The Breast

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Chapter 9 The Breast

Salvatore Mangione, MD

“Thy two breasts are like two young roes that are twins, which feed among the lilies.”

Song of Solomon, 4:5

A. Generalities

The clinical breast examination (CBE) is an effective screening tool for breast cancer; its accuracy depends on methodology and operator. Most of the research data stress palpation over inspection.

1 Why do a clinical breast examination (CBE)?

For either diagnosis of breast complaints (and primarily to rule out cancer) or for screening (to detect cancer in asymptomatic women). In primary care, CBEs are more screening than diagnostic (73% and 27%, respectively). They also get intertwined with medical litigation, since failure to detect breast cancer is a leading reason for malpractice claims, and primary care clinicians account for one half of all indemnities made.

2 Who should undergo a screening CBE? How frequently?

According to the American Cancer Society, CBEs should be carried out every 3 years in women between 20 and 39 years, and annually in women 40 and older. In this age group, the CBE can detect at least 50% of asymptomatic cancers and possibly contribute to a mortality reduction. A well-conducted exam cannot only detect potentially curable cancers, but also add to the yield of mammography, especially in women older than 70 (since fatty changes in their breast make lump detection easier).

3 What is the precision of CBE?

Hard to say, since CBEs are often carried out in nonstandardized fashion. Hence, their high interobserver variability. For example, 37 to 74 of 100 women screened by four different surgeons were found to have abnormal findings, and yet for only 25 of these women did all four surgeons agree on the findings. Agreement also varied by lesion: 13.5% for nipple discharge, 22.1% for dilated veins, 24.2% for “peau d’orange,” 59.4% for the lump per se, 61.5% for ulceration, and 68.1% for finding visibility.

4 What is the accuracy of CBE?

Hard to say, too, since to determine its screening accuracy the CBE should be compared to a standard criterion, which mammography cannot be, since cancers missed by mammograms can be found on CBE. Having said that, CBE sensitivity on pooled data is rather low (54%), but specificity is much stronger (94%). Overall, CBE has high false positive rates and even higher false negative rates. In silicone models, it has a sensitivity similar to that of population studies (40–71%), but a much lower specificity (41–77%).

5 What is the value of breast examination as compared to mammography?

CBE alone can detect 3–45% of cancers that screening mammography missed, with randomized clinical trials demonstrating reduced mortality rates in women screened by both techniques. Hence, CBE is an effective screening tool for breast cancer. Although unable to rule out disease when used alone, detection of certain abnormal findings by CBE can greatly increase the probability of breast cancer. Sensitivity of both professional and lay examiners can be improved by learning the correct examination method, and then practicing it on silicone breast models. Overall, for lesions of similar size, both examiner and patient factors can affect CBE’s accuracy.

6 What examiner’s factors are associated with CBE’s greater accuracy?

Longer duration of exam

Higher number of correct steps (a systematic search pattern, thoroughness, varying palpation pressure—fingers, finger pads, and circular motion)

Examiner’s experience (previous training with silicone models)

7 What patient’s factors can adversely affect CBE’s accuracy?

Age. Denser breasts (typical of younger women) are harder to examine than fatty breasts (typical of older women), thus making lump detection more difficult. Larger breasts are also difficult, and so are fibrocystic breasts, which tend to be rather lumpy.

8 What is the bottom line for CBE modifiers?

Duration of exam, number of correct techniques, patient’s age, and the size/lumpiness of the breast may all affect CBE’s sensitivity. Size and hardness of the cancer can do it, too.

(1) Inspection

9 Which areas should be examined?

Breast tissue is contained in an imaginary pentagon, whose lateral border follows the midaxillary line, from the middle of the axilla down to the inframammary (or bra) line (fifth to sixth interspace); the lower border crosses along the inframammary fold toward the xiphoid process; the medial border ascends the midsternal line toward the suprasternal notch; and the upper border follows the clavicle before turning down toward the midaxilla. This pentagon can then be divided into four quadrants (Fig. 9-1). Most cancers originate in the upper outer quadrant of the breast, and also below the areola and nipple, two areas containing a large amount of glandular tissue. Always inspect first and palpate later.

