Breast Examination

Question 1

What is the following clinical sign and what does it indicate?

Answer 1

lumpectomy (small scar)

Question 2

What is the following clinical sign and what does it indicate?

Answer 2

mastectomy (large diagonal scar).

Question 3

What is the following clinical sign and what does it indicate?

Answer 3

Nipple inversion is a normal finding in a significant proportion of women (e.g. congenital or weight-loss associated nipple inversion). However, if nipple inversion develops without a clear precipitant, the possibility of underlying pathology should be considered. Possible pathological causes of nipple inversion include breast cancer, breast abscess, mammary duct ectasia and mastitis.

Question 4

What does nipple discharge suggest?

Answer 4

Nipple discharge is benign is most cases (e.g. pregnancy, breast-feeding) however less commonly it can be associated with mastitis or underlying breast cancer (rare).

Question 5

What is the following clinical sign and what does it indicate?

Answer 5

Scaling of the nipple and/or areola associated with erythema and pruritis are typical features of Paget’s disease of the breast (see the example image). Paget’s disease is associated with underlying in-situ or invasive carcinoma of the breast.

Question 6

What is the following clinical sign and what does it indicate?

Answer 6

Puckering of breast tissue is typically associated with invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards.

Question 7

What can cause erythema of the breast?

Answer 7

Erythema of the breast tissue has a wide range of causes including infection (e.g. mastitis or breast abscess), trauma (e.g. fat necrosis) and underlying breast cancer.

Question 8

What is the following clinical sign and what does it indicate?

Answer 8

Peau d’orange (dimpling of the skin resembling an orange peel) occurs due to cutaenous lymphatic oedema. The dimples represent tethering of the swollen skin to hair follicles and sweat glands. Peau d’orange is typically associated with inflammatory breast cancer.

Question 9

What is tethering and what does it indicate?

Answer 9

Repeat inspection with the patient pressing their hands into their hips to contract the pectoralis muscles.

If a mass is visible, observe if it moves when the pectoralis muscle contracts which suggests tethering to the underlying tissue (e.g. invasive breast malignancy).

Question 10

If a breast lump is detected, what charachterestics should you assess?

Answer 10

• Location
• Size
• Shape
• Consistency
• Mobility
• Fluctuance
• Overlying skin changes

Question 11

How would you describe the location of a breast lump?

Answer 11

Location

Which quadrant of the breast is the mass located within?

How far away from the nipple is the mass located?

Question 12

How would you describe Size and shape of a breast lump?

Answer 12

Size and shape

What are the approximate dimensions of the mass?

What shape is the mass?

Question 13

How would you describe Consistency of a breast lump?

Answer 13

Consistency

What is the consistency of the mass on palpation? (e.g. smooth/firm/stony/rubbery)

Question 14

How would you describe Overlying skin changes of a breast lump?

Answer 14

Overlying skin changes

Are there any changes to the skin overlying the mass? (e.g. erythema/puckering)

Question 15

How would you describe Mobility of a breast lump?

Answer 15

Mobility

Assess the degree of mobility the mass has:

Does it move freely?

Does it move with the overlying skin?

Does it move with pectoral contraction?

Question 16

How would you describe Fluctuance of a breast lump?

Answer 16

Fluctuance

Hold the mass by its sides and then apply pressure to the centre of the mass with another finger. If the mass is fluid-filled (e.g. cyst) then you should feel the sides bulging outwards.

Question 17

If nipple discharge is present, what should you note?

Answer 17

• Colour (e.g. blood-stained, green, yellow)
• Consistency (e.g. thick, watery)
• Volume

Question 18

What does milky discharge indicate?

Answer 18

Milky discharge: normal during pregnancy and when breastfeeding (bilateral). Galactorrhoea (nonpuerperal lactation) is pathological and caused by the presence of a prolactinoma.

Question 19

What does purulent discharge suggest?

Answer 19

Purulent discharge: thick yellow, green or brown discharge with an offensive smell. Possible causes include mastitis and central breast abscess.

Question 20

What does watery and bloody discharge suggest?

Answer 20

Watery and bloody discharge: several possible causes however ductal carcinoma in situ is the most important diagnosis to consider.

Question 21

What do Enlarged, hard, irregular lymph nodes suggest?

Answer 21

Enlarged, hard, irregular lymph nodes are suggestive of metastatic spread.

Question 22

What further investigations/ examinations would you do?

Answer 22

Mammography: typically used in patients over the age of 35.

Ultrasound: typically used in patients under the age of 35 due to increased density of breast tissue making mammography less effective.

Biopsy: fine-needle aspiration or core biopsy may be considered if a breast lump needs further histological assessment.