Contents of this paper:

Why now?
Summary
Normal breast lumps
Localised normal breast lumps
Lumpology
Teaching patients how to palpate
Palpating the axilla
Innovations in recording   breast lumps
Questions for further   research
Notes and references:
Appendix 1. Notes on   palpating axillary   nodes

• steadily rising expectations
• some panic
• medicolegal crisis
• professional wish for continuing improvement
• novel unproven concepts

What follows is a discussion of the geography of the normal breast

Summary

Normal breast lumps have rarely been considered up till now.

There is need for a more detailed descriptive language for both normal and abnormal lumps, just as there are supposed to be 25 different Eskimo words for snow or for white. (Though an urban myth, this provides a handy metaphor). Both phrases and words are needed anew.

Women (and men) need better ways of learning how to palpate their breasts (and other parts of their body).
Breast lumps (and lumps in general) need to be described and recorded better.

Possible innovations presented here briefly are the gladwrap-ogram, the tilted photocopier, and digital camera jig. With the last, each clinical record can include a diskette or reference to a computer tile.

The act of palpation can be considered in terms of forces exerted by the fingers repeatedly over a short period of time. Some lessons can be learned from attempts at robotic simulation of sense or touch, part of a field referred to as "haptics".

The truth of these propositions rests on the outcome of future testing them.

Normal breast lumps
Existing models for teaching breast examination and breast self-examination are dismally misleading. They present the idealized homogeneous "Hollywood breast" and not the normal lumpy breast.

There are almost a dozen different types of normal lump. In time they may be correlated to the gross anatomy and arrangement of anatomical components of the breast. This discussion refers to examination both supine and seated, with arm by side (especially for the axilla - see below) and with the arm raised.

Localised normal breast lumps

Each of these will be laughingly obvious to some people, and utterly unobvious to others. A woman aware of her third rib for the first time during a typical public scare campaign about breast cancer may arrive for a consultation tense, pale, stressed, and in tears,

1. Outside the breast

• Ribs
• Pectoralis major

2. Within or on the breast tissue

• Peri-areolar shoulder of breast tissue abutting the cylinder of soft fat traversed by the lactiferous ducts
• Axillary tail fullness, where glandular tissue is covered by less fat.
• Accessory axillary breastHorizontal streaks of tissue, typically 2 - 4 in number, measuring I x 24 cm.
• A thickened horizontal ridge of tissue, typically 1-2 x 4-5 cm in older women in the lower half of drooping breasts, presumably fibrosis from repeated folding,
• A firmer horizontal ridge right at the lower margin of the breast, typically 2 by 5 cm (see note in Appendices)
  

3. Surgically related

• Scars
• Healing ridge of firm swollen recent granulation scar tissue for up to 8 weeks after excisional biopsy
• Dints from previous excision without adequate suture

4. Lumps changing with time

• Increased size and altered texture before and during the early part of each period
• Developing breast bud at puberty
• Life-time changes from childhood to old age

5. Scattered or multiple normal breast lumps

• Cooked rice grains, spherical or ovoid, 2 - 4 mm long
• Fat lobules, 1/2 to 2 cm across
• Larger areas (actually volumes) of increased thickness of 3 x 5 cm, often with projecting nodules of harder tissue merging into the general breast tissue, measuring I - 2 cm across.

6. Sporadic nodules of firmer tissue

• Additionally there should be noted the "pseudo-lipoma" described by Tom Ackland as occasionally masking a breast cancer.

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  This list of normal lumps is quite separate from a listing of abnormal lumps, detected by several different techniques and classified in several different ways - by pathology, aetiology, morphology ("breast mouse" for a localised fibroadenoma), radiology and other imaging, and other criteria.

Breast lump glossary

Lumps can be described using words, phrases, numbers, [expanding the notion of language] graphics,, eye-cons, ear-cons, smell-cons., and gestures (An example of a gesture is twiddling the fingers of the two hands in referrring to the thick ridge of healing tissue where the deep wound edges are "knitting together"). The only feel-cons may be a few models which simulate skin and deeper tissues.,

Consider clouds. By etymological definition these are nebulous, but the concepts are not. They can be considered as stratus, cumulus, nimbus, cirrus. and a hundred other categories and sub-categories.

Words for lumps similarly become tools for thought, and tools for action. Consider for example Kipling's six little servants of the journalist - who what why how when where.

Lumpology
Here in mnemonic form are 15 aspects of describing the morphology of lumps. Each of these terms can be further sub-sub-subdivided and become an essay in itself, when time allows.

