ANATOMY AND PHYSIOLOGY OF REPRODUCTIVE SYSTEM.pptx
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Breast exams.pptx
1. BREAST EXAMS
DR THANA RAM PATEL
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY
DR SN MEDICAL COLLEGE JODHPUR
2.
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6.
7. SCREENING TOOLS
• Clinical Breast examination
• Breast self examination
• Mammography
• Ultrasonography/elastography
• FNAC
• Cytology of nipple discharge
8. BREAST CANCER INCIDENCE
• Most common cancer in women worldwide.
• Most common cause of death from cancer among women.
• More than three fourths of these women in developing countries are
diagnosed in advanced stage of the disease. If these lesions are detected
early, most breast cancers can be effectively treated with good outcome.
• In India 144,937 women were newly detected with breast cancer in 2012, of
which 70,218 women died. Roughly, for every 2 women newly diagnosed
with breast cancer in India, one dies of this disease.
9. WHO TO BE SCREENED
• Women between the ages of 40-60 years of age
• All women identified with a breast mass that has previously not been clinically
evaluated need to be screened for breast cancer
• Women with high Risk factors can be offered screening from age 30 years such as
• Age over 40
• No children or children after 30 years of age
• Mother or sister with breast cancer
• History of breast biopsies or breast cancer
• Initiation of menses before 12 years of age
• Overweight
• Screening to be every 2 years
10. EXAMS
• Introduce yourself (name and position)
• Identity of patient (confirm name and date of birth)
• Informed consent and explain examination: “I’m going to examine your
breasts now. This will involve inspecting and pressing them quite firmly. Is
that OK?”)Note that any intimate examination (including the breast exam)
should bedone with a chaperone present, particularly if the doctor is male
• Privacy- Provide a cover such as a blanket or a hospital gown (with the
opening at thefront) and ensure the curtain or door is firmly closed
• Exposure-You need to be able to compare both breasts visually and then
palpate both breasts in turn. Most women will not have any issue with such
exposure provided you are relaxed and explain fully
• try to ensure your hands are warm
• Pain?Inform the patient they should let you know if you cause them any
discomfort
• Position - Initially sitting on the edge of the couch for inspection. Lying flat
11. CLINICAL BREAST EXAMINATION - TIPS
• Be sensitive to the woman by giving her opportunities to express any concerns before
and during the examination.
• Respect the woman’s sense of privacy.
• If the woman is anxious, assure her that you will do your best to make the examination
comfortable.
• Throughout the examination, approach the woman slowly and avoid any sudden or
unexpected movements.
• Do not rush through the examination. Perform each step gently and ask her if she is
having any discomfort during any part of the examination. Be aware of her facial
expressions and body movements as indications that she is uncomfortable.
• Always take into consideration any cultural factors when deciding what clothing the
woman should remove. Have a clean sheet or drape to cover the woman’s breast if
needed.
• These examinations should be performed in a clean, well-lit, private examination or
procedure room that has a source of clean water. A female assistant should be available
to accompany the woman when a male clinician is the examiner.
12. GETTING READY
• Tell the woman you are going to examine her breasts.
• This is a good time to ask if she has noted any changes in her breasts and whether she
does monthly breast self-examinations. Tell the woman that you will show her how to do
a breast self-examination before she leaves.
• Wash your hands thoroughly with soap and water and dry them with a clean, dry cloth or
allow them to air dry before beginning the examination.
• If there are open sores or nipple discharge, put new examination or high-level
disinfected surgical gloves on both hands.
• Ask the woman to undress till the waist. With the woman undressed from the waist up,
have her sit on the examining table with her arms at her sides.
• Examine both in sitting and lying down position
13. PERFORMING A CBE
• Steps of examination - CBE involves two main parts:
• Inspection to identify physical signs of breast cancer.
• Palpation which involves using the finger pads to physically examine all
areas of breast tissue including lymph nodes (underarm area) to identify
lumps
• 4 positions
• Arms by the side of trunk.
• Raising arms over the head.
• Pressing on the hips.
• Leaning forward.
