Breast Examination

Overview – Breast Examination

Breast examination is a vital clinical skill in OSCEs and real-world practice for evaluating breast lumps, nipple discharge, or suspicious skin changes. It plays a key role in the triple assessment of breast pathology alongside imaging and biopsy. Final-year medical students must demonstrate a confident, respectful, and systematic approach, including awareness of red flags for malignancy and metastatic disease, as well as an understanding of risk factors and staging. This article outlines a step-by-step guide for conducting a comprehensive breast exam — including inspection, palpation, lymph node assessment, and post-examination investigations.

General Principles

• Initial steps:
  • Wash hands, introduce yourself, confirm name and age
  • Explain the procedure clearly and obtain consent
  • Offer a chaperone (always with intimate exams)
  • Ask the patient to remove their top and sit upright on the bed
• Clarify the complaint:
  • Ask which breast is affected — left or right?

Inspection

Around the Bed

• Look for systemic signs of metastatic disease:
  • Dyspnoea, dysphonia, weight loss, jaundice, ascites, cachexia

Breast and Axilla

• Assess for:
  • Symmetry or visible lumps
  • Dimpling or skin retraction (due to Cooper’s ligament involvement)
  • Skin changes:
    • Ulceration (malignancy)
    • Scars (e.g., post-mastectomy)
    • Peau d’orange, prominent vasculature (malignancy)
    • Erythema: acute mastitis or abscess
    • Skin thickening with enlarged pores (cancer)
  • Nipple abnormalities:
    • Asymmetry, retraction, inversion
    • Scaling, rash, or ulceration (Paget’s disease or eczema)
    • Discharge types:
      • Bloody (cancer, intraductal papilloma)
      • Milky (galactorrhoea)
      • Serous (fibrocystic)
      • Greenish (ductal ectasia)
      • Purulent (abscess)

Dynamic Inspection

• Ask the patient to:
  • Press hands into hips
  • Raise arms overhead
  • Lean forward with arms raised
    → to reveal asymmetry, dimpling, or retraction

Palpation

Breast

• Patient lies supine, arm on examined side placed behind the head
• Start with the unaffected breast
• Use circular motion with middle three fingers in a clockwise fashion
  → Include nipple and axillary tail
• Palpation notes:
  • Light and deep palpation
  • If a lump is found → assess:
    • 4 S’s: Site, Size, Shape, Surface
    • 4 T’s + FCM:
      • Tenderness
      • Temperature
      • Transillumination
      • Texture (Consistency)
      • Fixation (skin, muscle, chest wall)
      • Mobility

Nipple

• Gently squeeze for discharge
  → Send any fluid for cytology

Lymph Node Examination

• Patient’s arm rested on your forearm; warn them of possible discomfort
• Axillary lymph node groups:
  1. Pectoral (anterior) – main breast drainage
  2. Subscapular (posterior)
  3. Humeral (lateral)
  4. Central (basal)
  5. Apical (deep in armpit, under clavicle)
• Also palpate supraclavicular and cervical nodes

Firm, non-tender, slow-growing nodes suggest malignancy

Post-Exam Assessment

Check for Metastases:

• Lungs: pleural effusion, consolidation
• Liver: hepatomegaly
• Spine: tenderness

Investigations:

• Bloods: LFTs, serum calcium
• Imaging: CXR, abdominal US, bone scan
• Ovary: transvaginal US (Krukenberg tumour)

Lymphatic Drainage

• Lateral drainage → Axillary nodes (Levels I–III relative to pectoralis minor)
• Medial drainage → Internal mammary nodes

Triple Assessment

1. Clinical Exam
2. Imaging:
   • Mammogram: ≥35yo; look for microcalcifications, spiculated masses
   • US: <35yo; solid = cancer, cyst = smooth
   • MRI: high-risk, dense breasts
3. Biopsy:
   • FNAC: C1–C5 grading
   • Core biopsy: distinguishes in situ from invasive carcinoma

Differential Diagnosis

Types of Breast Cancer

Non-Invasive:

• Ductal carcinoma in situ (DCIS): comedo necrosis
• Lobular carcinoma in situ (LCIS): bilateral, impalpable

Invasive:

• Ductal (commonest), Lobular, Mucinous, Medullary, Inflammatory (peau d’orange)

Prognosis

• Nottingham Prognostic Index = (0.2 × tumour size cm) + node score + grade
• TNM staging, Bloom-Richardson grading
• Her2 overexpression, ER/PR negativity, high Ki-67 = worse prognosis
• Triple-negative cancers → aggressive, high recurrence

Treatment

Surgery

• Breast-Conserving Surgery (BCS):
  • Lumpectomy + radiation (for <4cm, unifocal)
• Mastectomy:
  • Simple, skin/nipple-sparing, modified radical (Patey’s), radical (includes pectoralis minor)
• Complications: lymphedema, nerve injury, pain syndrome

Reconstruction

• Immediate or delayed
• Implants (Becker), flaps (DIEP, TRAM, LD)

Chemotherapy

• Neoadjuvant for large, node-positive, or metastatic
• Regimens: CMF, CAF, MMM
• SEs: alopecia, nausea, marrow suppression

Hormonal Therapy

• HER2+: Trastuzumab (check echo – risk of CHF)
• ER/PR+:
  • Premenopausal: Tamoxifen ± oophorectomy
  • Postmenopausal: Aromatase inhibitors (e.g., anastrozole)

Radiotherapy

• Indicated post-BCS, large tumours, or lymph node involvement

Lymph Node Management

• Sentinel node biopsy → Axillary clearance if >2mm metastasis
• Prevent lymphedema: elevation, compression, avoid BP cuffs

Metastasis

• Bone: bisphosphonates, radiotherapy
• Pleural effusion: drainage
• Brain/liver: directed radiotherapy or chemotherapy

Summary – Breast Examination

The breast examination is a core OSCE skill that requires a respectful, systematic approach, with attention to signs of malignancy, lymph node involvement, and metastatic spread. It plays a crucial role in the triple assessment, guiding further imaging and biopsy. Understanding the types of breast cancer, staging systems, and treatment options is essential for clinical competency. For a broader context, see our Clinical Skills Overview page.