Site [1]
Size
Shape

Colour
Contour
Consistency [2]

Temperature
Tenderness
Translucency

Skin
Surrounds [3]
Structures deep

Regional nodes
Rest of patient
Relevant tests

[I] including depth
[2] see Appendix
[3] including fixity or motility - see immediately below

Some terms stand out, for example orange-peel skin, tethering, stony-hard. Mobility is one of the most important and traditionally comes after "shape". In this schema it fits into "surrounds'".

Teaching patients how to palpate

Apart from the obvious medical aspects, it is likely that this is now a legal need. This subject is covered with varying degrees of accuracy and usefulness in a large and growing range of well-intentioned literature.

Small lumps and the well-defined edge of larger structures are best palpated with one fingertip. Non-mobile lumps are often felt much more clearly when the finger is moved in one direction and much less clearly when the finger is moved in a line at right angles to this. This will be important in demonstrating the lump to the patient when she is otherwise finding this difficult - see below.

The amount of force to be applied is quite light, in the range of100-200 grams weight or 1 - 2 Newton, or about 2 - 3 times the force to just depress the key on a good-quality electronic keyboard. A nervous patient, like a tense typist, is likely to press five or ten times harder. In some cases of fibroadenosis and in very nervous patients tenderness may restrict applied force to between 10 and 50 grams weight

For larger lumps, have one fingertip on either side of the apex of the lump or towards each edge, dipped alternately about 4 times over a couple of seconds, with a force of 50-200 grams weight.

One person demonstrating an obscure lump to another
A technique for showing patients how to feel specific lumps in the breast is for the examiner to put their own fingertip on the apex of the lump, have the patient put the tip of the index finger from the other side of the body on the examiner's fingernail, and withdraw their finger so that the patient's finger goes directly onto the lump. The patient then copies the movement direction,
extent, and force.

The same technique can be used in reverse, so the patient can show the examiner a lump they have found which is otherwise difficult for the examiner to locate, especially just before surgical excision or exploration.

Such a technique works also for the axillary nodes, including normal ones, which may measure 3 - 10 mm in diameter. They are amongst the most difficult lumps to palpate reliably, even for experienced examiners (see Appendix). Palpating them includes the sensation of flip and flippability. The ability to feel them depends obviously on their size, consistency, and the thickness and consistency of the overlying skin. A flip (or flick which is a finer movement) occurs when the lumps is felt to suddenly move from tensed tissue on one side or end of the fingertip to another.

Palpating the axilla

To palpate the axilla the fingernails need to be short, and it may take half a dozen attempts, pressing up into the axilla With a surprisingly large force of 2 to 3 kilograms weight (approximately- 20 - 30 Newton). This force can be simulated and estimated by pressing down onto a kitchen scale. To improve the surgeon's learning experience, the clinical findings should be correlated with the operative ones. More details are given in the Appendix.

Innovations in recording breast lumps

The traditional free-hand sketch or template (printed or rubber-stamped] carries the risk of inaccuracy, especially when a different clinician is to operate later. It can be improved on.

The gladwrap-ogram:

With a permanent felt-tip marker, mark on the patient's skin the orienting landmarks of sternal and xyphoid notches, one or two intercostal spaces, nipple, areola, scars, and moles (more so for obese breasts and possible recurrences)

After it dries, have help to apply an unwrinkled piece of gladwrap, trace the skin markings, remove and spread carefully onto photocopier and make 3 photocopies at the lowest setting. Mark each with name, d.o.b, date, with copies for the notes, the patient, and the referring doctor.

Digital camera jig

Dedicated camera on swing-out arm above examining couch. Download image file stored on diskette in patient's folder or in departmental or hospital computer.

Questions for further research (minimal or no funds needed!)

Clinical and epidemiological questions

• What is the incidence of the various normal lumps?
• How do they correlate with age, morphology, types of bras?
• What proportion of patients abandon self-examination because they are confused by normal lumps?
• To what extent will these propositions help the patient / person learn the individual features of their own breast. A typical reaction is, yes I knew that thickening or this lumpiness was there but I hadn't heard it put into words
• How common is this?
• Will these proposals improve detection of breast cancer
  - in the individual patient?
  - in teaching palpatory skills to many individuals?
• What place do they have in an era of rapidly improving imaging?
• Do they improve differentiation from non-malignant lumps?
• Do they-give patients increased confidence and reassurance?
  At this time the answer seems an overwhelming yes (Level 6 evidence), based on one clinician's experience.
• Is this wasting the time of busy distracted clinicians?
• Will it improve the medicolegal situation?
• Will it improve the public perception of what health providers set out to do in managing breast cancer?