14. PATIENT EXAMINED IN VARIOUS POSITIONS
• Semi-recumbent lying position (low)- Best position to find the tumor
• Sitting postion
• Hand lifting up position to look for Peau de orange, nipple retraction
• compressing the hands at hip - Alternately contracting and relaxing
the Pectoralis muscle to look for pectoralis major muscle involvement
(fixity) – [Swelling becomes prominent or not ]
• Leaning forward position helps to identify Chest wall involvement
(ribs, IC muscle, serratus anterior).(Breast falls equally on both sides if
not fixed)
17. INSPECTION
• In the sitting position first visually
inspect the breast, initially when
woman is sitting up right with arms on
her hips, and then with her arms raised
over head.
• Note any change in symmetry of breast
shape, size, skin changes–skin
dimpling or retraction or ulceration the
level of both nipples, retraction of
nipple(s), inverted nipple.
•
18.
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22. 2 Skin over breast
• Dilated veins
• Dimple/puckering/retraction
• Peau d’orange
• Nodules
• Ulceration/fungation
31. INSPECTION
4 Areola
• Color
• Size
• Surface
5. Arms and thorax
• Edema
• Nodules
6 Axilla
• Nodes may be seen
7. Supraclavicular fossa
• Fullness in that region
32. • Look at the breasts for shape and
size.
• Note any difference in shape, size,
nipple or skin puckering or dimpling.
Although some difference in size of
the breasts is normal, irregularities
or difference in size and shape may
indicate masses.
• Swelling, increased warmth or
tenderness in either breast may
suggest infection, especially if the
woman is breastfeeding.
33. • Look at the nipples and note their size
and shape and the direction in which
they point (e.g., do her breasts hang
evenly?). Also check for rashes or
sores and any nipple discharge.
• Have the woman first raise her arms
over her head and then press her
hands on her hips to contract her chest
wall (pectoral) muscles. In each
position, inspect the size, shape and
symmetry, nipple or skin puckering or
dimpling of the breast and note any
abnormalities. (These positions will
also show skin puckering or dimpling if
either is present.) Then have the
woman lean forward to see if her
breasts hang evenly.
35. BOUNDARIES OF BREAST EXAMS
• Consider the main area of breast tissue as a rectangle bordered by
the clavicle superiorly, the bra-strap line inferiorly, the
midsternum medially and the midaxillary line laterally
• The tail of the breast extends beyond the midaxillary line into the axilla
and must also be examined carefully
36. PALPATION
• Palpate the normal breast first but while presenting tell the affected side first
• Local temperature and tenderness
• Swelling
• Number
• Site
• size
• Shape
• Margin
• Consistency
• Fluctuation (Cystic swellings only)
• Tenderness
37. PALPATION
• Have the woman lie down on the examining table.
• Placing a pillow under her shoulder on the side being examined will spread the
breast tissue and may help in examining the breast.
• Place a clean sheet or drape over the breast you are not examining.
• Place the woman’s left arm over her head. Look at the left breast to see if it looks
similar to the right breast and whether there is puckering or dimpling.
• Use “Dial of clock method” for palpation, first use the finger pads of the middle three
fingers to palpate the entire breast, in overlapping circular motions, one area at a
time. Repeat both parts of the examination on both the left and rights breasts.
38. WOMAN IN LYING DOWN POSITION
• Light pressure for
superficial breast
tissue
• Medium pressure
for intermediate
layer
• Deep pressure for
tissue close to
chest wall
The finger pads of middle three
fingers should be used to palpate
the breast in circular motion
Palpation pressure
39. PALPATION
Pads of three middle fingers, hand
bowed up
Slide between palpations without
lifting fingers
Dime size circles
JAMA, Vol. 282, No 13, Oct. 1999
40. SPIRAL TECHNIQUE
• Using the pads of your three middle
fingers, palpate the breast using the
spiral technique. Start at the top
outermost edge of the breast. Press
the breast tissue firmly against the
ribcage as you complete each spiral
and gradually move your fingers
toward the areola. Continue this
until you have examined every part
of the breast. Note any lumps or
tenderness.
