Triple assessment - I Physical Examination of breasts

OBJECTIVES
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To detect the breast problems at the earliest stage. To differentiate between benign and malignant breast problems. To assess the extent of disease (stage of disease). To plan effective management & follow up. To document the data for audit. To counsel the patient and her attendants adequately. To learn the skills of examination.

Muhammad Shuja Tahir, FRCS (Edin), FCPS Pak (Hon)

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CLINICAL BREAST EXAMINATION (CBE)

Muhammad Shuja Tahir, FRCS (EdIn), FCPS Pak (Hon)

TRIPLE ASSESSMENT
It is a combination of three modalities of assessment performed to confirm the diagnosis and status of breast disease specially carcinoma of breast. It includes following different modalities to assess the disease process; Clinical data. (Clinical History and examination findings) ! Imaging # Ultrasound examination # Mammography # Magnetic resonance imaging. ! Cyto-histological examination. (FNAC / CORE / Excision Biopsy).
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The diagnostic sensitivity of triple assessment ranges from 85-95%. It covers all the medico-legal aspects of the diagnosis and treatment of breast malignancy. The reasons for breast examination training of the students is to learn to detect mass in the breast and to improve the clinical skills1. The objective of clinical breast examination is to

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differentiate normal physiological nodularity from discrete breast mass. If a discrete mass is detected, its evaluation is mandatory in all cases to exclude breast cancer. It is guided by clinical findings, age of patients and her 2 personal risk staus . A careful clinical examination is an essential part of breast screening in order to reduce false negative restuls3. A standardized system to describe clinical breast examination (CBE) alerts physician to an increased risk of delayed diagnosis of breast cancer4.

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or change in size of breast with duration. Menstrual cycle and its disturbances. Age of menarche. Number of pregnancies History of lactation. Relevant family history both in first and second degree relatives. History of contraceptive pill intake. History of hormone replacement therapy with its duration.

PHYSICAL EXAMINATION OF BREAST

It is the first part of triple assessment. It may be conducted by the doctor (clinical breast examination) or by the patient herself (breast self examination). PREPARATION The patient is dressed in hospital gown and settled in the examination room. The examining doctor introduces him/herself to the patient and checks the identity of the patient. Then he/she explains plan of clinical examination to the patient in a language clearly understandable by the patient. SPECIAL INTERVIEW Certain information such as; age of menarche, menstrual history of patient, obstetric history, history of lactation and breast feeding, history of breast cancer and other malignancies in the family is very carefully noted. History of hormonal intake for contraception or as replacement therapy. Following specific questions are asked before examination is started; ! Complaints of lump, nipple discharge, pain

EXPOSURE & POSITIONS Breasts are examined in the examination room with privacy but always in the presence of a nurse or a female attendant. The room temperature should be comfortable. The light should be adequate and patient should be completely exposed above the umbilicus. ALWAYS EXAMINE BOTH BREASTS In lying patient. In sitting patient. In sitting patient with hands abducted (over head). ! In sitting patient with hand pressing over the hips. ! In leaning (dependent) position. The patient stands away from the table and rests her hands on the table leaving her breasts hang freely.
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All the findings are recorded on the diagram.

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INSPECTION Both sides are examined simultaneously. NIPPLES Look for; ! Shape of the nipple. ! Discharge from the nipple (its amount and color) ! Retraction of the nipple (Whether recent or old) (Unilateral or bilateral) ! Cracks & fissures ! Eczema (Whether recent or old) (Unilateral or bilateral) ! Color of the skin AREOLA Look for; ! Color of the skin. ! Skin pigmentation or de pigmentation. ! Lumps. ! Surrounding area. BREAST PROPER Look for; ! Size of the breast. ! Shape of the breast. ! Color of the skin. ! Symmetry of breast. ! Visible veins. ! Scars. ! Signs of inflammation. ! Lumps. ! Peau-de-orange. ! Fungating Mass. ! Ulceration. PALPATION Patient is asked to point out the site of lesion.
Sitting patient with hands abducted

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Normal breast is palpated first. SUPERFICIAL PALPATION Whole of the breast should be palpated with the flat of hand gently. It makes the lump or tender areas obvious. DEEP PALPATION (PRECISE PALPATION) The precise palpation of the lump can be performed between thumb and fingers. The palpation is performed systematically to avoid missing lump in any part of the breast. Feel the; ! Nipples. ! Areola. ! Breast proper. Skin temperature is felt over and around the breast. Tenderness and point of maximum tenderness is noted.

Peau-de-orange appearance (Breast carcinoma)

Feeling the nipples

All observations are marked on the diagram. Note the following points as well; SITE Exact site in relation to the quadrants of the breast is recorded as;

Ulceration (Carcinoma Breast)

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Deep (precise) palpation for the lump

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Upper outer quadrant. Lower outer quadrant. Upper inner quadrant. Lower inner quadrant. Axillary tail.

Nipple and areolar lesions are noted. Side of the breast (Right or Left) is always mentioned. SIZE Exact size of the lump is measured and noted in centimeters in two dimensions. It is measured with help of a caliper. Measurement with the measuring tape is not correct in case of rounded, oval and irregular lumps. The

measurement is performed of the largest diameter with the caliper. It is essential for the proper staging of the disease. The speed of increase in size is mentioned in the history.

