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The Breast examination

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The Breast examination

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    1. The Breast examination Amina Al-Yassin

    3. General points Very common station Can be on a real woman! (or a model) Tests your attitudes, communication and sensitivity as well as clinical competence

    4. History Age: Mastitis, fibroadenoma, carcinoma P/C Lump, skin change, deformity Cyclical symptoms? Symptoms of metastasis? Risk factors* PMH/FH of breast disease Significant co-morbitidites DH: Including OCP Smoking ICE!

    5. Risk factors Oestrogen exposure Female Age at menarche (early) Age at menopause (late) Nulliparous Age of first pregnancy No breastfeeding Taking HRT Other Radiation exposure Age BRCA 1 +2 Family history

    6. Principles of the examination Introduction and Consent CHAPERONE Sensitivity towards the patient Inspection Inspection with different movements Palpation Other parts to examine Thanks

    7. Breast examination Introduction and Consent Full name and role, explain what you want to do Chaperone (females too!) Privacy to undress down to the waist Inspection With the patient sitting With the patient leaning forward Arms above head and push back Push hands into hips- reveals asymmetry What are you looking for? Chaperone- females and males Privacy- down to the waist but minimal exposure at all time MIRROR THE PATIENTS ACTION- Makes them feel less stupidChaperone- females and males Privacy- down to the waist but minimal exposure at all time MIRROR THE PATIENTS ACTION- Makes them feel less stupid

    8. A- Skin hardening B- Pinching C- Skin erosions D- Erythema E- Discharge F- Dimpling G- Mass H- Growing vein I- Nipple retraction J-Asymmetry K- Peu d’orange L- Invisible massA- Skin hardening B- Pinching C- Skin erosions D- Erythema E- Discharge F- Dimpling G- Mass H- Growing vein I- Nipple retraction J-Asymmetry K- Peu d’orange L- Invisible mass

    9. Inspection Asymmetry Obvious masses or scars Obvious LN enlargement Puckering, dimpling, tethering Peau d’orange changes of the skin or any erythema Paget’s disease of the nipple (eczematous) Nipple discharge Signs of previous treatment: scars, radiation burns, telangiectasia, ink marks

    10. Breast scars: TRAM flap The TRAM (transverse rectus abdominis myocutaneous) flap uses abdominal muscle, fat, and skinThe TRAM (transverse rectus abdominis myocutaneous) flap uses abdominal muscle, fat, and skin

    11. Breast scars: Latissmus Dorsi (LD) flap

    12. Breast examination- Lymph nodes Whilst patient sitting on edge of bed, examine lymph nodes Ask about pain before starting! Axillary Cervical Infraclavicular Hold her right arm with your right arm (take the weight) and palpatewith free hand

    13. Cervical Lymph nodes Submental Submandibular Parotid Preauricular Postauricular Occipital Anterior cervical Supraclavicular Posterior cervical

    14. Axillary Lymph nodes Apical Lateral Medial Anterior Posterior

    15. Palpation Patient at 45 degrees Ask patient to point to lump with one finger Any pain? Start with the normal breast One arm behind head Use flats of fingers All 4 quadrants Axillary tail Don’t forget the nipple Ask about discharge- and ask to express it if relevant + take sample for cytology

    16. Palpation methods Vertical strips Radial spoke Circular SweepingVertical strips Radial spoke Circular Sweeping

    17. You’ve found a lump! Position Colour and texture of overlying skin Temperature Tenderness Shape Size Surface Edge

    18. Differential diagnosis Dischargey Duct ectasia and mastitis, duct papilloma and ductal carcinoma in situ Lumpy Cancer (75% ductal, 25% lobular), cysts, fibroadenoma, fibrocystic disease, abscess, fat necrosis, galactocoele, ectopic breast tissue

    19. Breast examination Also examine for: Vertebral tenderness Hepatomegaly (palpate and percuss- get on knees) Pleural effusion Finally: Thank the patient (?) COVER THEM UP Report your findings

    20. Investigations Buzzword: ‘Triple assessment’ Clinical assessment: History and examination Diagnostic imaging by mammography (above 35) or US (below 35). Mammorgaphy: Lateral oblique and cranio-caudal view, look for irregular lumps and calcification Cytology (FNAC) or histology (core biopsy) Later (if cancer): staging and hormone status Cytology looks at cells, and is done via FNA Histology looks at the tissue, and is done via core needle biopsy Cytology looks at cells, and is done via FNA Histology looks at the tissue, and is done via core needle biopsy

    21. Management Cancer staged Stage 1: Unfixed Stage 2: Unfixed and nodal involvement Stage 3: Fixed and nodal involvement Stage 4: Metastatic Stage 1+2: Surgical Mx with wide local excision and identify sentinel nodes (if LN clear= ? if not, do axillary clearance) Radiotherapy Chemotherapy (90-95% patients) ER+ and PR+: Tamoxifen 5 years (best prognosis) Her2-R: Worst prognosis but can have Herception Others: 5FU, Epinbicin, cyclophosphamide

    22. Thanks for listening! Any questions? Email me: aa1708

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