41. CHECK FOR NIPPLE DISCHARGE
• Using the thumb and index finger,
gently squeeze the nipple of the
breast. Note any discharge: clear,
cloudy or bloody. Any cloudy or bloody
discharge expressed from the nipple
should be noted in the woman’s record.
Although it is normal to have some
cloudy discharge from either or both
breasts up to a year after giving birth or
stopping breastfeeding, rarely it may be
due to cancer, infection or a benign
tumor or cyst. Repeat these steps for
the right breast.
42. AXILLARY TAIL/ LYMPH NODES
• To palpate the tail of the breast, have
the woman sit up and raise her left arm
to shoulder level. If needed, have her
rest her hand on your shoulder. Press
along the outside edge of the pectoral
muscle while gradually moving your
fingers up into the axilla to check for
enlarged lymph nodes or tenderness. It
is essential to include the tail of the
breast in the palpation because this is
where most cancer occurs.
43. DIAL OF A CLOCK METHOD
Palpation will be done in each segment until entire breast is covered.
• Pads of finger (not tips of fingers) of middle three fingers (index, middle and ring) with hand held in slightly bowed
position will be used for palpation.
• In the “dial of a clock” method the whole breast is palpated as if it was a dial of a clock, 12 O’ clock being the highest
point at upper edge of breast just below the midclavicular point and 6 O’ clock being at the inframammary crease. The
palpation is begun at 12 O’clock from periphery to the nipple by describing small circles of about 3 cm in diameter.
Following circular movement of the “pad of fingers” 3 times with increasing pressure and without lifting the fingers, the
next circle is felt towards the nipple , overlapping with the previous circle to about half in diameter. Once the areola and
nipple area is reached, the next segment /sector is palpated at 1-O’clock. The procedure of palpation with “pad of 3
fingers” is repeated sequentially at 2 0’ clock, 3 0’, 4 0’, 5 0’, 6 0’, 7 0’, 8 0’, 9 0’, 10 0’ and 11 0’. If a lump is detected, its
size should be measured using a Vernier caliper. The palpation of mammary ducts is done by gently rolling the ducts
between the index finger and the thumb. Any thickening, tenderness or discharge is noted while palpating the mammary
ducts. In case of retraction of the nipple an attempt is made to pull the nipple forward to see if the nipple could be
brought forward or not and if any lump is present underneath the areola, whether the nipple and the ducts are tethered to
the lump or not. The skin overlying the lump is gently pinched and moved with the fingers to see if the skin could be
moved freely from /off the lump. If the skin is free from the lump but the movement of lump away from skin causes
dimpling of skin, the skin is considered “tethered”. If no movement of skin is possible, it is considered “fixed”. The fixity of
lump to underlying pectoralis major muscle is ascertained by requesting the lady to push her hand against the hip to
contract the muscle and then moving the lump.
44.
45.
46. • Note any discharge from the nipple(s), colour of the discharge, swelling/ lumps,
consistency of the lumps, swelling in the armpit (axillary area), above the collar bone
(supraclavicluar area) and root of the neck (infraclavicular area).
• Repeat this step for the right side.
• After completing the examination, have the woman dress herself. Explain any abnormal
findings and what, if anything, needs to be done. If the examination is entirely normal,
tell her everything is normal and healthy and when she should return for a repeat
examination (i.e., annually or if she finds any changes on breast self-examination).
• The optimal time for a CBE in a premenopausal woman is 5-10 days after the onset of
menses, avoiding the week before the period is preferable. Postmenopausal women
may have CBE performed at any time. On average, the time required to perform a CBE
ranges is 6 to 8 minutes
• Show the woman how to perform breast self-examination.
• Record your findings
47. LYMPH NODE EXAMINATION
• Request the patient to sit on a bed or a stool. For axillary nodes
palpation, pectoralis muscle is relaxed by examiner supporting
patient’s forearm with his own forearm, while facing the patient. The
medial or central, pectoral and lateral axillary nodes were palpated
from in front while supraclavicular, infraclavicular and posterior axillary
nodes were palpated in sitting position with examiner standing behind
the patient.
• Please record the findings of a skin change, nipple change, nipple
discharge, any lump and lymph node enlargement in axilla or neck on
Case record form in a pictorial manner.
