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  1. 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. 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. 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
  5. 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. 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. 7. Assessing the Breasts  Obtain a breast history.  Perform a breast physical assessment. Differentiate between normal and abnormal findings.
  8. 8. History taking & clinical examination
  10. 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. 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. 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. 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. 14. Changes in nipples: Retraction of nipple Inversion of nipple
  15. 15. Retraction of nipple: differentiating from nipple inversion a retracted nipple appears flat & broad An inverted nipple can be pulled out
  16. 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
  18. 18. Symptoms related to distant metastases : Localizing neurologic signs ,Altered cognitive function. Breathing difficulties Abdominal distension ,Jaundice  Bone pain
  20. 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. 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. 22. Examination of breast SBE:Self breast examination CBE: Clinical breast examination
  23. 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. 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. 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. 26. Clinical breast examination Inspection: Palpation Lymph node examination Examination to rule out metastasis expose up to waist  maintain privacy
  27. 27. Inspection: various positions & their importance
  28. 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. 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. 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. 31. Arms overhead Arms raised straight above head makes the lump or dimple more marked.
  32. 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. 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. 34. ON INSPECTION OF BREAST.. Areola: color, size, surface, montgomery’s tubercles Skin over breast: color ,texture, engorged veins, Peau d’ orange
  35. 35. On inspection… Note the retraction of left nipple due to presence of carcinoma in upper outer quadrant ;swelling seen
  36. 36. Fungated carcinoma in breast with axillary lymphadenopathy On inspection..
  37. 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. 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. 39. • Use the finger pads of the 2nd, 3rd, and 4th fingers, keeping the fingers flat. It is important to be systematic.
  40. 40. Technique of palpation • Palpate the breasts using one of the three different patterns • circular or clockwise, • wedge, • vertical strip.
  41. 41. Levels of palpation Vary the level of pressure LIGHT – superficial MEDIUM – mid-level tissue Deep – to the ribs
  42. 42. Palpation :Supine with shoulder support, Vertical Strip Method Preferred Use pads of fingers of dominant hand
  44. 44. Bimanual palpation
  46. 46. PALPATION FOR THE NIPPLES: press the areola to see any discharge Bloody discharge is seen in papilloma & breast carcinoma
  47. 47. PALPATION FOR THE LUMPECTOMY OR MASTECTOMY SITE • Mastectomy or lumpectomy scar • Lymphedema • Signs of inflammation
  48. 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. 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. 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. 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. 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. 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. 54. fixity to chest wall • If the tumor is fixed irrespective of contraction of any muscle: it is fixed to chest wall
  55. 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. 56. Gezira 2005 Motwakil. A. H. Moneer what about the Characteristics of Discharge?
  57. 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. 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. 59. Brawny edema of arm due to extensive neoplastic infiltration of axillary Lymph node
  60. 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. 61. Inflammatory carcinoma breast
  62. 62. Breast cancer presenting with unilateral enlargement of the nipple in a middle aged woman
  63. 63. Breast lump. Note the breast lump with inverted, elevated nipple. Note also the prominent blood vessels suggesting neo-angiogenesis
  64. 64. Paget’s disease: Ulcerated nipple in a middle aged woman
  65. 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. 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. 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. 68. Axillary LN examination • Axillary lymph node groups • Pectoral group • Brachial group • Subscapular group • Central group • Apical group
  69. 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. 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. 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. 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. 73. SUBSCAPULAR NODES • The nodes are palpated along antero-internal surface of post. axillary fold with palm of examining hand looking backwards
  74. 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. 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. 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. 77. Palpation of supra clavicular node
  78. 78. 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
  79. 79. 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. 81. Thank you