Breast cancer physical examination

Peau d’ orange appearance in breast cancer. Case courtesy of Rajendran MC. http://generalsurgeryclinics.blogspot.com/2013/06/peau-d-orange-appearance-in-carcinoma.html

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Soroush Seifirad, M.D.[2] Mirdula Sharma, MBBS [3]

Overview

Patients with breast cancer usually are generally well appearing. Physical examination of patients with breast cancer is usually remarkable for lump in the breast, peau d'orange, and inverted nipple.

Physical Examination

General Appearance

• Patients with breast cancer are generally well appearing. Patients are generally oriented to time, place, and person.
• Nevertheless, in late stages patients appear ill, pale, and might present with decreased level of consciousness.

Vital Signs

• Vital signs are generally normal in early stages.
• In the advanced disease state, almost any abnormality is possible due to brain, bone, liver, and lung metastases.

HEENT

• HEENT examination of patients with breast cancer is usually normal, particularly in the early stages.
• In metastatic breast cancer the following abnormalities might be present:

• Icteric sclera due to liver metastasis
• Ophthalmoscopic exam may be abnormal with findings of increased ICP due to brain metastasis.
• Erythematous throat with/without tonsillar swelling, exudates, and/or petechiae due to chemotherapy or widespread disease immunosuppression.

Neck

• Enlarged supraclavicular lymph nodes

Lungs

• Pulmonary examination of patients with breast cancer is usually normal, particularly in early stages.
• In metastatic breast cancer the following abnormalities might be present suggesting consolidation and pleural effusion due to metastatic disorder::

• Asymmetric chest expansion OR decreased chest expansion
• Hyporesonant lung auscultation
• Fine/coarse crackles upon auscultation of the lung bases either unilaterally or bilaterally
• Rhonchi
• Vesicular breath sounds OR distant breath sounds
• Normal/reduced tactile fremitus

Heart

• Cardiovascular examination of patients with breast cancer is usually normal/none contributory.

Breast

• Lump

• May be attached to the skin or chest wall and cannot be moved.
• The lump may feel hard, irregular in shape and very different from the rest of the breast tissue
• The lump maybe tender, but it is usually not painful.

• Dimpling of the skin
• Peau d'orange

• Thickening and dimpling of the skin

• Change in size of affected breast
• Inverted nipple
• Redness, swelling and increased warmth - in inflammatory breast cancer
• Crusting, ulcers or scaling on the nipple - in Paget's disease of breast
• Discharge from nipple - mostly bloody

Abdomen

• Abdominal examination of patients with breast cancer is usually normal/none contributory, particularly in the early stages.

• In metastatic breast cancer the following abnormalities might be present:

• Abdominal distension
• Abdominal tenderness in the right/left upper/lower abdominal quadrant
• A palpable abdominal mass in the right/left upper/lower abdominal quadrant due to peritoneal seeding
• Hepatomegaly / splenomegaly / hepatosplenomegaly
• Shifting dollness suggesting Ascites

Skin

With respect to the disease stage and complications, the skin could be either normal, pale, or icteric.

Extremity

Signs of metastasis

Neuromuscular

Signs of metastasis

• Headache
• Seizure
• Personality change
• Papilloedema

Back

• Back examination of patients with breast cancer is usually normal, particularly in the early stages.
• In metastatic disease, vertebrae is one of the most common sites of metastasis, hence point tenderness over the vertebrae is quite common.

Genitourinary

• Genitourinary examination of patients with breast cancer is usually normal.

Neuromuscular

• Neuromuscular examination of patients with breast cancer is usually normal.

OR

• Patient is usually oriented to persons, place, and time
• Altered mental status
• Glasgow coma scale is ___ / 15
• Clonus may be present
• Hyperreflexia / hyporeflexia / areflexia
• Positive (abnormal) Babinski / plantar reflex unilaterally/bilaterally
• Muscle rigidity
• Proximal/distal muscle weakness unilaterally/bilaterally
• ____ (finding) suggestive of cranial nerve ___ (roman numerical) deficit (e.g. Dilated pupils suggestive of CN III deficit)
• Unilateral/bilateral upper/lower extremity weakness
• Unilateral/bilateral sensory loss in the upper/lower extremity
• Positive straight leg raise test
• Abnormal gait (describe gait: e.g. ataxic (cerebellar) gait / steppage gait / waddling gait / choeiform gait / Parkinsonian gait / sensory gait)
• Positive/negative Trendelenburg sign
• Unilateral/bilateral tremor (describe tremor, e.g. at rest, pill-rolling)
• Normal finger-to-nose test / Dysmetria
• Absent/present dysdiadochokinesia (palm tapping test)

Extremities

• Extremities examination of patients with breast cancer is usually normal.
• The followings are suggesting metastatic disorder:

• Cyanosis in lung metastasis
• Pittingedema of the lower extremities suggesting malnutrition and liver involvement
• Muscle atrophy due to malnutrition is late stage metastatic cancer
• Bone tenderness
• Pathological fractures