CLINICAL BREAST EXAMINATION Assist.Prof. Arzu Akalın M.D.

CLINICAL BREAST EXAM includes; careful history-taking, visual inspection, palpation of both breasts, armpits and root of the neck educating women on breast self-examination and awareness, particularly on breast lumps.

Risk Factors A familial history of breast cancer increases the risk by a factor of two or three. Some mutations, particularly in BRCA1, BRCA2 and p53 result in a very high risk for breast cancer. Prolonged exposure to endogenous estrogens, such as early menarche, late menopause, late age at first childbirth Oral contraceptive and hormone replacement therapy use Alcohol use, Overweight and obesity, Physical inactivity Breastfeeding has a protective effect

HISTORY TAKING age at menarche, marital status, parity, age at first child birth, history of lactation and breast-feeding, age at menopause, family history of breast and ovarian cancers in first degree relatives (mother, sisters, aunts, grandmothers), history and duration of oral contraceptive use, hormone replacement therapy (HRT), treatment for infertility tobacco and alcohol use.

Breast Anatomy

Breast Anatomy The breast is composed of 15-20 lobes and contains glandular, ductal, fibrous, and fatty tissue.

More lobes are present in the outer quadrants, especially the upper outer quadrants, Therefore many breast conditions (among them, breast cancer) occur more frequently in these regions

Axillary tail of breast tissue An axillary tail of breast tissue extends toward the anterior axillary fold.

Examination of the Breast (Inspection & Palpation) The exam should be performed in a well-lit room and privacy is facilitated by draping parts of the body not being examined.

Examination of the Breast (Inspection & Palpation) Occurs with the patient seated, Arms at side; With hands on hips; and With arms above the head. Changes in size, shape, symmetry, or texture are noted.

INSPECTION

Examination of the Breast (Inspection & Palpation) Is performed with the patient supine, arms flexed at a 90-degree angle at the sides. Palpation includes supraclavicular, infraclavicular, and axillary nodes. Compression may identify a mass and/or elicit a discharge. Nipples should be examined for deviation, retraction, skin changes, or discharge.

Supraclavicular L N Infraclavicular LN Axillar LN Internal Mammary LN

Benign Breast Masses General Considerations Benign breast masses will often change with the menstrual cycle, while worrisome masses are persistent throughout. Greater than 90% of palpable breast masses in women between 20 and 55 are benign. Masses may be discrete or poorly defined, but differ from the surrounding breast tissue and the corresponding area in the contralateral breast. Cancer should be excluded in a woman who presents with a solid mass.

Benign Breast Masses Breast cysts Fibrocystic breast changes Fibroadenoma Ductal papilloma

Nipple Discharge Categorized as Physiologic Pathologic (nonphysiologic). Physiologic Pathologic Nonspontaneous Spontaneous Bilateral Unilateral Arising from multiple ducts Arise from a single duct

Carcinoma of the Breast Most common malignant tumor among women 1/8 of women will develop breast cancer

Physical Signs a. Slowly growing, painless mass b. May demonstrate retracted nipple c. May be bleeding from nipple d. May be distorted areola, or breast contour e. Skin dimpling* in more advanced stages with retraction of Cooper’s ligaments *Dimple=Gamze Note skin dimpling in the 6 o'clock radius

f. Attachment of mass g. Edema of skin 1)with “orange skin” appearance (peau d’orange) due to blocked lymphatics h. Enlarged axillary or deep cervical lymph nodes

Breast Cancer Screening Guidelines of ACS* 2012 BSE ages ≥20 monthly or irregular CBE ages 20-30 part of periodic examination at least every 3 year ages ≥40 annually Mammography begin anuual mammography at age 40 * American Cancer Society