Figure 9-1 Breast anatomy—glandular area.

10 What is the best way to inspect the breasts?

By examining the patient supine and then seated. Look for the breasts’ size, shape, and contour. Identify asymmetries, swelling, erythema, increase in venous pattern, and skin dimpling. Also search for nipple changes, including deviation, retraction, and inversion.

11 Which bedside maneuver can help to detect breast abnormalities on inspection?

The most commonly taught and used maneuvers include a change in position of the patient’s arms and hands, first described by Haagensen (Fig. 9-2). To do so, ask the patient to carry out the following sequence:

1. >Rest the hands on the lap (to relax the pectoralis muscles).

2. Press them over the hips (to tense the pectoralis muscles and make dimpling and retraction more visible).

3. Raise them above the head, clasping them behind it (to also trigger skin dimpling, an important harbinger of cancer).

4. Lean forward (to allow the breasts to hang out pendulous from the chest).

Figure 9-2 Physical examination of the breast. A, Observation with patient sitting and arms resting at side. B, Observation with arms raised above the head. C, Systematic palpation with palm side of hand and fingers while patient is supine. D, Palpation of supraclavicular region of sitting patient with examiner supporting and elevating arm. E and F, Examination of axillae with volar surface of fingers by examiner standing on opposite side and totally supporting patient’s arm.

(From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987.)

Although these positions are commonly taught and practiced, they do take time. Moreover, the screening value of positioning (and even inspection) remains largely unproven. In a series of 296 breast cancers found on exam, 96% were discovered by palpation, 3% by visible nipple abnormalities, and only 1% by retraction alone. Yet, if the patient is symptomatic (or an abnormality is discovered during palpation), then careful inspection should definitely be carried out.

12 What are the most significant abnormalities that can be detected by inspection?

Noncongenital nipple asymmetry/deviation and retraction/inversion (both valuable clues to an underlying cancer). Nipple inversion may actually be normal, but only if long standing and correctable by manual pulling. Skin inspection also is important. Look for:

Dimpling

“Peau d’orange”

Scaly, red dermatitis of the areola and nipple (which suggests Paget’s disease of the breast) Look for these in each Haagensen’s position.

A slight depression or indentation in the breast’s surface (Fig. 9-3). This is an important clue to an underlying infiltrating carcinoma, causing fibrosis and retraction of the breast tissue. The same mechanism is responsible for nipple deviation.

Figure 9-3 Nipple retraction and skin dimpling.

(From Seidel HM, Ball JW, Dains JE, Benedict GW: Mosby’s Guide to Physical Examination, 3rd ed. St. Louis, Mosby, 1995.)

14 What are the suspensory ligaments of the breast?

Suspensory (or Cooper’s) ligaments are thin, fibrous bands that run through the breast, attaching stroma to skin. Tension on these ligaments produces the characteristic dimpling that sometimes occurs over malignant masses.

15 What is peau d’orange?

It is French for orange peel—an apt description of the skin overlying an infiltrating cancer. It is due to lymphatic blockage by the tumor, resulting in localized lymphedema, with skin thickening and unusually large pores. It typically involves the lower aspect of the breasts.

16 What is Paget’s disease of the breast?

A malignant lesion of the areola and/or nipple, almost always associated with an in situ or invasive carcinoma. It is caused by extension of neoplastic cells from the lactiferous ducts into the epidermis, eventually causing it to become irritated. It presents as a scaly dermatitis of the nipple, with itching, crusting, and even erosion. Eventually, it involves the skin extensively, possibly without any palpable underlying mass. It may resemble other scaly and excoriative nipple diseases, such as eczema or the trauma of nursing.

