Examination of the Breast (Gynecology)

History (Before Physical Examination)

• Breast development - age of onset, changes over time
• Breastfeeding history - previous lactational experience
• Menstrual history - relation of symptoms (pain/discharge) to menstrual cycle
• Marital/reproductive status - fibroadenosis and breast cancer are more common in nulliparous women
• Medications - e.g., OCPs, HRT (can cause breast tenderness/discharge)
• Previous breast surgery or trauma - location of scars (especially periareolar)
• Family history - first-degree relatives with breast cancer
• Systemic illnesses - tuberculosis, connective tissue disease
• Presenting complaint details - lump, pain, discharge, nipple change, skin change, weight loss

Positions for Examination

Inspection

1. The Breasts (Overall)

• Position - displaced or asymmetrical?
• Size and shape - larger or smaller than its fellow; gynecomastia in males
• Puckering or dimpling - skin dimpling is made more prominent by lifting the breast gently upward; in scirrhous carcinoma the breast may be shrunken
• Presence of a swelling or ulcer - note quadrant

2. Skin

• Colour and texture - erythema/warmth in acute mastitis
• Engorged veins - seen in large fibroadenoma, rapidly growing sarcoma, lacteal duct obstruction
• Peau d'orange - blockage of subcuticular lymphatics by carcinoma causes oedema; deepens mouths of sweat glands and hair follicles giving the classic "orange peel" appearance
• Dimpling/retraction/puckering - scirrhous carcinoma
• Nodules - often metastatic
• Ulceration and fungation - advanced carcinoma

3. Nipple

• Level - a raised or deviated nipple compared to the other side is significant
• Retraction - recent retraction is strongly suggestive of underlying carcinoma; long-standing retraction since puberty may be developmental
• Surface - cracks, fissures, eczema (bilateral suggests benign), Paget's disease (unilateral, starts as bright red areolar change → weeping ulcer)
• Discharge - note whether from nipple or from surrounding skin (mammary fistula); note character

4. Areola

• Colour - pale pink in young girls; darkens in adults; becomes brown in pregnancy
• Size - may enlarge in soft fibroadenoma/sarcoma; may diminish in scirrhous carcinoma
• Montgomery's glands - small nodules that normally line the areola; become enlarged (Montgomery's tubercles) in pregnancy
• Surface/texture - in Paget's disease, the areola becomes bright red early → destroyed leaving a red weeping ulcer

5. Arm and Thorax

• Brawny oedema of the arm - extensive neoplastic infiltration of axillary nodes (lymphatic blockage) or post-mastectomy
• Cancer en cuirasse - multiple cancerous nodules with thickened infiltrated skin like a coat of armour on the arm and thoracic wall

6. Axilla and Supraclavicular Fossa

• Inspect carefully for any visible swelling

The "Seven Ps" of Breast Examination

1. Positions - multiple positions as above
2. Palpation - systematic technique
3. Pads of fingers - use pads of the 3 middle fingers (not fingertips, not grasping)
4. Pressure - three levels: light, medium, deep
5. Perimeter - cover the entire breast including axillary tail
6. Pattern of search - vertical stripe (up-and-down) method preferred
7. Patient education - about self-examination and reporting changes

Palpation

Figure: A. Inspection with arms at sides. B. Inspection with arms raised. C. Palpation in supine position. D. Palpation of axilla. (Schwartz's Principles of Surgery, 11e)

Technique

• Always palpate the normal breast first - to establish the baseline texture for that individual (varies from soft/smooth to firm and lobulated)
• Use palmar surface of the fingers with the hand flat - NOT the fingertips and NOT a grasping/pinching motion
• Positions: sitting → semi-recumbent (45°) → supine
• In the supine position, place a small pillow under the scapula on the examined side so the breast rests evenly on the chest wall
• Arm may be raised over the head during palpation

Systematic Pattern

• Clavicle → inframammary fold (superiorly to inferiorly)
• Sternum → latissimus dorsi (medially to laterally)
• Include the axillary tail (tail of Spence)
• Palpate just behind the nipple (a small lump may be present here as the only abnormality)
• Preferred pattern: vertical stripe (up-and-down) rather than concentric circles or radial methods (which often miss the edges)

What to Note on Palpation (For Any Mass)

Nipple Assessment

• Gently compress the nipple to elicit any discharge
• Note: single duct discharge (duct papilloma, carcinoma) vs. multi-duct (fibrocystic change, duct ectasia)
• Bloody discharge - suspect carcinoma or papilloma; clear/serous - papilloma; milky - hyperprolactinaemia; purulent - infection

Lymph Node Examination

• Support the patient's arm/elbow to relax the shoulder girdle
• Use gentle palpation with fingertips up into the apex of the axilla
• Assess all three levels of axillary nodes (relative to pectoralis minor):
  • Level I - lateral to pectoralis minor
  • Level II - behind pectoralis minor
  • Level III - medial/apical (Rotter's nodes)

• Supraclavicular nodes - in the supraclavicular fossa
• Infraclavicular nodes
• Parasternal/internal mammary nodes

Breast Self-Examination (BSE)

