459 A Manual on Clinical Surgery B. PALPATION Palpation should be made initially in sitting position, in semirecumbent (45") position and later on in recumbent position. It is advantageous to put a small pillow under the scapula on the side to be examined, so that the breast concerned rests evenly on the chest wall and does not fall to the side of the body. Sometimes it is necessary to put her arm above her head during palpation. It is advisable to palpate the normal breast first. The texture of the breast varies from woman to woman. In some it is soft and smooth when it is quite difficult to distinguish the glandular tissue from the subcutaneous tissue, whereas in others it is firm lobulated with nodularity. Palpation should be made with palmar surface of the fingers (Fig. 30.13) with the hand flat and not with the 'flat of the hand' as this means with the palm of the hand which is pulps of the fingers and the thumb to know more about impression with nodularity. Now the affected side is palpated in a similar fashion keeping in mind the findings of the normal side and comparing them with those of the affected side. The four quadrants should be palpated systematically. Also feel the axillary tail. Do not miss to palpate just behind the nipple. There may be a small lump here and no other abnormality in the whole of the breast. This will be missed if the students do not make habit of this examination as a routine. While palpating this region an eye must be kept on the nipple-whether any discharge is being expressed out of the nipple or not. In case Fig. 30.13: Palpating the breast not correct. Palpation should also be made between the palmar surface of the fingers with the hand flat. Remember breast carcinoma is best b a swelling. The normal breast gives a firm lobulated with this method and with the flat of the hand. of duct papilloma or duct carcinoma blood will come out. If any lump is detected in this examination, it should be felt by the palmar surfaces of the fingers with the hand flat. Remember, breast cancer is best felt by the hand flat, which being less sensitive fails to feel any other lump than carcinoma (e.g., fibroadenosis, fibroadenoma, etc) If a lump is detected the following points should be noted: 1. Local temperature and tenderness: Local temperature is best felt by the back of the fingers. A warm and tender swelling is generally inflammatory in origin, but one should keep in mind acute mastitis carcinomatosa which may present the similar features. 2. Situation (in which quadrant): Carcinoma can occur anywhere in the breast including the axillary tail (a prolongation of breast tissue into the axilla), but is commonly found in the upper and outer quadrant. Fibroadenosis also occurs more often in the upper and outer quadrant and in the axillary tail. Fibroadenoma is more commonly seen in the lower half than in the upper half though it may occur in any part of the breast. 3. Number: Though majority of the breast lesions are solitary, yet fibroadenosis is known for its multiplicity. Multiple lumps are felt. Even the opposite breast may be affected. 4. Size and shape: Whether globular (fibroadenoma) or uneven (carcinoma). 5. Surface: Smooth surface is a feature of benign condition, whereas an uneven surface is a significant feature of carcinoma. Margin: In case of fibroadenosis the margin all-defined. In case of fibroadenoma (a firm umor within the soft tissue) and more so in Broadenoma the margin is regular and tends carcinoma (stony hard tumor within the soft surrounding) the margin is well defined. In 10 slip off the palpating fingers, whereas in carcinoma the margin is very much irregular and does not tend to slip away from the palpating Angers as it is fixed to the breast tissue. Consistency: Consistency of the lump must be assessed properly-whether cystic, firm, hard or story hard. In case of soft cystic swelling test ubber feel is characteristic of fibroadenosis. for fluctuation. A firm, sotty or diffuse India-A fibroadenoma is a firm encapsulated tumor, whereas carcinoma is stony hard in consistency. In case of sarcoma consistency may vary from place to place. Fig. 30.14: Shows the method to elicit fluctuation in a is held by the sides (watching fingers and kept fixed. whereas with index finger of the other hand (displacing case of a breast lump. The examination is carried out from behind. With one hand using two fingers the lump finger) the center of the lump is pressed to displace fluid & Fluctuation: A cystic swelling should be within the lump tested for fluctuation (Fig. 30.14). The clinician stands behind the patient, who sits on a stool. His two hands should go above the patient's shoulder. With one hand he holds the cyst and with index finger of the other hand gentle tap is made on the center of the cyst. Besides a cyst the fluctuation test will be positive in chronic abscess (it may not be tender) and lipoma. A very tense cyst may not show fluctuation test positive. Transillumination test: This can only be effectively carried out in a dark room. The torch is placed on the undersurface of the breast so that the light is directed through the breast tissue to the examiner. Fat is translucent but a solid tumor is opaque. 