT:
1. Antibiotics (flucloxacillin/ co-amoxiclav)

32. • Local heat and Analgesia for pain.
• Infection not resolved for 48 hrs. : Incisi-
on and drainage.
• Or repeated incision using antibiotic
cover.
• TUBERCULOSIS OF THE BREAST:
• Rare.
• Associated with active pulmonary TB
or TB cervical adenitis.
• PRESENTATION: Multiple chronic sinuses
and abscesses.
• Bluish appearance of the surrounding skin.
• DX: Bacteriological and histological examin-
ation.
• TREATMENT: Anti- TB chemotherapy.
• Mastectomy in persistent cases.

33.  M O N DO R’S
D I S EAS EOF T H E
B R EA S T
Thrombophlebitis of the
superficial veins of the chest
and ant. Chest wall.
In the absence of injury
cause is unknown.
PRESENTATION:
Thrombosed subcutaneous
vein .attached to the skin.
When the arms are raised, a
shallow groove appears.
TREATMENT: RESTRICTED
ARM
MOVEMENTS/RESOLVES
SPONTANEOUSLY.

34. DUCT ECTASIA/ PERI-DUCTAL ECTASIA

35. DUCT ECTASIA/PERI DUCTAL MASTITIS:
• It’s a dilation of the breast ducts.
• Often associated with peri-ductal inflammation.
• COMMON IN SMOKERS( increases the virulence of commensal bacteria).
• PATHOGENESIS; Disorder of dilation in one or more lactiferous ducts.
• Which fill with brown or green secretions>discharge> irritation> periductal
mastitis.
• CLINICAL FEATURES:
• Sub areolar mass.
• Nipple discharge.
• Abscess.
• Fistula of mammary duct.
• Nipple retraction(slit like) due to fibrosis.
• TREATMENT: In case of nipple retraction and mass carcinoma must be
excluded
• Antibiotic therapy.
• SURGERY: HADFIELD’S OPERATION( EXCISION OF ALL THE MAJOR DUCTS).

36. CARCINOMA OF
BREASTB R E A S T C A N C E R I S O N E O F T H E L E A D I N G
C A U S E O F D E AT H I N M I D D L E A G E D W O M E N
I N W E S T E R N C O U N T R I E S . T H E I N C I D E N C E I S
T H O U G H T TO C O N T I N U E R I S I N G A LT H O U G H
M O R E S L O W LY T H A N P R E V I O U S LY D U E TO
R E D U C E D U S E O F H R T D R U G S .

37. AETIOLOGICAL FACTORS:
• 1.GEOGRAPHICAL ( mostly occurs in western countries 3-5% death in all
women)
• 2. AGE( extremely rare before age of 20,incidence rises so that at 90yrs
almost 20% are effected)
• 3.GENDER (< 0.5% are male)
• 4. GENETIC( occurs most commonly with family history)
• 5. DIET( alcohol consumption and links with diet low in phyto-oestrogens.
• 6.ENDOCRINE ( most commonly in nulliparous women, post menopausal
obese women, long term use of combined preparation of HRT); ( breast
feeding and having first child at an early age is thought to be protective).
• 7.PREVIOUS RADIATION ( Women who have been treated with mantle
radiotherapy in Hodgkin’s disease, risk appears after a decade of
radiation therapy)

38. PATHOLOGY:
 Breast cancer may arise from the duct system anywhere from the
nipple end of the major lactiferous ducts to the terminal duct unit
, which is the breast lobule.
 Disease maybe entirely in situ.
 Degree of differentiation: 03 grades ( well differentiated,
moderately differentiated or poorly differentiated)
 Commonly, numerical grading system : Based on 3 factors is used
 1. Nuclear pleo-morphism
 2.Tubule formation
 3. Mitotic rate
 With grade 3 equating to poorly differentiated group.
 On the basis of gene analysis 05 types have been identified.

39. INVESTIGATION OF BREAST LUMP
USING FINE NEEDLE CYTOLOGY
• CYSTIC : Lump disappears ,clear fluid Discharge patient
Residual thickening, blood stained fluid. Investigate/core biopsy
• SOLID : Benign Offer excision or observe
Atypical Investigate/ core biopsy
Malignant Treat for cancer.

40. NOMENCLATURE OF BREAST
CANCERS:
• 1.DUCTAL CARCINOMA ( most common variant, DCIS classified using Van Nuys
classification, combines age, type, presence of micro calcifications, extent and size of
disease)
• 2. LOBULAR CARCINOMA( 15% of cases , E-cadherin antibody positive, on immuno-
histochemical assay, multifocal and bi-lateral, MRI for assessment)
• 3.MIXED
• 4.COLLOID OR MUCINOUS CARCINOMA(rare, better prognosis, contains abundant
mucin)
• 5.MEDULLARY CARCINOMA(solid sheets of cells, marked lymphocytic reaction,
• 6.INFLAMMATORY CARCINOMA( rare, highly aggressive, presents as painful, swollen
breast ,warm with edema, mimics an abscess

43. PAGET’S
DISEASE OF
THE
NIPPLE:

44. SPREAD OF BREAST CANCER:
• LOCAL SPREAD: ( Tends to involve the pectoral muscle and chest
wall if dx late)
• LYMPHATIC SPREAD: ( To Axillary and Internal mammary nodes,
involvement of contralateral and supra clavicular nodes represents
advanced stage)
• SPREAD BY THE BLOOD STREAM( via this route skeletal metastasis
occurs)
• Order of frequency ; 1. Lumber vertebrae 2.Femur 3. Thoracic
vertebrae 4.Ribs and Skull.
• Metastasis also commonly occurs in the liver, lungs and brain.