• No longer routinely recommended for average-risk women (no improvement in survival; increases biopsies for benign lesions)
• For women who wish to perform BSE: examine 7-10 days after onset of menstrual cycle (premenopausal) or on a fixed calendar date (postmenopausal) - as instructed in Berek & Novak's Gynecology
• Method: inspect before mirror → palpate with vertical stripe method → soap and water in the shower can improve sensitivity

Clinical Breast Examination (CBE) vs. Screening

• CBE is part of routine gynecologic care
• It has limited sensitivity (~54%) and specificity compared to mammography
• Findings to prompt further workup: any palpable mass, nipple discharge, skin changes, or lymphadenopathy
• Key next steps after finding a mass: triple assessment (clinical examination + imaging + biopsy)

• Berek & Novak's Gynecology, Chapter on Breast Disease (p. 961-968)
• S. Das - A Manual on Clinical Surgery, 13e, Chapter 30 (pp. 415-422)
• Schwartz's Principles of Surgery, 11e, Chapter 17
• Creasy & Resnik's Maternal-Fetal Medicine, Chapter 11 (p. 239)

Breast Examination Findings - Illustrated Guide

1. Peau d'Orange ("Orange Peel Skin")

Fig. 30.9 - Classic peau d'orange appearance. Note the dimpled texture identical to orange peel skin. (S. Das - A Manual on Clinical Surgery, 13e)

Close-up of peau d'orange in breast carcinoma - the multiple small pits correspond to hair follicle openings tethered by lymphoedema.

• Inflammatory breast carcinoma (most classic cause) - carcinoma erysipeloides
• Locally advanced breast cancer with lymphatic permeation
• Rarely: severe mastitis/cellulitis (reactive, resolves with treatment)

2. Nipple Retraction / Inversion

Fig. 30.5 - Considerable retraction of the left nipple due to underlying carcinoma. Note also the dimpling/peau d'orange texture visible around the areola. (S. Das, 13e)

• Raises both arms over the head
• Presses hands on hips (contracts pectoralis)
• Leans forward from the waist

3. Nipple Retraction with Elevated Nipple Level

Fig. 30.10 - Retraction of the left nipple (elevated level, shown by arrow) due to a carcinoma at the upper outer quadrant. A swelling is also visible at the arrow site. The dashed line shows the level difference between the two nipples. (S. Das, 13e)

4. Advanced Breast Carcinoma with Fungation and Ulceration

Fig. 30.8 - Advanced carcinoma showing extensive fungation (cauliflower-like tumour growth through skin) and excavation. This represents very late-stage disease. (S. Das, 13e)

5. Cancer en Cuirasse with Ulceration

Fig. 58.29 - Cancer en cuirasse: advanced breast cancer with extensive tumour infiltration of the skin of the breast and axilla, with ulceration and necrosis extending to the lateral chest wall. (Bailey & Love's Short Practice of Surgery, 28e)

6. Skin Dimpling Demonstrating Fixity

Fig. 30.4 - Demonstration of peau d'orange. Note the pitting of the skin around the nipple-areola region. (S. Das, 13e)

Summary Table: Key Breast Inspection Findings

• S. Das - A Manual on Clinical Surgery, 13e, pp. 416-422
• Bailey & Love's Short Practice of Surgery, 28e, p. 954
• Schwartz's Principles of Surgery, 11e
• Wikidoc - Peau d'orange in Breast Cancer

Techniques of Palpation of the Breast - Detailed Description

Prerequisite Setup Before Palpation

• Always palpate the normal breast first - establishes individual baseline texture (varies from smooth/soft to firm and lobulated)
• Small pillow under the ipsilateral scapula when supine - so the breast rests evenly on the chest wall and does not fall laterally
• Ipsilateral arm raised above the head - flattens and spreads the breast tissue over the chest wall, making deep structures more accessible
• Examine in three positions: sitting → semi-recumbent (45°) → supine (lying flat)

Boundaries to Cover

Breast quadrants: upper outer (UOQ), upper inner (UIQ), lower outer (LOQ), lower inner (LIQ), with the axillary tail of Spence. (Stanford Medicine 25)

• Superiorly - clavicle
• Inferiorly - inframammary fold / upper rectus sheath
• Medially - sternum
• Laterally - latissimus dorsi / mid-axillary line
• Special areas - axillary tail of Spence + directly behind the nipple

Part A: Search Patterns (Routes of Travel)

The three search patterns: Circles (concentric), Wedges (radial), Lines (vertical strip). (Stanford Medicine 25)

Figure 74.6 - Clinical breast examination search patterns: vertical strip, radial spoke, and concentric circles. (Mulholland & Greenfield's Surgery, 7e)

1. Vertical Strip Method (Lawnmower / Lines Pattern)

• Begin at the axilla (most lateral point of breast tissue)
• Move fingers in a straight vertical line downward from the clavicle to the inframammary fold
• At the bottom, shift the fingers one finger-width medially
• Move upward in the next vertical strip
• Continue in alternating up-down columns, working medially across the breast toward the sternum
• Each column should overlap slightly with the previous one to ensure no area is missed
• The final columns cover the sternum and then loop back to include the axillary tail