10. Fixity to the skin: This can be tested in the following ways: (i) An attempt to move the tumor side to side or up and down will make the appearance of dimpling or tethering of the skin; (ii) the skin is made to slide over the tumor which is not possible; (iii) the skin over the tumor is pinched up, this is also not possible if the tumor is fixed to the skin. When a wide area of the skin over the tumor is attempted to pinch up, peau d' orange will become prominent. Hard nodules may be felt in the skin in late stage of breast cancer as part of cancer-en-cuirase. Two terms must be understood in this respect-"Tethered' to the skin and 'fixed' to the skin. (i) The term 'tethered' to the skin means that the malignant disease has spread to the fine fibrous septae that pass from the glandular tissue of the breast to the skin. These are called Astley Cooper's ligament. Infiltration of these strands makes them shorter and inelastic and thus pull the skin inwards resulting in puckering of the skin. The lump at this stage can still be moved independently of the skin for some distance after which this may cause puckering of the skin. So tethering of the lump to the skin can be tested by moving the lump side to side and watching if the skin dimples at the extremes of movement. (ii) 'Fixity' means that there is direct and continuous infiltration of the skin by the tumor and the tumor cannot be moved independent of the skin and the overlying skin cannot be pinched up. must be remembered that any tumor Iving immediately deep to the nipple will be fixed to the nipple be it benign or malignant as the main mammary ducts may have traveled throug the growth and so the nipple becomes fixed. 11. Fixity to the breast tissue: This is demonstrated by holding the breast tissue with one hand and gently moving the tumor with other hand. A fibroadenoma is not fixed to the breast ti and can be easily moved within the breast substance. That is why it is called a 'Breast moov A carcinoma on the other hand is fixed to the breast substance and cannot be moved within it Fibrous strands can be felt radiating from the mass into the breast substance. 12. Fixity to the underlying fascia and muscles (pectoralis major and serratus anterior): The patient is asked to place her hand on her hip lightly. The lump is moved in the direction of the fibers of pectoralis major first and then at right angles to them as far as possible. The lump is mobile in both the directions. Now the patient is asked to press her hip as hard as possible. Feel the anterior fold of the axilla to verify that the muscle has been made taut (Figs. 30.15 and 30.16). Move the lump once more in the same directions and compare the range of mobility. Any restriction in mobility indicates fixity to the pectoral fascia and pectoralis major. There will be total restriction of mobility along the line of the muscle fibers if it is fixed to it but slight movement along the right angle of the fibers may be possible. A swelling occupying the outer and lower quadrant of the breast will lie on serratus anterior, to which it may be fixed. This is ascertained by asking the patient to push against a wall with the outstretched hand of the affected side while the mobility of the swelling is tested. The swelling. if fixed to serratus anterior, will move very little. 13. Fixity to the chest wall: If the tumor is fixed irrespective of contraction of any muscle, it is fixed to the chest wall. 14. Palpation of the nipple: It is very important to palpate the nipple and the breast tissue just deep to the nipple. Tumor just deep to the nipple is usually fixed to the nipple. The underlying lump is moved and see if this movement causes or increases nipple retraction. Gentle pressing of such tumor may express discharge from the nipple. Note its color and nature. Note whether it appears from one or many ducts. When the scharge is visible, try to decide its nature-whether blood, serum, pus or milk. Take the Bacteriological swab for culture. The source of such discharge must be found out by gently pressing on each segment of the breast and areola. If the nipple is retracted, press gently from both sides deep to the nipple. This will evert it if the retraction is congenital or spontaneous. If is due to carcinoma the nipple cannot be everted like this If there is any ulcer, examine it as discussed in Chapter 4 EXAMINATION OF LYMPH NODES This