45. CLINICAL PRESENTATION/STAGING:
• Breast cancer is most frequently found in upper outer
quadrant.
• Mostly present as hard lump, with in drawing of nipple.
• Skin maybe involved with peau d’orange appearnce.
• Cancer may involve the chest wall and known as cancer-en-
cuirasse.
• STAGING: by means of TNM( tumor node metastasis) OR UICC
UICC (Union contre le cancer)
• Staging evaluation Includes: careful clinical examination , chest
X ray, CT of the chest and abdomen and isotope bone scan.

47. TREATMENT OF CANCER OF THE
BREAST:
• Two basic principles: 1. To reduce local recurrence 2. To reduce risk of
metastatic spread.
• Early breast cancer: surgery with or without Radiotherapy(local
treatment).
• Systemic therapy i.e. Radiotherapy and chemotherapy is added when
worse prognostic factors present such LN involvement.
• Chemotherapy include Herceptin if Her-2 positive.
• Hormone therapy: if oestrogen receptor or progesterone receptor
positive.
• It’s a Multidisciplinary team approach: Good-patient communication

48. SURGERY:
• Plays a central role.
• Trials have shown equal efficacy between mastectomy and local excision.
• Mastectomy: indicated for large tumours, central tumours beneath or involving the
nipple, multifocal disease, local recurrence.
• MODIFIED PATEY MASTECTOMY: More commonly used.
• The breast and associated structures are dissected en bloc.
• The excised mass is composed of:
• The whole breast
• Large portion of skin, always includes the nipple.
• All of the fat, fascia and LNS of the axilla.
• Pectoralis muscle is either retracted or divided to gain access to the axilla.
• The veins and nerves to the serratus anterior and litissimus dorsi are preserved.
• The wound is drained using wide bore suction tube.
• Early mobilization and physiotherapy is encouraged.

49. CONSERVATIVE BREAST CANCER
SURGERY:• Removes the tumour plus a rim of at least 1cm of breast tissue.
• Commonly referred to as wide local excision.
• Lumpectomy is used for benign tumours excision.
• Quadrectomy: includes removing entire segment of breast containing the
tumour.
• Both of these surgeries include AXILLARY SURGERY via separate incision.
• SENTINAL NODE BIOPSY: Standard in management of the patient in node
negative disease.
• Axillary surgery is done to stage the patient, presence of metastatic
disease in axillary nodes is the best marker for prognosis.
• Higher rate of recurrence even combined with radiotherapy.

50. • RADIOTHERAPY:
• In higher risk patients radiotherapy to the chest wall after mastectomy is indicated.
• Includes large tumours, high risk of recurrence, large no. of positive nodes,or extensive
lympho-vascular invasion.
• Local excision is combined with radiotherapy as excision alone has very high recurrence
rates.
• ADJUVANT SYSTEMIC THERAPY:
• Outcome of the treatment depends on the extent of MICROMETASTATIC DISEASE.
• Systemic therapy targeting these micro-metastasis delays relapse and prolong survival.
• Adjuvant chemo or radiotherapy will improve relapse free survival rate by 30%.
• HORMONE THERAPY:
• Tamoxifen most widely used.
• Reduce annual recurrence by 25%.
• Others agents includes ;LHRH agonists induce reversible ovarian suppression.
• AIs (oral aromatase inhibitors) for post-menopausal women.

51. CHEMOTHERAPY:
• Using first generation regimen such as;
• Six monthly cycle of cyclophosphamide, methotrexate
and 5-flurouracil.
• Reduce 25% reduction in relapse for 10-15 years.
• Anthracycline(doxorubicin) over CMF considered in newer
regimens.
• Follow up:
follow up for life
yearly or two yearly mammography recommended.

52. • PEAU D’ORANGE:
• Resulting from lymphatic obstruction
in advanced breast cancers.
• Cause by cutaneous lymphatic
oedema.
• Appears as purple or red color of the
skin with pitting or thickening of skin,
resembling an orange peel.
• Late edema of the arm is troublesome
complication of breast cancer
treatment.
• Due to lymphatic and venous
blockage.
• Limb elevation, elastic arm stockings
and pneumatic compression devices
are helpful.

53. TREATMENT MODALITIES:
• Breast reconstruction can be
offered immediately after
mastectomy.
• Silicone gel implant under the
pectoralis major muscle.
• Musculocutaneous flap can be
constructed using latissimus dorsi
(LD flap) or tranversus abdominis
muscle (TRAM FLAP).
• Screening: by mammography in
women over 50 yrs is
recommended.

54. CARCINOMA OF THE MALE BREAST:
• Less than 0.5% cases.
• Predisposing causes :
gynaecomastia, endogenous
and exogenous steroids.
• Presents as as LUMP.
• Mostly commonly as infiltrating
ductal carcinoma.
• Treatment : local excision with
mastectomy.