Examination of the Breast

Physical examination of the breasts is important both in the evaluation of a breast complaint and screening for asymptomatic breast pathology such as a breast mass. The examination involves inspection of the breasts to look for asymmetry or skin/nipple changes, as well as palpation of the breasts, nipples, and axilla. Coupled with medical history, the outcome of a breast examination can be normal, lead to a clinical diagnosis (e.g., infection), or require additional diagnostic evaluation (e.g., the evaluation of a palpable breast mass or skin/nipple changes).

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Table of Contents

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Introduction

Informed consent

  • To start, the practitioner should:
    • Explain the indication for the breast examination.
    • Describe the steps of the examination and what to expect.
    • Review what information might be obtained during the exam and subsequent steps for further evaluation if needed.
  • The practitioner should ensure the individual has good understanding, questions are answered, and agrees to proceed with the examination.
  • Given the sensitivity of the breast exam, a chaperone may be present in the room during the examination for the individual’s comfort.

Positioning for the exam

  • The individual is examined in both the sitting and supine positions.
  • The practitioner should be positioned: 
    • In front of the individual when examining in the sitting position 
    • To the right of the individual when examining in the supine position
  • Ensure good lighting and privacy.
  • Practice proper draping to preserve modesty.

Components of the breast examination

  • Inspection 
  • Palpation

Anatomy

The anatomy of the breast and axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus as well as the relationship to the thorax should be reviewed before starting. Knowledge of the underlying tissue anatomy makes interpreting and describing the findings easier.

  • Structures include:
    • Skin
    • Nipple
    • Areola
    • Ducts
    • Lobules
    • Fatty tissue
    • Lymph nodes
  • Breast tissue: 
    • Lies against the anterior thoracic wall, extending from the clavicle and 2nd rib down to the 6th rib, and from the sternum across to the midaxillary line.
    • Consists of proportionally more glandular tissue in premenopausal women, and fatty tissue in postmenopausal women (when glandular tissue regresses)
  • Axilla:
    • Axillary tail of breast tissue
    • Lymphatics

Inspection

Inspection

  • With the individual seated, undressed from the waist up, breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts exposed, and arms relaxed, observe for:
    • Scars: may indicate previous surgery (e.g., breast augmentation, breast reduction, lumpectomy, or mastectomy)
    • Asymmetry: breast outline/contour and bulging areas (may represent an underlying mass)
    • Skin changes: dimpling or retraction, edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema, ulceration, erythema, or eczematous appearance (e.g., scaly, thick, raw skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin)
    • Nipple changes: symmetry, inversion, retraction, nipple discharge, or crusting
  • The individual raises the hands over and behind the head: Observe for tethering of breast tissue to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall.
  • The individual places the hands on the hips and leans forward:
    • The position contracts the pectoralis muscle, which accentuates puckering of skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin if a mass is tethered to the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall.
    • Observe for any areas of retraction.

Skin changes associated with breast pathology

  • Puckering of breast tissue: underlying malignancy invading the suspensory ligaments 
  • Peau d’orange: 
    • Dimpling of the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin resembling an orange peel
    • Associated with inflammatory breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer
  • Erythema: 
    • Area of redness and often breast tenderness
    • Differential diagnosis includes:
      • Infection: mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis (particularly if nursing), cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis, or abscess
      • Trauma
      • Breast cancer
Inspection of the breasts highlighting skin dimpling (peau d’orange)

Inspection of the breasts Breasts The breasts are found on the anterior thoracic wall and consist of mammary glands surrounded by connective tissue. The mammary glands are modified apocrine sweat glands that produce milk, which serves as nutrition for infants. Breasts are rudimentary and usually nonfunctioning in men. Breasts highlighting skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin dimpling (peau d’orange)

Image by Lecturio.

Nipple findings

  • Differential diagnosis of nipple/areolar scaling associated with erythema and pruritus includes:
    • Paget disease
    • Eczema Eczema Atopic dermatitis, also known as eczema, is a chronic, relapsing, pruritic, inflammatory skin disease that occurs more frequently in children, although adults can also be affected. The condition is often associated with elevated serum levels of IgE and a personal or family history of atopy. Skin dryness, erythema, oozing, crusting, and lichenification are present. Atopic Dermatitis (Eczema)
    • Psoriasis Psoriasis Psoriasis is a common T-cell-mediated inflammatory skin condition. The etiology is unknown, but is thought to be due to genetic inheritance and environmental triggers. There are 4 major subtypes, with the most common form being chronic plaque psoriasis. Psoriasis
  • Nipple inversion:
    • Can be a normal finding
    • Possible underlying pathological causes:
      • Breast cancer
      • Breast abscess
      • Mastitis
      • Mammary duct ectasia
  • Accessory nipple(s):
    • Congenital, extra nipple(s) along the mammary line
    • Usually a benign finding
  • Nipple discharge: 
    • Note if the discharge is spontaneous or only present when expressed with palpation of the nipple/areolar complex.
    • Potential causes of breast discharge:
      • Milky discharge:
        • Normal in pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding
        • Medications: oral contraceptives, antidepressants, and antipsychotics 
        • Pituitary tumor (i.e., prolactinoma)
      • Purulent discharge:
        • Mastitis
        • Central breast abscess
      • Bloody discharge:
        • Breast cancer (rare)
        • Ductal carcinoma in situ
        • Intraductal papilloma
        • Mammary duct ectasia