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SHAPE It should be drawn in the diagram of the breast. CONSISTENCY The lump is palpated between thumb and the index finger and the consistency is recorded as; Soft (similar to touch of cheek). Cystic (similar to touch of water filled balloon). Firm (similar to touch of tip of nose). Hard (similar to touch of forehead). SURFACE It is felt and recorded whether smooth or nodular. MARGINS Margins of the lump are felt. These can be; Diffuse (Not clearly demarcated) Clearly demarcated Regular Irregular MOBILITY / FIXITY Fixity or mobility in relation to overlying skin or underlying structures is examined. The skin is lifted up between thumb and the index finger. The skin is rolled over the lump in all directions. It clears the fixity or mobility of the skin. The lumps present in the skin become obvious as well. The patient is asked to push against both iliac crests. This puts the pectoralis major muscles into contraction on both sides. The lump is moved over the fixed and contracted (Hard) pectoralis major muscles in all directions. It clearly shows the freely mobile or fixed nature of the lump. FLUCTUATION It is tested carefully. The lump is fixed between two fingers of one hand and it is pressed with the index finger of the opposite hand. The lift up of the stationary finger is felt. The fluctuation is tested in two planes at right angles to each other. It is positive in cystic (fluid filled) lesions.

TRANSILLUMINATION It is performed in the dark room with a powerful pencil torch. Fluid filled lumps (Cysts) become obvious showing (red glowing areas) transillumination test positive.

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group of glands which is involved in disease process at the earliest. LEVEL-II These glands are next group to be involved and these are present posterior to pectoralis minor muscle. LEVEL-III These glands are present supero-medial to the pectoralis minor muscle. These are the last ones to get involved and show worse outcome of the disease process.

OTHER FEATURES FOR EXAMINATION Jaundice, pallor and edema especially of upper limbs is noted. Complete examination of liver, lungs and spine is performed to search of distant metastasis. The assessment of breast lump after physical examination is described as below;

CLINICAL STAGING OF THE CARCINOMA BREAST(TNM)

T N M TUMOR LYMPH GLANDS METASTASIS

T STAGES

T-x
REGIONAL LYMPH GLANDS All of the regional lymph glands draining the breast are carefully examined and recorded. All groups of axillary lymph glands, infra-clavicular lymph glands supra-clavicular lymph glands are palpated and observations are noted. EXAMINATION OF GLANDS DURING SURGERY The lymph glands are specially explored and felt during axillary exploration. These are examined histologically according the level of their site such as; LEVEL-I These are the lymph glands present infro lateral to the pectoralis minor muscle. These are the Primary tumor cannot be assessed. (Post operative patients who were not staged initially).

T-is
Carcinoma in situ. Incidental finding showing presence of malignant cells without invasion of basement membrane.

T-0
No palpable primary tumor. It is an incidental finding. Malignant cells are present in the biopsy specimen and basement membrane has been just invaded. It is a next step in progress of malignancy to carcinoma in situ.

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T-1
Tumor size 2 cm or less. No fixity. No nipple retraction.

N-2
Fixed ipsilateral axillary lymph glands.

T-2
Tumor size 2-5 cm.

N-3
Palpable supra clavicular lymph glands mobile or fixed. Edema of the arm. Involvement of ipsilateral internal mammary glands. M STAGES

T-3
Tumor size 5-10 cm.

T-4
Tumor size more than 10 cm. Any size with infiltration or ulceration of the skin. Tumor fixed to the chest wall. Peau-de-orange appearance of the skin.

M-0
No metastasis.

M-1
Distant metastasis including skin involvement outside the breast. Opposite breast involvement. Involvement of the lymph nodes of the opposite axilla and supra clavicular lymph glands. Other distant metastasis. STAGE I (T0, T1,N0, M0) This includes growths confined to the breast. Tumor less than 2 cm diameter in size. No nodal involvement. No distant metastasis. The tumor should not be adherent to the pectoral muscles or chest wall. STAGE II (T0, T1 OR T2 and N1, M0) Tumor size less than 5 cm in diameter but there are affected mobile lymph glands in the axilla of the same side. Tumor size 5 cms without lymph node involvement.

N STAGES

N-x
Axillary node cannot be assessed.

N-0
No palpable axillary lymph glands.

N-1
Palpable but mobile ipsilateral axillary lymph glands.

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No distant metastasis. False negative results of clinical examination are about 25-30%. STAGE III (T0, T1, T2, T3, T4, N2 and M0) All breast cancers of any size. Skin involvement or peau-de-orange present in larger areas than the tumor itself but these are limited to the breast. Tumor fixed to pectoral muscles but not to the chest wall. Axillary lymph nodes, internal mammary node and Supra clavicular nodes are involved. Edema of the arm may be present. STAGE IV (Any T or any N with M1) Skin involvement extending outside the breast. REFERENCES 1. Madam Ak, Aliabadi-Wahle S, Balbom Posner M, Beech DJ. Education of medical students in ceinicae breast examination during surgical clerkship. Am J Surg 2002 Dec; 184(6): 637-40, discussion 641. 2. Freund KM. Rationale and technique of clinical breast examination. Medscape women health 2000 No; 5(6):E2.

Distant metastasis either lymph borne or blood borne. Involvement of opposite breast. The patients is covered and allowed to change the end of completion of examination after the examining doctor leaves the rooms. COUNSELING The patient is informed about the disease status as assessed clinically. Plan of investigations and possible modes of treatment are informed. Necessary documentation and appointments are made and recorded. Whole of this information is also sent to the referring doctor.

3. Park BW; Kim SI; Kim MH; Kim EK; Park SH; Lee KS: Clinical examination (CBE) for screening of a symptomatic women. The importance of CBE for breast cancer detection. Yonsei Med J. (Korea 2000 Jun: 41 (3):312-8. 4. Goodson WH; Moorl DH: Overall clinical breast examination as a factor in diagnosis of breast cancer. Arch Surg 2002 Oct; 137 (10): 1152-6.

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