Clinical Case

Examination of a Breast Lump - Systematic Approach

General Setup

• Examine the patient first in sitting position, then semi-recumbent (45°), then recumbent
• Place a small pillow under the scapula of the side being examined so the breast rests evenly on the chest wall
• Always palpate the normal breast first to establish a baseline for texture and nodularity
• Use the palmar surfaces of the fingers (hand flat) - not the palm
• Also use pulp of fingers and thumb to better characterise a swelling

Inspection (sitting, arms at sides then raised)

• Asymmetry, skin changes
• Nipple - retraction, deviation, discharge
• Skin - dimpling, puckering, peau d'orange, prominent veins
• Scars or ulcers

Palpation of the Lump - 12 Key Points

1. Local temperature and tenderness - felt with the back of the fingers. Warm + tender = inflammatory (but beware acute mastitis carcinomatosa)
2. Situation - which quadrant? Carcinoma is commonest in the upper outer quadrant; fibroadenosis also occurs there; fibroadenoma is more often in the lower half but can occur anywhere
3. Number - solitary vs multiple (fibroadenosis is known for multiplicity; opposite breast may also be affected)
4. Size and shape - globular, irregular, etc.
5. Surface - smooth (fibroadenoma), irregular (carcinoma)
6. Margin - well-defined (fibroadenoma) vs ill-defined (carcinoma, fibroadenosis)
7. Consistency - cystic / firm / hard / stony hard
   • Firm, encapsulated = fibroadenoma
   • "India-rubber" diffuse feel = fibroadenosis
   • Stony hard = carcinoma
   • Variable = sarcoma
8. Fluctuation - stand behind patient; hold cyst with one hand and tap its centre gently with index finger of the other. Positive in cysts, chronic abscess, lipoma
9. Transillumination test - done in a dark room; torch placed on under-surface; fat is translucent, solid tumour is opaque
10. Fixity to skin - attempt to move the skin over the lump; also pinch the skin above the lump. Skin fixity = carcinoma
11. Fixity to pectoralis major - ask patient to press her hip firmly (contracts pectoralis); then try to move the lump along the direction of the muscle fibres. Restricted movement = deep fixity (carcinoma)
12. Fixity to chest wall - ask patient to place hands on hips and lean forward; try to move the lump in all directions

Lymph Node Examination

• Axillary nodes - examine with patient's arm supported relaxed; palpate apex, anterior, posterior, medial walls of axilla, and central nodes
• Supraclavicular nodes - palpate from behind
• No lymphadenopathy in fibroadenoma; nodes enlarged in carcinoma and inflammatory lesions

Findings Expected in This Case (Fibroadenoma)

Differential Diagnoses to Consider

1. Fibroadenoma - most likely given age, mobility, smooth well-defined lump, no fixity
2. Fibroadenosis (fibrocystic disease) - nodular, multiple lumps, bilateral, tender pre-menstrually
3. Cyst - soft, fluctuant, transilluminates, "blue-domed cyst of Bloodgood"
4. Breast carcinoma - always exclude; stony hard, irregular, fixed, skin/nipple changes; does not exclude in young patients

"Carcinoma should not be excluded if the patient is young or the lump is free from the skin or deeper structure or if the lymph nodes are not involved." - S Das, Manual on Clinical Surgery, p.433

Triple Assessment (next steps)

1. Clinical examination (as above)
2. Imaging - Ultrasound (preferred in <35 years); mammography if ≥35
3. Tissue diagnosis - FNAC or core needle biopsy (Sentinel LN Biopsy is relevant if malignancy is confirmed, as noted in your notes)