Pearl:

Redness and thickness of the nipple should always be considered suspicious. When appropriate, biopsy must be carried out to exclude Paget’s disease.

17 Who was Paget?

“/>Sir James Paget (1814–1899) was a British surgeon who spent his entire career at the St. Bartholomew’s Hospital of London. A tall, brilliant, and charming man, he was so much enamored with clear and concise language to often quip, “To be brief is to be wise.” His fame grew to the point that Prime Minister Gladstone remarked that people are divided into two classes, “those who had, and those who had not heard of James Paget.” His name is linked to the first demonstration of trichinosis in humans (which he reported while still a medical student), osteitis deformans (described the same year in which he was made a baronet), the aforementioned breast disease, and a skin cancer of the apocrine glands presenting with the same cells as Paget’s disease of the breast.

(2) Palpation

18 What is the best way to palpate the breast?

One that uses (1) proper patient position; (2) awareness of breast boundaries; (3) adequate examination patterns; and (4) correct finger position, movement, and pressure. Duration of palpation is also crucial to success, with longer exams having overall a better yield. Note that a careful examination of an average-sized breast takes at least 3 minutes (6 minutes for both breasts), which is much more than the average 1.8 minutes physicians usually spend teaching breast self-examination (BSE) and examining both breasts.

19 Describe the proper patient position.

Since CBE requires flattening of the breast tissue against the chest, the patient must be supine. To further flatten the breast, one could try bedside maneuvers, especially in women with larger breasts. For example, to flatten the lateral part of the breast, you can ask the patient to roll onto her contralateral hip, rotate the shoulders back into a supine position, and place her ipsilateral hand on the forehead. Conversely, to flatten the medial part of the breast, you can ask the patient to lie flat on her back and raise her elbow until it is at the same level with her shoulder.

20 What should the examiner remember about breast boundaries?

Since breast tissue extends laterally toward the axilla (axillary tail) and superiorly toward the clavicle, you should cover a rectangular area that is bordered superiorly by the clavicle, medially by the midsternum, laterally by the midaxillary line, and inferiorly by the bra line. This will ensure that you examine all breast tissue.

21 What is meant by an adequate examination pattern?

Although two fifths of physicians may use no discernible pattern, proper technique is key for lesion detection. The two traditional methods are the radial spoke pattern and the concentric circles pattern (Fig. 9-4). However, the vertical strip pattern has been found to be more thorough. Begin your palpation in the axilla, and extend it in a straight line down the midaxillary line toward the bra line. Then move your fingers medially, continuing palpation up the chest, and in a straight line to the clavicle. Cover the entire breast, going up and down between the clavicle and bra line in a vertical strip pattern (or lawnmower technique). To cover all breast tissue, overlap rows.

Figure 9-4 Traditional patterns of breast palpation. A, Spokes of a wheel approach. B, Concentric circles approach.

(From Swartz MH: Pocket Companion to Textbook of Physical Diagnosis, 3rd ed. Philadelphia, WB Saunders, 1997.)

22 Describe the correct finger position, movement, and pressure.

The MammaCare method is a breast palpation technique that combines vertical strip pattern and specific finger techniques to allow detection of a soft 2-mm lump in simulated breast tissue. In this technique, the three middle fingers are held together, with the metacarpal–phalangeal joint slightly flexed, and the surface examined by the finger pads (not tips). Each area is palpated by:

Making small circles, as if following the edge of a dime

Making three circles at each spot, using three different pressures—light for superficial structures (skin and subcutaneous tissue), medium for the breast per se, and deep for the chest wall. This ensures that all levels of tissue are reached.

Examining each area carefully, all the way down to the thoracic wall. Pay attention to the tactile quality of skin, subcutaneous fat, and breast tissue

hen moving on to the next area, always using a consistent pattern

23 What are the final steps in the CBE?

Complete the exam by palpating for adenopathy in the supraclavicular and axillary fossae (Fig. 9-5). Then examine the nipple, through palpation and a squeeze. Although search for adenopathy is a routine component of the CBE, breast cancer is present in only 10–30% of women with isolated axillary lymphadenopathy and an otherwise normal CBE.