examination is very important. On the finding of this examination the staging of the breast cancer can carried out in sitting position. The muscles and fasciae he judged as also the prognosis. This examination is around the axilla should be relaxed. If this cannot be properly achieved this examination can be done in lying down position. Palpation of the axillary group of lymph nodes 1 PECTORAL GROUP: This group is situated just behind the anterior axillary fold. The patient's arm is elevated and using the right hand for the left side the fingers are insinuated behind the pectoralis major. The arm is now lowered and made rest on the clinician's forearm (Fig. 30.17). This will relax the pectoralis minor. With the pulps of the fingers try to palpate the lymph nodes. The palm should look forward. The thumb of the same hand is used to push the pectoralis major backwards from the front (Fig. 30.18). This facilitates palpation. 2 BRACHIAL GROUP: This group lies on the lateral wall of the axilla in relation to the axillary vein. To palpate this group left hand is used for the left side. The group is felt with the palm directed laterally against the upper end of the humerus (see Fig. 30.22). 3. SUBSCAPULAR GROUP: This lies on the posterior axillary fold and is best examined from behind. Standing behind the patient the examiner palpates the anterointernal surface of the posterior fold while with the other hand the patient's arm is semilifted. Now the nodes are palpated lying on this surface with the palm of the examining hand looking backwards (Fig. 30.19A). Fig. 30.17: Show the position of the arm while examining the lymph nodes of the axilla, Note that the arm is adducted and allowed to rest comfortably on the clinician's forearm Figure 30.20 shows the lymphatic drainage and blood spread in case of carcinoma breast 30.20: Diagrammatic representation of lymphatic drainage (single line) and blood spread (double line in carcinoma of the breast. Lymphatic drainage from the subareolar plexus of Sappey and outer quadrant of the breast takes place first to the pectoral (P), then central (C) and lastly to the apical (A) group of axillary lymph nodes. The other two groups of the axillary nodes, viz. the subscapular and lateral group may be involved in a retrograde way. From the apical group the supraclavicular group may be affected. On the left side the supraclavicular group is affected by retrograde permeation. The upper quadrant of the breast drains partly to the deltopectoral node but mainly to the apical group. From the inner quadrant the lymph spread occurs to the internal mammary group (In. M) and to the other breast (Br). From the lower and inner parts of the breast the lymph vessels form a plexus over the rectus sheath and pierce the costal margin to communicate with the subperitoneal lymph plexus. From this place, cancer cells may drop by gravity into the pelvis (transcoelomic implantation) and may cause metastases in the ovary (Krukenberg) tumor). It may be noted that the liver may be involved in two ways-subperitoneal plexus and by blood spread Blood spread-occurs in addition to the liver, to the bones, especially to the sternum, ribs, spine and upper ends of the humerus and femur. Lungs may be affected. CENTRAL GROUP: This group of the left side is examined with the right hand. At first the patient's arm is slightly directing the palm towards the lateral thoracic wall. The patient's arm is now brought to the side of her body and the forearm rests comfortably on the clinician's forearm. The other hand of the clinician is now placed on the opposite shoulder to steady the patient. Palpation is carried by sliding the fingers against the chest wall when the lymph nodes can be felt to slip out from out the fingers (Fig. 30.24). 5. APICAL GROUP: Examination is carried out in the same manner as the previous one, but the fingers are pushed further up. If the lymph nodes are very much enlarged they may push themselves through the clavipectoral fascia to be felt through the pectoralis major just below the clavicle. B. Palpation of cervical lymph nodes One must always examine the supraclavicular group to conclude the examination of the lymph nodes. To examine this group the clinician stands behind the patient and dips the fingers down behind the middle of the clavicle. Two sides are simultaneously palpated and compared (see Fig. 30.19B). Passive elevation of the shoulders would relax the muscles and fasciae of the neck to facilitate palpation. One must always flex the neck of the patient slightly for better palpation of this group of lymph nodes. While palpating the lymph nodes careful assessment must be made as to their number, size, consistency, mobility, etc., as discussed in Chapter 8. Simplified

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