48. INTERPRETATION & DOCUMENTATION
The results of CBE will be interpreted in the following ways:
• Normal/negative: No abnormality on visual inspection or palpation
• Abnormal: Definite asymmetric finding on either visual inspection or
palpation. Presence of lump(s) in the breast, any swellings in the
armpit, recent nipple retraction or distortion, skin dimpling or retraction
,ulceration, any nipple discharge
49. WARNING SIGNS
The changes that can be seen are:
Unusual increase in the size of one
breast
One breast hangs unusually lower
Puckering of the skin Dimpling or puckering of a nipple or areola
Swelling in upper arm Change in the appearance of the nipple
Milky or bloody discharge from the
nipple
The changes that can be found on feeling the breasts are:
Lump in the breast Enlargement of lymph nodes in axilla or
neck
50. BREAST SELF EXAMINATION
• It is best to examine your breasts 7–10 days after the first day of the
menstrual period. (This is the time when the breasts are less likely to be
swollen and tender).
• You should examine your breasts every month, even after your
menstrual period has stopped forever. If you are no longer menstruating,
you should pick the same day each month (e.g., the first day of the month)
to examine your breasts.
• Breast self-examination can be done after bathing or before going to sleep.
Examining your breasts as you bathe will allow your hands to move easily
over your wet skin.
51. BREAST SELF EXAMINATION
• First, look at your breasts.
• Stand in front of a mirror with your arms
at your sides and look for any changes
in your breasts. Note any changes in
their size, shape or skin color or if there
is any puckering or dimpling.
• Look at both breasts again, first with
your arms raised above your head and
then with your hands pressed on your
hips to contract your chest muscles.
Bend forward to see if both breasts
hang evenly.
52. BREAST SELF EXAMINATION
• Size, shape, color
• Even ,no distortion
• Swelling
• Dimpling, puckering, bulging of
skin,
• Nipple discharge, position
• Red, sore, rash
54. • Then, feel your breasts.
• You may examine your breasts while standing up or
lying down. If you examine your breasts while lying
down, it will help to place a folded towel or pillow
under the shoulder of the breast you are examining.
• Raise your left arm over your head. Use your right
hand to press firmly on your left breast with the flat
surface (fat pads) of your three middle fingers. Start
at the top of the left breast and move your fingers
around the entire breast in a large spiral or circular
motion. Feel for any lumps or thickening. Continue to
move around the breast in a spiral direction and
inward toward the nipple until you reach the nipple.
• Be sure to check the areas between the breast and
the underarm and the breast and the collarbone.
• Raise your right arm over your head and repeat the
examination for the right breast.
Lie flat, arm below, with opposite hand and
rotatory movements, feel for any irregularity in
breast. Collarbone to abdomen, armpit to
cleavage.
56. WHAT TO LOOK FOR
• A change in the size or shape of the breast.
• A puckering or dimpling of the breast skin.
• A lump or thickening in or near the breast or underarm area. If the lump is smooth or
rubbery and moves under the skin when you push it with your fingers, do not worry about it.
But if it is hard, has an uneven shape and is painless, especially if the lump is in only one
breast and does not move even when you push it, you should report it to your healthcare
provider.
• If your breasts are usually lumpy, you should note how many lumps you feel and their
locations. Next month, you should note if there are any changes in the size or shape (smooth
or irregular). Using the same technique every month will help you know if any changes occur.
• Any nipple discharge that looks like blood or pus, especially if you are not breastfeeding,
should be reported to your healthcare provider.
• There may be some discharge from one or both breasts for up to a year after having a baby
or stopping breastfeeding
57. CLINICAL ALGORITHM
Negative Positive
Evaluation by surgeons
Mammography
Ultrasonography
FNAC
Core biopsy
CBE
Normal
Reentry into primary screening
Suspicious of malignancy
Refer to Medical College/ Regional
Cancer Centre for staging/treatment
63. RISK FACTORS FOR BREAST CANCER
• Female
• Aging
• First degree relative had breast cancer /
ovarian cancer.