Figure 9-5 A and B, Technique for axillary examination.

(From Swartz MH: Textbook of Physical Diagnosis: History and Examination, 4th ed. Philadelphia, WB Saunders, 2002.)

24 What is the bottom line of the breast exam?

Use a vertical strip pattern to cover all tissue. Make circular motions with the pads of the middle three fingers. Examine each area with thee different pressures. Spend 3 minutes per breast.

25 How does normal breast tissue feel?

It depends on the phase of the menstrual cycle. Premenstrual and perimenstrual breasts, for instance, are swollen, tender, and with prominent glands. Tenderness is usually (but not always) a sign of benignity, being common in mastitis or fibrocystic disease.

26 How should a breast lump (or nodule) be described?

Size: Assess it by using a ruler, tape measure, or, even better, plastic calipers. Remember that larger lumps (>2 cm) are more likely to be neoplastic.

Location: Describe it in relation to the breast’s four quadrants and the distance from the areolar rim. Report the finding by using the clock analogy.

Tenderness: Usually a sign of benignity

Consistency or firmness: Rock-hard in cancers; soft, compressible, and at times even cystic in benign lesions

Shape: This should include an assessment of regularity/irregularity and contour. Lesions with indistinct and irregular margins are more likely to be malignant.

Relation to surrounding tissue: Use Haagensen’s maneuvers to evaluate mobility over superficial and deep planes. Fixed lesions are more likely to be malignant.

Character of the overlying skin: Look for warmth, redness, swelling, or retraction.

27 What are the characteristics of malignant breast tissue?

A carcinomatous lesion is typically painless, irregular in contour and shape, hard in consistency, not mobile, and not well demarcated from the surrounding tissues. Retraction signs are usually a late phenomenon. A serous (or serosanguineous) nipple discharge can be an important sign of intraductal carcinomas (see questions 37–40).

28 Are lumps ever normal?

Yes. In fact, normal breasts are often lumpy, but these lumps are typically movable, regular, and soft or cystic. They also may change with the menstrual cycle. Neoplastic lumps are instead hard, fixed, and irregular. Nonmovable and large lesions (>2 cm) are especially ominous (likelihood ratio [LR] = 2.4). Yet many cancers do not read the books. In fact, one half of all breast lesions in one study were well circumscribed, soft, and movable. The opposite is also true, with benign masses often resembling cancer. Correlation with presence or absence of risk factors can further increase/decrease the likelihood of disease. Still, since the characteristics of neoplastic and benign lumps often overlap, breast cancer is rarely diagnosed on CBE alone. Instead, the CBE should be used to locate abnormalities and guide further evaluation.

29 How common is breast cancer? What are its risk factors?

Breast cancer will occur in approximately 12% of American women over their lifetimes, with risk affected by age (annual incidence at age 70 being 20 times higher than at age 30) and family history (having two first-degree relatives with breast cancer at an early age quadruples the risk). Other risk factors include genetic mutations (BRCA1 and BRCA2 genes) and estrogen exposure (age of menarche, first pregnancy and menopause, parity, and estrogen replacement therapy). Strong risk factors increase the likelihood of any neoplastic abnormality detected on exam.

30 How accurate is physical exam for the detection of a breast lump?

Variable, depending not only on examiner’s skills but also on the size and location of the lesion. For example, tumors <1 cm are difficult to palpate (unless very superficial), whereas 2–3 cm lesions are easily detectable. In silicone models, the sensitivity of exam ranges between 17% and 83%, increasing not only with examiner’s experience but also with the exam’s duration. In real patients, the sensitivity of the breast exam for detecting a neoplastic lesion can be as low as 24% and as high as 62%. Because of its much greater sensitivity, mammography should always supplement (but not substitute) physical examination. False negative rates of mammography range from 3% to 63% (usually around 20%). In a study by Hicks, 7% of all cancers detected by exam were misdiagnosed as benign by mammography, whereas as many as one fourth of all detected cancers were picked up during self-examination between mammograms.