Academic questions

• What happens in palpation?
• Does the fingertip actually rise up in the air on palpating a lump or is it nearly all the different in resistance sensed by adjacent tactile nerve endings?

Palpation is a dynamic "haptic" process requiring arrays of touch receptors in a deformable matrix, sensing of force, and movement. It has strong analogies to stereoscopic vision and its related central cerebral processing. It has a rich but immature literature.

Notes and References:
An earlier reference to a "normal lump": How To Do Breast Self-Examination 1988, American Cancer Society, Inc. brochure. Revised April 1993 88-200M
Rev.4193-No. 2088, Internet version, states: "A firm ridge in the lower curve of each breast is normal." This is the only such mention found so far, though the vast literature on breast disease may others.

For a discussion of forces exerted during clinical examination and in surgery, and simple methods of measuring them., see:
Patkin M (1970) Measurement of tenderness, with description of a simple instrument, Med. J. Aust, 1, 670-2.
Patkin, M and Isabel, L (1995) Ergonomics, engineering and surgery of endosurgical dissection. JRCSEd 40: 120-132.

For current research on the mechanics, biology, and other aspects of palpation, see:
Russell RA (1990) Robotic Tactile Sensing. Prentice Hall 1997 International Symposium on Experimental Robotics, Barcelona, Spain.
June 1997. Mechanical Design and Control of a High-Bandwidth Shape
Memory Alloy Tactile Display. Parris S. Wellman William J. Peine Gregg E.
Favalora Robert D. Howe. Internet publication at
http://hrl.harvard.edu/-parris/research.html (see other papers and video files at this site).
Internet search, Yahoo, on Haptics (see separately)
Medline search on breast + self-examination (see separately)

Appendices

Consistency:
Deformability, fluctuation, sign of emptying, pulsatility, transmitted pulsation. The term "diffluent" has been used in place of "fluctuant" to describe the consistency of soft fat lobules often found in the breast but is only found in a major reference such as the Oxford English Dictionary of 20 volumes in hardback..

It would be interesting to develop an analogue for Mob's scale of hardness used in geology - ten grades - talc, gypsum, calcite, fluorite, apatite, orthoclase, quartz, topaz, corundum, diamond.

Such as spectrum might include gassy, watery, thick liquid, soft and fluffy, soft sponge rubber, firm sponge rubber, soft and uniform, soft balloon, squash ball, tennis ball, soft rubbery, average rubbery, hard rubbery, wooden hard, stony hard, rock-hard, diamond-hard.
Commercially, measurements are made of the firmness of fruit as an index of ripeness in in the quality control of vehicle tyres.

Appendix 1. Notes on palpating axillary nodes
from comments by Luis Isabel, former registrar to J J (Jeff) Price, General and Breast Surgeon, Bradford Royal Infirmary, Duckworth Lane, Bradford UK

The technique of palpating axillary nodes is badly taught. While Hugh Dudley once wrote a paper reporting that nodes were palpable by surgeons in only 50 per cent of axillary examinations, Price (who has published little) taught that they are practically always palpable.

To palpate axillary nodes, abduct the patient's arm a little, put 4 fingertips up to the head of the humerus, adduct the arm, and move the fingertips down the axilla while massaging the area with slow small circular movements of the fingers. The nodes will move down with the fingertips and then suddenly jump back up. [Note the usual BSE advice to abduct the arm widely, which puts the skin and underlying tissues under tension, restricting or preventing flick or flip, and perhaps more importantly carries the fat containing the nodes upwards out of possible reach - an interesting proposition to test during axillary dissection].

The anterior "pillar" of nodes can be palpated by rotating the hand so that the palm faces anteriorly, and again with the pulp of the fingers, massaging as above to feel the globular type of lymph glands.

For the posterior pillar, rotate the hand so the palm faces posteriorly, insert the thumb into the apex, then into in the groove between axilla and latissimus dorsi, and again assaging a little and gently to palpate better..

Nodes can then be described as small mobile, pathological mobile, enlarged, or in other terms.

This is quite different to "put your hand in there and have a feel". On the contrary, this means taking more time (the number of minutes and the number of attempts could be specified) in teaching students - or surgeons how to examine the axilla.

-o0o-

Working notes:
Extra items for use in discussions:
Kitchen scale to demonstrate forces exerted by the fingers
Push-pull Chatillon gauge
Form for force measurements
Gladwrap, felt-tip pen
Examples
Tabular summary
Clinical notes
Diskette of acrobat files
Computer plus large monitor
Overhead transparencies