• Menstrual history: early onset, late
menopause
• Child birth >30yrs
• Long term HRT, 30% increased risk.
• Oral Contraceptives, risk slight, risk
returns to normal once the use of OC’s
has been discontinued.
• Prior radiation exposure to breast at
young age.
• Breast disease
• Atpyical Hyperplasia
• Intraductal carcinoma in situ
• Intralobular carcinoma in situ
• Obesity, high BMI
• Diet rich in Fats, Alcohol
• Genetic risk factor
• BRCA-1
• BRCA-2
• P53
• Her-2/neu
64. BREAST CANCER RISK ASSESSMENT
Modified Gail model, 7 factors to calculate risk:
• Age>35 years
• First degree relative with breast cancer
• Prior breast biopsies – atypical ductal hyperplasia
• Age at menarche
• Age at first child birth
• Ethinicity
Risk of developing breast cancer is indicated by composite score of relative risk for
each factor.
65.
66. FACTORS THAT INFLUENCE SURVIVAL
• Age at diagnosis
• Tumor size
• Stage at diagnosis
• Biologic characteristics of tumor:
• Hormone receptor status (less
significant)
• HER 2
67. MAMMOGRAPHY
Look for:
• Masses
• Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the
breast that can sometimes indicate an early cancer.
• spiculated appearance
68.
69. THE STAGES OF BREAST CANCER
Breast Cancer is diagnosed according to stages (stages 0 through IV) under the TNM
classification.
Factors used in staging of Breast Cancer:
• Tumor Size
Size of primary tumor
• Nodal status
Indicates presence or absence of cancer cells in lymph nodes
• Metastasis
Indicates if cancer cells have spread from the affected breast to other areas of the
body (i.e. skin, liver, lungs, bone)
Source: National Cancer Institute
70. STAGING BREAST CANCER
Stage 0
Ductal carcinoma in situ (DCIS) is very early breast cancer that has not
spread beyond the duct.
Stage I
Tumor is < 2 cm and has not spread outside the breast.
Stage IIA
No tumor is found in the breast, but cancer is found in the axillary lymph
nodes, or tumor is ≤ 2 cm and has spread to the axillary lymph nodes, or
tumor is 2-5 cm but has not spread to the axillary lymph nodes.
Stage IIB
Tumor is 2-5 cm and has spread to the axillary lymph nodes or is > 5 cm
but still confined to the breast.
Source: National Cancer Institute
71. ADVANCED BREAST CANCER
Stage IIIA
The tumor in the breast is smaller than 5 centimeters and the cancer has spread to underarm
lymph nodes that are attached to each other or to other structures, OR the tumor is more than 5
centimeters across and the cancer has spread to the underarm lymph nodes.
Stage IIIB
Tumor has spread to tissue near the breast (i.e. the skin or chest wall) and may have spread to
lymph nodes within the breast area or under the arm.
Stage IIIC
Tumor has spread to the lymph nodes beneath the collarbone and near the neck, and may have
spread to the lymph nodes within the breast area or under the arm and to the tissues near the
breast.
Stage IV
Tumor has spread to other organs of the body (i.e. lungs, liver, or brain).
Source: National Cancer Institute
72. BREAST CANCER TREATMENT
Surveillance LCIS, DCIS Physical exam, mammography, MRI
Surgery DCIS: Lumpectomy if DCIS in 1 area,
Mastectomy if DCIS in 2 area or large
or multifocal
Radiotherapy DCIS Usually accompanies lumpectomy
Hormonal therapy DCIS In selected ER+ve, for 5yrs lowers
cancer risk.
TNM stage 0
73. BREAST CANCER TREATMENT
Breast conservative Surgery Lumpectomy
Quadrantectomy
Radiotherapy Axillary dissection
Affected breast chest wall
Adjuvant chemotherapy Combination chemotherapy 3-6 mths
Adjuvant Hormonal therapy Premenopausal: tamoxifen in ER+ve,
Postmenopausal: Tamoxifen &
aromatase inhibitor.