31 How high is the interobserver variability in describing a breast lump?

Quite high. For example, in a study of 232 women presenting with a breast lump, two observers disagreed on lesions’ consistency and margins in one third of the cases. They also disagreed on the presence of axillary nodes in one half of the cases. In another study, four breast surgeons detected a lump in 32/42 patients and agreed on biopsy in 11/15 patients eventually diagnosed with cancer.

32 What are the most common benign breast lesions?

Fibroadenomas: The most common benign neoplasms. They present as solitary, well-demarcated, rubbery, mobile, nontender masses, often round, but also ovoid or oblong. May occur at any time after puberty, but less frequently after menopause.

Benign cysts: The most common breast lumps. Since they are often part of a fibrocystic pattern, they tend to coexist with other cysts. They are round, mobile, soft, and cystic in feel. They vary with the menstrual cycle, becoming tender before menses, and smaller immediately after (hence, to avoid misdiagnosis do a breast exam only in this phase of the menstrual cycle). They regress after menopause.

33 What is a florid nipple adenoma?

A benign lesion that presents as an areolar nodule. This often becomes ulcerated and thus may be confused with Paget’s disease.

34 What is the differential diagnosis of an inflammatory breast mass?

It depends on whether it is diffuse or localized:

Diffuse inflammatory breast masses include acute mastitis and inflammatory breast carcinoma.

Localized inflammatory masses are instead the result of an acute breast abscess—a well-localized, tender, swollen, erythematous, and often fluctuant lesion. Patients usually present with systemic signs and symptoms of infection (like fever, malaise, and leukocytosis), usually in a setting of lactation, since abscesses are often the end result of an acute mastitis.

35 How can one separate acute mastitis from inflammatory breast carcinoma?

Both conditions present with diffuse and tender masses:

Acute mastitis is a glandular infection that involves only a single breast quadrant, usually during lactation. The affected area is red, swollen, tender, and associated with systemic signs of infection (fever, malaise, elevated white blood cell count).

Inflammatory breast carcinoma involves instead the entire breast and is typically associated with axillary adenopathy (usually absent in acute mastitis). Lack of association with lactation and lack of response to antibiotics should raise the suspicion for neoplasm and prompt a biopsy.

36 Describe the lymphatic drainage of the breasts.

The superficial and central areas are drained by lymphatics that radiate from the areola and then converge toward the low/central axillary nodes and the subclavian nodes.

The deep tissue is drained instead by pectoral, subclavian, and internal mammary nodes. These eventually drain into mediastinal stations.

Finally, other breast lymphatics drain into hepatic and subdiaphragmatic nodes (Fig. 9-6).

Figure 9-6 Lymphatic drainage of the breast. The major direction of lymphatic flow is lateral and upward toward the central axillary nodal region. Drainage is then medially to the apical subclavicular nodes, the latter also receiving lymph directly from the interpectoral lymphatics. Lymphatics from the central and medial breast communicate with internal mammary nodes, which drain cephalad and communicate with the deep cervical lymphatic system behind the clavicle.

(From James EC, Corry RJ, Perry JF: Principles of Basic Surgical Practice. Philadelphia, Hanley & Belfus, 1987.)

B. Nipple Discharge

37 How do you assess for nipple discharge?

By applying gentle pressure at the base of the nipple, with the thumb and first or second finger (Fig. 9-7). Note that a discharge that occurs only with nipple compression/squeezing is usually physiologic. In a study of 448 women complaining of discharge, none of the 178 who had it only after expression was found to have cancer. Conversely, cancer was present in 2% (3/151) of those with spontaneous discharge but otherwise normal CBE.