Palpation

Positioning

  • The individual lies supine with the ipsilateral arm Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). Arm raised overhead and shoulders resting on the exam table. 
  • The position stretches out breast tissue against the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall making palpation easier.

Draping

To preserve modesty, cover the individual with an extra gown/sheet and expose only the breast to be examined.

Palpation technique

  • Includes the breast and axillary tail (also known as the tail of Spence), the part of the breast extending into the axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus
  • Palpation procedure:
    • Use small, overlapping, concentric circles with the pads (not the tips) of the middle 3 fingers.
    • Start at the axillary tail and move toward the anterior axillary line.
    • Overlap concentric circles in a vertical strip pattern (lawnmower approach) to cover the entire breast; the breast tissue extends from the sternum to the midaxillary line, and from the 2nd rib (clavicle) to the 6th rib.
  • Perform palpation at 3 depths:
    • Superficial, medium, and deep layers of the breast 
    • Use light, medium, and deep pressure in each area.
    • Include palpation of the subareolar tissue.
  • Palpate the nipple-areola complex to assess for nipple discharge:
    • Place the pad of the index finger in radial positions around the nipple, compressing the areolar tissue towards the nipple.
    • Note expression of discharge from any of the duct openings.
  • Palpation technique for regional lymph nodes:
    • Axillary nodes:
      • Lay the individual supine with relaxed shoulders.
      • When examining the right axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus, the individual’s right forearm Forearm The forearm is the region of the upper limb between the elbow and the wrist. The term "forearm" is used in anatomy to distinguish this area from the arm, a term that is commonly used to describe the entire upper limb. The forearm consists of 2 long bones (the radius and the ulna), the interosseous membrane, and multiple arteries, nerves, and muscles. Forearm should be held with the right hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand and palpated with the left hand Hand The hand constitutes the distal part of the upper limb and provides the fine, precise movements needed in activities of daily living. It consists of 5 metacarpal bones and 14 phalanges, as well as numerous muscles innervated by the median and ulnar nerves. Hand (vice versa for examination of the left axilla Axilla The axilla is a pyramid-shaped space located between the upper thorax and the arm. The axilla has a base, an apex, and 4 walls (anterior, medial, lateral, posterior). The base of the pyramid is made up of the axillary skin. The apex is the axillary inlet, located between the 1st rib, superior border of the scapula, and clavicle. Axilla and Brachial Plexus).
    • Supraclavicular nodes:
      • Start medially in the supraclavicular fossa.
      • Work outwards towards the lateral border.
    • Infraclavicular nodes:
      • Start medially, inferior to the clavicle.
      • Work laterally.

Describe and Report Findings

Describe findings accurately to allow the practitioner to monitor for changes and, when imaging is required, communicate findings to the radiologist.

Inspection

  • Symmetry or asymmetry
  • Any skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin changes
  • Any nipple changes

Palpation

  • Describe masses or changes in the texture of the breast tissue:
    • Size in cm
    • Location:
      • Quadrant of the breast and distance from the nipple in cm 
      • Quadrant of the breast: upper outer, upper inner, lower outer, and lower inner
      • May also be described by numbers on a clockface and distance from the nipple
    • Shape: round, disc-like or irregular in contour
    • Consistency: soft, firm, or hard
    • Delimitation: well-circumscribed or not
    • Tenderness
    • Fluctuance
    • Mobility: fixed or mobile:
      • Moves freely
      • Moves with overlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin
      • Moves with pectoral contraction
  • Describe any overlying skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin changes (e.g., erythema or puckering).
  • Describe any nipple discharge:
    • Color (e.g., milky, green, yellow, or bloody)
    • Consistency (e.g., thick or watery)
    • Quantity
  • Describe any palpable lymph nodes:
    • Size in cm
    • Location: axillary, supraclavicular, or infraclavicular
    • Consistency: soft, firm, or hard
    • Tender or nontender
    • Fluctuance
    • Mobility: fixed or mobile

Important conditions

Table: Common breast masses
Fibroadenoma Fibroadenoma Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenoma Fibrocystic changes Breast cancer
Usual age 15–35 years old 30–50 years old with regression after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause (except on estrogen replacement therapy) 30–90 years old (most common over the age of 50)
Number Usually single but may be multiple Single or multiple Usually single although may coexist with other nodules
Shape Round, small Round Irregular or stellate
Consistency Firm Soft to firm, usually elastic Firm or hard
Delimitation Well-delineated Well-delineated Not clearly delineated from surrounding tissues
Mobility Mobile Mobile May be fixed to the skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin or underlying tissues
Tenderness Usually nontender Often tender Usually nontender
Retraction signs Absent Absent May be present

