Clinical Assessment of the Breast

Question 1

What is triple assessment of the breast?

Answer 1

1. Clinical assessment - history and examination
2. Imaging - mammography; ultrasound
3. Pathological assessment - histology (core biopsy); (very rarely now, cytology, FNAC)

Question 2

General questions to ask in breast history?

Answer 2

1. Patient details
2. Family history of breast cancer
3. Smoking history
4. Prescribed medication
5. Allergies
6. Alcohol history
7. History of breast disease
8. Educational background
9. Occupation
10. Past medical history
11. Past hospital admissions
12. HIV status

Question 3

Obstetric history in breast history?

Answer 3

1. Age at first menarche
2. Menstrual history : cycle, date of last period
3. Contraceptive history
4. Age of first pregnancy
5. How many pregnancies
6. History of breast feeding
7. Age at menopause
8. Use of hormone replacement
9. HIV status

Question 4

What should be noted in history of presenting complaint of breast disease?

Answer 4

1. When it was first noticed
2. What made them first notice
3. Pain
4. Associated symptoms
5. What made them present to the clinic
6. How long did they wait to come
7. Why did they wait to come?
   - patient delays or system delays
8. How have they been treating it? Traditional medicine?

Question 5

Components of inspection?

Answer 5

1. Correct positions
2. Clinical signs: shape
3. Clinical signs: skin

Question 6

3 positions for clinical inspection?

Answer 6

1. Erect: at rest
2. Erect: arms elevated
3. Erect: pectorals contracted
   • Akimbo - waist squeeze
   • Akimbo - hip press
   • Prayer position

Question 7

What does the prayer position show?

Answer 7

Skin dimpling may become apparent or be accentuated

Question 8

Clinical signs with regards to the shape of the breast?

Answer 8

1. Symmetry
2. Contour
3. Nipple position

Question 9

Clinical signs with regards to skin on the breast?

Answer 9

1. Dimpling
   - Skin tethering
   - Muscle tethering
2. Peau d’orange
3. Erosion/ulceration/fungation
4. Nipple/areola: retraction/distortion/ inversion/erosion/eczema/oedema

Question 10

Skin dimpling?

Answer 10

sunken pitted area with an uneven texture

Question 11

Skin tethering?

Answer 11

relative to skin, a lump is said to be tethered when it can be moved independently of the skin for a limited distance

Question 12

Muscle tethering?

Answer 12

Mass has invaded the muscle so is now immobile

Question 13

Peu d’orange?

Answer 13

hair follicles become buried in edema giving the skin an orange peel appearance

Question 14

Palpation?

Answer 14

1. Position patient
   - flat on couch
   - arms behind head
   - flatten breast
2. Position yourself
   - flat of middle three fingers, distal third, both hands
3. Superficial palpation
   - stroking round clock
4. Deep palpation
   - rotation - around clock

Question 15

Palpation of the axilla?

Answer 15

1. support elbow (fully, relax pecs)
2. same part of hand as for breast
3. fingertips to top of axilla
4. stroke firmly down ribs

Question 16

Describing a lump?

Answer 16

1. Describing a lump in o’clock position
2. size in two dimensions
3. distance from nipple
4. surface/contour: smooth, irregular etc
5. texture: hard, soft, rubbery etc
6. mobility/fixation
7. tenderness

Question 17

3 finger technique for Palpation?

Answer 17

1. Palpate the breast using the distal part of palmar surface of the middle three fingers, not the finger tips
2. Two hands should be used to support and palpate the breast.
3. If a lump is found, use two hands to assess its characteristics

Question 18

Tethered lesion?

Answer 18

• A tethered lesion is suggestive of locally advanced cancer and occurs when the fibrous strands that radiate between the pectoral fascia and the skin, through the breast tissue are
  shortened.
• These ‘ligaments’ are anchored to the skin so that shortening them puckers the skin and pulls it inwards, although the lesion is still mobile and can be moved independently of the skin.
• A fixed lesion may have spread into the skin itself so that the mass cannot be moved independently of the skin and implies more advanced local disease
• Alternatively it may have invaded the muscle and so is fixed to the muscle. Note: You must distinguish between
  skin and muscle fixation.

Question 19

Nipple discharge?

Answer 19

• During breast examination DO NOT routinely squeeze nipples in women who have no complaint of nipple discharge (and then only with specific consent):

Question 20

History of nipple discharge?

Answer 20

1. Investigate all women with new discharge >50yrs
2. Investigate women under 50 with
   - bloodstained discharge
   - spontaneous uniduct discharge
   - bilateral discharge sufficient to stain clothes
3. Examine and if normal (2/3 NORMAL WOMEN HAVE BILATERAL MULTIDUCT DISCHARGE) => reassure
   Note: this physiological discharge may range from clear through
   cream/yellow/green to almost black
4. Any abnormality on examination, proceed to triple assessment