Clinical Breast Exam

Clinical Breast Exam

Women in their 20s-30s should have their breast clinically examined (clinical breast exam- CBE) as part of their annual health examination. For women over their 30s, this is usually a complement to other types of screenings such as mammograms.

The physical examination begins with the patient in the upright sitting position. The breasts are carefully visually inspected for obvious masses, asymmetries, and skin changes. The nipples are inspected and compared for the presence of retraction, nipple inversion, or excoriation of the superficial epidermis such as that seen with Paget disease. The use of indirect lighting can unmask subtle dimpling of the skin or nipple caused by a carcinoma that places Cooper's ligaments under tension. Simple maneuvers such as stretching the arms high above the head or tensing the pectoralis muscles may accentuate asymmetries and dimpling. If carefully sought, dimpling of the skin or nipple retraction is a sensitive and specific sign of underlying cancer.

Edema of the skin produces a clinical sign known as peau d'orange. Peau d'orange and tenderness, warmth, and swelling of the breast are the hallmarks of inflammatory carcinoma but may be mistaken for acute mastitis.

Common physical findings during breast examination. A, Nipple discharge. Discharge from multiple ducts or bilateral discharge is a common finding in healthy breasts. In the case shown, the discharge is from a single duct orifice and may signify underlying disease in the discharging duct. In this patient, a papilloma was the source of her symptoms. B, Paget disease of the nipple. Malignant ductal cells invade the epidermis without traversing the basement membrane of the subareolar duct or epidermis. The disease appears as a psoriatic rash that begins on the nipple and spreads off onto the areola and into the skin of the breast. C, Skin dimpling. Traction on Cooper's ligaments by a scirrhous tumor is distorting the surface of the breast and producing a dimple best seen with angled indirect lighting during abduction of the arms upward. D, Peau d'orange (skin of the orange) or edema of the skin of the breast. This finding may be caused by dependency of the breast, lymphatic blockage (from surgery or radiation), or mastitis. The most feared cause is inflammatory carcinoma, in which malignant cells plug the dermal lymphatics—the pathologic hallmark of the disease.
Visual inspection should be followed by palpation of the regional lymph nodes and breast tissue. While the patient is still in the sitting position,
Then the patient lies down, and the breast is palpated. The breast is best examined with compression of the tissue toward the chest wall, with palpation of each quadrant and the tissue under the nipple-areolar complex. Palpable masses are characterized according to their size, shape, consistency, and location and whether they are fixed to the skin or underlying musculature. Benign tumors, such as fibroadenomas and cysts, can be as firm as carcinomas; usually, these benign entities are distinct, well circumscribed, and movable. Carcinoma is typically firm but less circumscribed, and moving a carcinoma produces a drag of adjacent tissue. Cysts and fibrocystic changes can be tender with palpation of the breast; however, tenderness is rarely a helpful diagnostic sign. Most palpable masses are self-discovered by patients during casual or intentional self-examination.