• Covers the entire breast systematically with minimal risk of omitting the periphery
• Studies show the concentric circle and radial methods often miss the edges of the breast tissue
• Berek & Novak's Gynecology specifically states: the up-and-down vertical stripe is preferred over concentric circular or radial methods "in which the edges of the breast tissue often are omitted"

2. Concentric Circles Method (Circular Pattern)

• Begin at the outermost perimeter of the breast - identify the full extent of breast tissue
• Trace a large circle around the entire breast, maintaining steady finger contact
• At the end of each complete circle, move the fingers inward by one finger-width
• Continue tracing progressively smaller circles, spiralling inward toward the nipple
• Finish with direct palpation at the nipple-areola complex
• The innermost circle includes the subareolar tissue directly behind the nipple

• The outer edges are the most likely areas to be missed if the starting circle is placed too small
• Requires discipline to ensure each circle is complete and overlaps properly

3. Radial Spoke Method (Wedge / Clock Pattern)

• Conceptually divide the breast into segments like slices of a pie (or positions on a clock face)
• Begin at the 12 o'clock position at the outer edge of the breast
• Palpate inward toward the nipple along this "spoke"
• Return to the outer edge and move to the next clock position (e.g., 1 o'clock)
• Repeat for all positions around the full clock (12 "spokes" for a thorough exam)
• Each spoke is palpated from periphery to nipple

• Intuitive for documentation (e.g., "mass at 10 o'clock, 4 cm from nipple")

• The tissue between each spoke can be missed if spokes are spaced too far apart
• Less thorough coverage of the subareolar zone unless explicitly repeated

Part B: Search Techniques (Finger Movements)

1. Rubbing Movement (Most Accurate)

• Use pads of the three middle fingers (index, middle, ring)
• Press the pads into the breast and rotate in small circles OR push back and forth
• Apply at each spot for 2-3 seconds before moving to the next
• Apply three pressures at each spot (see Pressure section below)

2. Vertical Movement (Dipping Technique)

• Place finger pads on the breast surface
• Press downward firmly into the tissue, then release
• Repeat this dipping motion 2-3 times at each location
• Advance to the next spot and repeat

3. Piano Fingers Technique (Least Accurate - Avoid)

• Each finger independently presses down and releases, then the next finger presses, in sequence

• Highest failure rate - 36.5% of lesions missed overall; 46.5% miss rate in some studies
• The sequential single-finger pressure fails to compress breast tissue adequately between fingers, allowing lumps to "escape" to either side
• Should not be used as the primary examination technique

Part C: Depth of Pressure (Three-Level Palpation)

Part D: Bimanual Technique (for Large or Pendulous Breasts)

Figure 74.5 - A: Axillary node exam with ipsilateral arm supported. B: Bimanual upright. C: Bimanual supine with arm raised. (Mulholland & Greenfield's Surgery, 7e)

• One hand placed behind the breast (underneath/supporting)
• Other hand palpates anteriorly on top
• The breast tissue is trapped between both hands and compressed gently
• Most useful for large or pendulous breasts where single-hand palpation leaves deep tissue inaccessible
• Also used to check for retraction - cupping or molding the breast in the examiner's hands to reveal skin tethering

Part E: Palpation of the Nipple-Areola Complex

• Done last, after the full breast is examined
• Gently compress the nipple with the thumb and index finger
• Note any discharge (character, colour, whether from a single or multiple ducts)
• Duct papilloma or duct carcinoma - produces blood on expressing the nipple
• Palpate the subareolar tissue directly behind the nipple - a small lump here can be the only abnormality in the entire breast

Part F: Skin and Retraction Assessment During Palpation

• Skin fixity test: Try to move the lump while tenting the overlying skin; if the skin dimples or moves with the lump, it is fixed to skin (suggests carcinoma invading dermis)
• Traction test: Pinch a fold of skin over the lump; if it adheres to the lump rather than sliding freely, fixity is present
• Breast cupping: Cup both hands around the breast and mold it; any retraction that was not seen on inspection becomes apparent

Part G: Axillary Node Palpation

• Support the ipsilateral arm/elbow to fully relax the pectoral muscles and shoulder girdle - this is the single most important step
• Reach the fingers high into the apex of the axilla
• Palpate systematically:
  • Level I - lateral/inferior to pectoralis minor (most accessible)
  • Level II - posterior to pectoralis minor (central group)
  • Level III - medial/apical (highest, hardest to reach)
  • Pectoral group - medially along pectoralis major
• Also palpate supraclavicular and infraclavicular fossae

Summary Comparison Table

• Berek & Novak's Gynecology - Seven Ps of breast examination
• S. Das - A Manual on Clinical Surgery, 13e, pp. 418-422 - Palpation technique
• Mulholland & Greenfield's Surgery, 7e, Fig. 74.5-74.6 - Search patterns and bimanual technique
• Rescuing the Clinical Breast Examination (PMC5360550) - Rubbing vs. vertical vs. piano fingers accuracy evidence
• Stanford Medicine 25 - Illustrated search patterns