This document provides information about breast examination techniques and breast conditions. It discusses taking a history, performing a physical exam including inspection and palpation of the breasts and lymph nodes, and triple assessment with imaging and tissue sampling. Common benign breast conditions like fibroadenomas and cysts are explained. Breast cancer risk factors, staging, and treatment options including surgery, radiation, chemotherapy, and endocrine therapy are outlined.

1. DEPARTMENT OF MIDWIFERY
GROUP ASSIGNMENT
TITTLE:- BRAST EXAMINATION
GROUP MEMBERS
1.ABDULHAKIM MOHAMMED
2.BELAYNEW ASHAGIRE
3.WORKU BELAYNEW
4.
MINILIK II MEDICAL AND
🚑 HEALTH SCIENCE 🚑
🎓 COLLEGE 🎓

2. Breast Examination

3. Topics
• Breast history
• Examination
• Investigations
• Breast conditions
– Benign / Malignant
• Treatment

4. History
• Presenting complaint is important
• Lump;
– always ask how long been present
– Relation to menstrual cycle
– Does its size vary? Is it getting larger?
• Pain;
– Is it cyclical? Is the lump painful?

5. • Nipple discharge; ascertain
– Colour, Quantity, pattern, frequency
• Age of patient; cancers are uncommon
<30yrs, but fibroadenomas are
• Ask if noticed any;
– Nipple retraction
– Breast distortion
– Metastatic related symptoms
• Previous breast disease
– Was it investigated / treated

6. • Family history
– Genetics; 5-10% are inherited dominantly
• They have early onset & associated with other tumours
e.g. Bowel, ovarian.
• BRCA1 (chromosome 17q21)
• BRCA2 (chromosome 13q24)
• P53 gene chromosome 17
• Medications; HRT, pill
• Gynae / Obstetric Hx;
– Menarche, menses
– Parity? When? After 30 increases risk

7. Examination
• Introduce yourself to patient
• Undress to waist, sit on couch at 45 degrees
• Maintain patient dignity e.g. Bed sheet
• Assess in following positions
– Patient’s hands behind their head (accentuate lumps,
asymmetry, tethering)
– Pushing against their hips (accentuate lumps attached
to pectoralis muscle)
– Patient leaning over side of bed (accentuate
abnormalities in large breasts)
• Exam good breast first, then the ‘diseased’ breast

8. • Inspection
– 6 S’s
• Site
• Size
• Shape
• Symmetry
• overlying Skin
• associated Scars
• Fungation; comment on presence of fungating carcinoma
(check inframammory fold)
• Asymmetry; carcinoma may be present in higher breast
• Tethering; due to infiltration of ligaments of Astley-Cooper
• Peau d’orange; micro-oedema
• Lymphoedema; may indicate lymphatic infiltration by
carcinoma or previous surgery with LN removal
• Erythema

9. • Nipple signs; 6 D’s
Paget’s Disease Depression Deviation
Discharge Displacement Destruction

10. • Palpation
– Ask about pain and if patient has a lump.
– Examine good breast first then diseased breast
– Patient puts hand behind head on exam side
– Check for temperature change
– Use following with lumps;
• Surface
• Edge
• Consistency (hard, firm, soft)
• Fixity to skin and underlying structures
• Fluctuance
• Pulsatility and expansility
• Transilluminability
• Reducibility

11. • Palpate using palmar surfaces of index, middle
& ring fingers of both hands, sweeping down
clock face positions.
– N.B. Most carcinomas present in upper, outer
quadrant

12. • Remember;
– Inframammary fold
– Axillary tail of Spence
– Nipple discharge (explain important to check for
discharge, gain permission, gain permission)

13. • Axillary lymphadenopathy
– Support their arm with your corresponding arm
e.g. Patients right arm with you right arm and
palpate with your left hand
– Examine anterior, posterior, medial and lateral
walls in addition to the apex
• Medial wall (seratus anterior)
• Lateral wall (body of humerus)
• Anterior wall (pectoralis major)
• Posterior wall (latisimus dorsi)
• Apices (arch of armpit – high in the head of the
humerus)

14. • Cervical and supraclavicular lymphadenopathy
• Always cover the patient when examination
complete and thank the patient.
• For completion;
• Respiratory exam; ?mets
• Abdomen exam; palpate liver (if hepatomegaly
think mets)
• Spinal exam; tenderness ? Mets
• Encourage self exam; encourage patient to
regularly monitor their breasts using simple
examination infront of a mirror
• Triple Assessment; If lump detected continue to
this

15. Triple Assessment
1. Clinical Examination
2. Imaging; Mammogram (false negative rate
10% / USS (in <40yr)

16. 3. Tissue Sampling;
- FNAC (cytology exam of aspirate, can have 95%
sensitivity)
- Core Biopsy
- Open Biopsy

