hx and pe of the breast

1. Clinical Examination of the
Breast
Angeli Andrea Cocos-Alcantara MD
Breast and General Surgeon

2. ANATOMY

4. Blood supply
• (a) perforating branches
• of the internal mammary
artery;
• (b) lateral branches of the
posterior intercostal
arteries; and
• (c) branches from the
axillary artery, including
the highest thoracic,
lateral thoracic, and
pectoral branches of the
thoracoacromial artery

5. Venous drainage
• (a) perforating
branches of the
internal thoracic vein
• (b) perforating
branches of the
posterior intercostal
veins, and
• (c) tributaries of the
axillary vein.
• d) Batson’s vertebral
venous plexus

6. Lymphatic drainage
Six axillary lymph node groups:
LEVEL 1
a. Axillary vein group
b. External mammary group
c. Scapular group
LEVEL II
a. Central group
b. Interpectoral group (rotter’s
nodes)
LEVEL III
a. Subclavicular group

7. Nerve supply
• Medially – anterior branches of
the 1st to 6th intercostal nerves
• Laterally – lateral branches of
the 2nd to 6th intercostal nerves
• Nipple areola complex –
supplied by the anterior branch
of the 4th intercostal nerve (skin
of the nipple areola complex
contains free nerve endings,
Meissner’s corpuscles and
Merkel disc endings)

8. Microscopic anatomy
• Lactiferous ducts- dilated portion of each duct, lined by stratified squamous epithelium.
• Cooper’s suspensory ligament – fibrous band of connective tissue travelling through breast and
inserting into dermis

9. Microscopic anatomy
• The epithelial lining of the
duct shows a gradual
transition to two layers of
cuboidal cells in the
lactiferous sinus and then
becomes a single layer of
columnar or cuboidal
cells through the remainder
of the duct system.
• Myoepithelioid cells of
ectodermal origin are
located within the
epithelium between the
surface epithelial cells and
the basal lamina.

10. HISTORY

11. History
Most common breast complaints
–Breast pain
–Breast mass
–Nipple discharge

12. Mastalgia
• Classified as cyclic (~67-70%) and non-cyclic (~26-30%)
• Etiologies
– Menstrual cycle hormone changes
– Hormonal contraception methods, hormone replacement
– Other medications (antidepressants, digoxin, methyldopa,
spironolactone, chlorpromazine)
– Fibrocystic breast changes

13. Mastalgia
• History
– Cyclic or non-cyclic
– Timing and character
– Unilateral or bilateral
– Quality of pain
• Physical exam
– Comprehensive breast
exam
– Exam of chest wall
• Diagnostics
– Pregnancy test!
– Imaging, to rule out
malignancy
• Differential diagnosis
– Chest wall abnormalities
– Costochondritis
– Pleuritis
– Mastitis
– Shingles

14. Mastalgia
• Management
– Non-pharmacologic measures
• Reassurance!!
• Reduction in caffeine, fat (mixed evidence)
• Wearing a supportive, well-fitting bra (strong evidence)
– Pharmacologic measures
• Danazol, tamoxifen, bromocriptine effective (Danazol only
FDA approved treatment for mastalgia)
– Significant side effects may outweight benefits
• Evening primrose oil, Agnus castus, isoflavones (mixed
evidence)
• Analgesics (eg. Paracetamol)

15. Nipple Discharge
• Physiologic
• -bilateral
• -milky, green or yellow
• -multiple nipple duct openings
• -associated with nipple stimulation
• -resolves spontaneously
• -e.g. Hyperprolactinemia, certain
medications
Pathologic
-unilateral
-bloody
-single-duct
-spontaneous
-persistent
-e.g. Ductal ectasia, papilloma,
infection, DCIS, breast cancer

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

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

18. Physiologic nipple discharge

19. Pathologic nipple discharge
• 80-88% benign (papilloma, ductal ectasia, infection, fibrocystic disease, idiopathic etc)
• 5-21% malignant; increases with age
• diagnostics are needed (mammography, breast ultrasound, ductoscopy, microdochectomy)

20. Approach to Breast
Mass
• History
– Onset, duration
– Other breast symptoms
– Menstrual/medical/family
history
• Physical exam
– Comprehensive breast
exam
• Describe mass
• Tender, moveable, skin
changes
• Lymphadenopathy
• Diagnostic testing
– Age < 40: ultrasound
– Age ≥ 40: mammogram +
ultrasound

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

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

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

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

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

28. Physical Examination
1. INSPECTION
2. PALPATION

29. • 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.

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

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

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

33. • Arms pressing on hips • Leaning forward

35. skin
Skin retraction
Dimpling

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

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

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

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

40. Inspect whole skin
• Raise the breast to inspect the
undermined skin.

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

42. • 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

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

44. •Ask pt. if with
Tenderness
before start
touching them.
•Warm your hands
Tenderness

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

46. 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

47. •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.

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

49. 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

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

51. Examination of Axilla

52. 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

53. Pectoral group Central and apical

54. Posterior group

55. supraclavicular infraclavicular

57. GYNECOMASTIA

59. 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

60. 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

61. 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).

62. 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

64. 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.

68. Mondor’s disease: thrombophlebitis

69. Phyllodes tumor

70. BREAST DRAWING