Clinical Relevance

  • Fibroadenoma Fibroadenoma Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenoma: the most common benign breast tumor. The etiology is unknown, but a hormonal relationship exists. Exam findings include a well-defined, mobile, firm mass. A diagnosis is made using a core biopsy. Most fibroadenomas do not require intervention, but surgical excision may be indicated to confirm the diagnosis.
  • Breast cancer: the most commonly diagnosed malignancy globally (surpassing lung cancer Lung cancer Lung cancer is the malignant transformation of lung tissue and the leading cause of cancer-related deaths. The majority of cases are associated with long-term smoking. The disease is generally classified histologically as either small cell lung cancer or non-small cell lung cancer. Symptoms include cough, dyspnea, weight loss, and chest discomfort. Lung Cancer). A hard, immobile, single, dominant mass with irregular borders on exam, which requires further evaluation with imaging studies and biopsy. Suspicion for cancer can also be raised on screening mammography in the absence of a palpable mass. Management includes surgical removal (lumpectomy or mastectomy) and may also include chemotherapy, radiation, and/or hormone therapy.
  • Mastitis: lactational or nonlactational inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of breast tissue, which may or may not be accompanied by infection. Mastitis is often caused by a blocked milk duct. Exam findings include erythema, swelling, induration, tenderness, and warmth to the touch. Diagnosis is clinical. Management is symptomatic of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain and swelling, complete emptying of the breast (lactational), and sometimes antibiotic therapy.
  • Breast abscess: a localized collection of inflammatory exudate in the breast tissue. A breast abscess is the 1st sign of a breast infection, or a consequence of mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis or cellulitis Cellulitis Cellulitis is a common infection caused by bacteria that affects the dermis and subcutaneous tissue of the skin. It is frequently caused by Staphylococcus aureus and Streptococcus pyogenes. The skin infection presents as an erythematous and edematous area with warmth and tenderness. Cellulitis not responding to antibiotic treatment. Exam findings include a fluctuant, tender, palpable mass. Diagnosis is made clinically and can be confirmed via ultrasonography. Management is by incision and drainage or ultrasound-guided aspiration. 
  • Paget disease of the breast: a rare breast carcinoma presenting with scaly, itching, bleeding or ulcerative lesions, beginning on the nipple and spreading to the areola. Exam findings include scaling of the nipple/areola and occasionally bloody nipple discharge. Diagnosis is made by biopsy. Management is by surgery and may include chemotherapy and/or radiation therapy.
  • Galactorrhea: milky, unilateral or bilateral nipple discharge unrelated to breastfeeding Breastfeeding Breastfeeding is often the primary source of nutrition for the newborn. During pregnancy, hormonal stimulation causes the number and size of mammary glands in the breast to significantly increase. After delivery, prolactin stimulates milk production, while oxytocin stimulates milk expulsion through the lactiferous ducts, where it is sucked out through the nipple by the infant. Breastfeeding. Common causes include excessive breast stimulation, benign pituitary tumor (prolactinoma), hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto's disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism, and medications. Management involves addressing the underlying cause.

References

  1. Potter, L. (2021). Breast examination – OSCE guide. Geeky Medics. Retrieved from https://geekymedics.com/breast-examination-osce-guide/
  2. Bickley, L.S. (2017). The Breasts and Axillae. Bates’ Guide to Physical Examination and History Taking (12th edition, pp. 419-445).
  3. Drake W.M. et al. (2018). General patient examination and differential diagnosis. In Glynn M. et al. (Ed.), Hutchison’s Clinical Methods (24th edition, pp. 26-27)
  4. Sabel, M.S. (2021). Clinical manifestations, differential diagnosis, and clinical evaluation of a palpable breast mass. In Chagpar A.B. et al. (Ed.), UpToDate. Retrieved October 4, 2021, from: https://www.uptodate.com/contents/clinical-manifestations-differential-diagnosis-and-clinical-evaluation-of-a-palpable-breast-mass
  5. Newton, E.V. (2018). Breast Examination. In Isaacs C. et al. (Ed.), Medscape. Retrieved October 4, 2021, from: https://emedicine.medscape.com/article/1909276
  6. Sung, H.S., Ferlay, J., Siegal, R. L., Laversanne, M., Soerjomataram, I., Jemal, A., Bray, F. (2021). Global Cancer Statistics 2020: GLOBOCAN Estimates of Incidence and Mortality Worldwide for 36 Cancers in 185 Countries. CA: A Cancer Journal for Clinicians. 04 February. Retrieved from: https://doi.org/10.3322/caac.21660

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