TNM stage 1 & 2
74. BREAST CANCER TREATMENT
Surgery Lumpectomy
Mastectomy
Radiotherapy Chest wall, regional lymph nodes
Adjuvant chemotherapy Combination chemotherapy 4-6 mths
Adjuvant Hormonal therapy If ER+ve or PR+ve,
TNM stage 3
75. BREAST CANCER TREATMENT
Surgery Select cases to relieve symptoms
Radiotherapy Select cases to relieve symptoms and
control local disease.
Chemotherapy Primary treatment, single agent or
Combination chemotherapy.
Hormonal therapy If ER+ve or PR+ve,
Monoclonal antibody HER 2 +ve
TNM stage 4
76. LOCAL THERAPY: SURGERY
Local therapy provides adequate control of locoregional disease, includes surgery and
radiotherapy.
Surgery:
• Mastectomy:
Modified radical with sentinel LN evaluation
Radical /total mastectomy with sentinel LN evaluation
May include breast reconstruction
• Breast conservation surgery:
Wide local excision
Quadrantectomy
Lumpectomy , includes axillary dissection if disease invasive.
77. COMPLICATIONS OF SURGERY
• Lymphedema
• 10-305 women who undergo axillary dissection
• 3% if sentinel node biopsy only
• Numbness
• Reduced shoulder mobility
• Psychosocial problems of mastectomy
• Phantom breast sensation
78. LOCAL THERAPY: RADIOTHERAPY
• Adjuvant radiotherapy in ESBC
• Reduces risk of recurrence
• May improve survival
• Radiotherapy in MBC
• Relieves symptoms such as pain, in pts with bone, brain metastasis while not
effecting a cure.
79. RT: METHODS OF DELIVERY
• External beam irradiation, to entire breast.
• Partial breast irradiation, including brachytherapy
• Radioactive seeds/pellets placed internally near site of tumor for local effects.
• Can deliver high dose rate radiation, allowing shorter treatment regimes
compared to traditional RT
• 5yr survival rates comparable to whole breast RT.
80. SYSTEMIC THERAPY FOR BREAST CANCER
• Hormonal therapy
• Chemotherapy
• Targeted therapy
• Clinical trails provide support for optimal implementation for above
therapies in pts with breast cancer.
81. EVOLUTION OF SYSTEMIC ADJUVANT
THERAPY FOR ESBC
Mastectomy alone
Adjuvant CMF
Adjuvant CAF, CEF
Adjuvant AC, EC, FEC
Adjuvant AC + T
Dose dense AC+T TAC
Addition of
Tamoxifen/
Aromatase
inhibitor
Progressive
improvement in
disease free and
overall survival
83. PREFERRED CT: MBC
Single agent options:
• Anthracycline – doxorubicin, epirubicin
• taxane: - paclitaxel, docetaxel
• Capecitabine
• Others – vinoretbine, irinotecan
Combination options
• CAF/FAC -docetaxel, capecitabine
• AT – paclitaxel, gemcitabine
• FEC
• CMF
• AC, EC – paclitaxel, carboplatin, trastuzumab.
• Single drug/combination controversial topic
• Combinations preferred in MBC
• Newer combinations improve outcome &
manageable safety profile
• Sequential therapy may be appropriate for pts
with indolent disease or nonvisceral MBC>
84. SUMMARY: ADJUVANT CT IN ESBC
• Adjuvant CT improves survival inESBC
• Improved survival outcomes demonstrated with CMF
• Regimes with anthracycline or a taxane improve outcome
• Dose dense approach has demonstrated benefit in disease free and
overall survival.
85. TARGETED THERAPY OPTIONS IN BC
• HER2 inhibitor family
• Antibodies
• Trastuzumab
• Small molecules
• Gefitinib
• Erlotinib
• Lapafarnib
• Angiogenesis inhibitor
• Antibodies
• Bevacizumab
86. CONCLUSIONS
• Although breast cancer incidence has increased, mortality rates due to
breast cancer are reducing.
• Advances in conventional therapy include less radical surgery and reduced
radiation field.
• Cytotoxic CT advances include improved types, doses, scheduling.
• Improvements in hormonal therapy.
• Newer target therapy
• Treatment regimes: individualized.
