Clinical Exercise: Clinical Breast Exam

Scenario:

A patient is performing a routine self-examination of her breast and detects what feels like a lump on her left breast. She also notices some discoloration of the skin superficial to the lump.

Diagnosis:

You recognize that the patient may have a breast cancer. You also observe the dimpling with discoloration of the skin superficial to the lump and the patient.

You do not have immediate access to a mammogram and decide to perform a clinical breast examination to confirm the patient self-examination result of a lump in the vicinity of the discoloration.

Mechanism:

The skin discoloration is termed peau-d'orange (French for “skin of an orange”). Breast cancer commonly leads to a lump or swelling, and inflammatory type of breast cancer can also lead to peau-d'orange when located superficially in the fascia. However, multiple conditions can lead to peau-d'orange so the physical examination in insufficient to confirm or rule out breast cancer in the patient.  A mammogram and/or a small needle biopsy are diagnostic tools you would use to narrow your differential diagnosis.

Early detection of breast cancer is strongly correlated with improved outcome. The clinical breast examination (CBE) performed by a physician is no longer a standard of care recommendation from the American Cancer Society in favor of mammograms as standard of care. Although there is controversy between organizations in these recommendations. CBE is still ~60% sensitive and ~95% specific for detecting breast cancer. While not as accurate as a mammogram, in the absence of access to a mammogram the CBE is better than no screening at all. 

Mammograms are the gold standard for detection of breast masses and should be performed annually starting at age 45, then every two years from age 55. A mammogram can detect masses that are significantly smaller than those which could be detected by a CBE.

A breast self-examination (BSE) as part of routine wellness does play an important a role in detection and reporting of any changes to the patient's health care provider. 

Examination (perform these steps on the donor in a mock procedure):

1) With the donor in a supine position (on their back) extend the arm out to the side such that you can access the axilla on both sides of the patient.

Dry the arm with paper towel to prevent fluid spill onto the floor and monitor during the exercise to ensure appropriate cleanliness.

Perform the physical examination whether your donor is male or female. While breast cancer is of very low incidence in males, it can occur, and an examination would be conducted in a very similar manner.

2) Use the pads of three of your fingers firmly press the skin while making small circular motions (circumscribing a radius about the size of a dime) to feel for any masses or textural inconsistencies.

Simple downward compression is less effective at detecting an underlying mass than a 'sliding' motion of circular movement of the finger pads over the tissue.

The most sensitive parts of the fingers are the pads of the digits, not the tips, and the use of multiple fingers further enhances sensitivity during palpation.

3) Use a systematic pattern as you move across the breast so as not to miss any region.

This pattern should cover from the lateral edge of the sternum from ribs 2 through 6 to cover the body of the breast. Ensure that the physical examination extends through the upper outer quadrant to the axilla, so that the axillary tail of glandular tissue is also covered by examination.

The three most common patterns to the exam are concentric circles spiraling out from the nipple, wedges radiating out from the nipple, or lines making a grid covering the entire breast. The style of pattern does not affect the exam and is used only to ensure systematic coverage of all breast tissue without missing a region.

4) If you detect any irregularities or masses use a marker to circumscribe the location on the breast so that your transection in the next laboratory can pass through the irregularity to investigate the potential mass.

Detection of masses within an embalmed donor has considerably reduced sensitivity compared to a living patient. Later, in the privacy of your home, conduct a self-examination to compare the tissue density differences.

Outcome:

The CBE performed confirms both the presence of a mass and the peau-d'orange. You schedule the patient for a mammogram which shows the presence of an inflammatory breast cancer.  Following surgical treatment, the patient has no further incidents.