Inspection

Ask the patient to sit up with her chest fully exposed. There is controversy about the value of inspection of the breasts as part of the examination, but advanced cancers may be obvious at this stage. Look at the nipples for retraction (due to cancer or fibrosis; in some patients retraction may be normal) and Paget’s disease of the breast (where underlying breast cancer causes a unilateral red, bleeding skin).

Next inspect the rest of the skin. Look for visible veins (which if unilateral suggest a cancer), skin dimpling, and for peau d’orange skin (where advanced breast cancer causes oedematous skin pitted by the sweat glands).

A persistent erythematous plaque in the areola area may be contact dermatitis or skin irrigation, but if asymmetric or it has not responded to treatment this may be the malignancy Paget disease of the breast.

Ask the patient to raise her arms above her head and then lower them slowly. Look for tethering of the nipples or skin, a shift in the relative position of the nipples or a fixed mass distorting the breast (Figure 14.1).

Figure 14.1 Carcinoma of the right breast, showing elevation of the breast, dimpling of skin, and retraction of the nipple

Note whether there are any obvious visible masses in the axillae.

Next ask her to rest her hands on her hips and then press her hands against her hips (the pectoral contraction manoeuvre). This accentuates areas of dimpling or fixation.

Palpation

Examine both the supraclavicular and axillary regions for lymphadenopathy. It may be difficult, however, to distinguish an axillary fat pad from an enlarged lymph node.

Then ask the patient to lie down. The examination can be performed only if the breast tissue is flattened against the chest wall. If the breasts are large, it can be helpful to have the patient place her hand on her forehead for the palpation of the lateral aspect of the breast and bring her elbow up level with the shoulder for the palpation of the medial side of the breast.

Palpation is performed gently with the pulps of the middle three fingers parallel to the contour of the breast. Feel the four quadrants of each breast systematically (Figure 14.2a). Don’t pinch the breast as you may think you then feel a mass. The total examination should involve a rectangular area bordered by the clavicle, sternum, mid-axillary line and the bra line. Start in the axilla and palpate in a line down to the bra line inferiorly. The pattern of palpation is like that of mowing a lawn, a series of vertical strips that cover the whole of the rectangle (Figure 14.2b).

Figure 14.2 Examination of the breast: (a) quadrants; (b) systematic examination

Each area is palpated three times, using small circular movements and slightly increasing pressure. Palpation is more difficult when a breast implant is present. It is probably best to examine such a patient in a supine position and to keep the ipsilateral arm down at her side.

Next feel behind the nipple for lumps and note if any fluid can be expressed: bright blood (from a duct papilloma, fibroadenosis or carcinoma), yellow serous (fibroadenosis) or serous (early pregnancy) fluid, milky (lactation) or green (mammary duct ectasia) fluid.

Don’t mistake normal breast structures for a mass!⁴ You may feel a rib or costochondral junction normally on deep palpation. The inferior ridge of breast tissue (inframammary fold) may be felt and is symmetrical. You may feel normal rubbery-type plaques (fibroglandular tissue), especially in the upper outer quadrant. It is normal to feel firm breast tissue at the areola border.

Evaluation of a breast lump

The following five points need to be carefully elucidated if a lump is detected.

A palpable breast mass is likely to be significant (called a dominant mass) if it is:⁴

A palpable breast mass is more likely to be malignant if it has the following characteristics:⁴

Remember that many normal breasts have palpable lumps and that although benign lumps tend to be soft, moveable and regular, they can also have the characteristics of malignant lumps (Good signs guide 14.1). Causes of a lump in the breast are listed in Table 14.1.

TABLE 14.1 Causes of a breast lump

* Alexander Tietze (1864–1927), Chief Surgeon, Allerheiligen Hospital, Breslau, Poland. He described the condition in 1921.

In men with true gynaecomastia, a disc of breast tissue can be palpated under the areola. This is not present in men who are merely obese. Causes of breast enlargement in men are presented on page 316.

GOOD SIGNS GUIDE 14.1 Breast lump characteristics and likelihood of cancer in a woman of average risk³

From McGee S, Evidence-based physical diagnosis, 2nd edn. St Louis: Saunders, 2007.