17. Breast Disease
• Classify as benign or malignant
– Benign aetiology classified as Aberrations of
normal development and involution (ANDI)
Peak Age (years)
15-25 Development Fibroadenoma & excessive Breast
development
25-40 Cyclical Hormonal Cyclical nodularity & mastalgia
35-55 Involution Lobular:
Ductal:
Epithelial:
Cyst
Duct ectasia & periductal mastitis
Hyperplasia & fibrosis

18. • What is a fibroadenoma?
– Most common benign neoplasm. Fibroepithelial
tumour, composed of glandular tissue & stroma.
– Peak onset 15-25yrs.
– Painless, smooth, firm, rubbery lump, highly mobile.
– Approx 10% resolve spontaneously within 1yr
• What are breast cysts?
– Fluid-filled, distended & involuted lobules.
– Present as smooth lumps. Maybe painful
– Peak age onset 35-55yr.
– FNA may relieve symptoms and can be analysed

19. • What are cyclical nodularity & mastalgia?
– Affect pre-menopausal females & are hormonal
dependent.
– Cyclical breast changes occur, result lumps
(nodularity) & pain (mastalgia) related to
menstrual cycle.
– Treatment options classified as;
Conservative Medical Surgical
Reassurance Evening primrose oil Mastectomy (for
treatment resistant
severe mastalgia)
Firm supporting bra Analgesia
Evening primrose oil OCP
Danazol
Bromocriptin
Tamoxifen

20. • What is duct ectasia?
– Involution & dilatation of subareolar ducts
– Clinical features; nipple inversion, nipple discharge
(may be cheese / blood stained), subareolar mass,
mastalgia.
• What is periductal mastitis?
– Inflammation, often due to infection of subareolar
ducts.
– May present like duct ectasia
– Pus discharge from nipple & mastalgia

21. • What is epithelial hyperplasia?
– Increase no. of epithelial lining cells of the
terminal lobular unit.
– Atypical dyplasia increased risk of progression to
carcinoma.
• What is fat necrosis?
– Often after trauma to fatty breast tisssue e.g.
Surgery / breastfeeding.
– Inflammation, fibrosis & calcification may occur
– Can be similar to carcinoma
– Most cases resolve spontaneouly

22. • Classification of breast tumours
Benign Pre-Malignant / in situ Malignant / Invasive
Fibroadenoma Ductal carcinoma in situ Invasive Ductal Carcinoma
(80% of invasive)
Intraductal Papilloma Lobular carcinoma in situ Invasive Lobular Carcinoma
(10% invasive)
Lipoma Invasive Medullary,
Mucinous, Tubular &
Papillary Carcinomas (10%
invasive)

23. Breast Cancer
• Incidence 1:11
• Age; rare <30yr
• Risk factors;
– Early menarche, late menopause
– 1st child >30yr
– FHx in 1st degree relative
– Hx of breast feeding
– Prev breat ca
– Radiation exposure
– Exogenous hormones
– High intake of saturated fats, alcohol

24. • Staging of cancer
– Bloods; FBC, LFTs, U&Es, ALP, Ca2+, ESR
– CXR
– 2nd line investigation; Liver USS, bone scan, CT-scan, axillary node
staging
– Clinical staging – TMN
• Tis (no tumour palpable) CIS / Paget’s
• T1 < 2cm. No skin fixation
• T2 2-5cm. Skin distortion
• T3 5-10cm. Ulceration + pectoral fixation
• T4 >10cm. Chest wall extension, skin involved.
• N0 No nodes
• N1 Ipsilateral mobile nodes
• N2 Ipsilateral fixed nodes
• N3 Internal mammary nodes
• M0 no mets
• M1 Mets in liver, lung, bone

25. Treatment
• Surgical;
– WLE plus DXT (need 1cm excision margin)
– Mastectomy
– Axillary sampling (removal of lower axillary nodes)
– Axillary clearance (removal of contents below the
level of the axillary vein)
• Level 1 = below pec minor
• Level 2 = behind pec minor
• Level 3 = above pec minor (full clearance)
– SLNB

26. • Systemic treatment
– Can be adjuvant or neo-adjuvant
1. Radiotherapy
- Breast and chest wall
- Axilla
- Palliation (e.g. For bony tenderness)
2. Chemotherapy
- Recurrent disease
- <70yr with > 1 +ive axillary node
- Very large tumours

27. • 3. Endocrine therapy and Tamoxifen
– Tamoxifen in ER + ive females
– Up to 15% of ER –ive females also respond
– Beneficial in pre- and postmenopausal women,
not effective in ER –ive premenopausals
– Increased risk of endometrial carcinoma
– Aromatase enzyme inhibitor = Anastrazole
(Arimidex)
• For post-menopausal women ER +ive