(10) Breasts and Axillae Flashcards
Female Breast location
- lies against anterior thoracic wall
- extends from clavicle and 2nd rib down to 6th rib & from sternum across to midaxillary line
- surface usually rectangular instead of round
- overlies pectorals muscle and inferior margin of serrates anterior
how to describe breast clinical finding location
- 4 quadrants + tail of spence (axillary tail of breast tissue)
- face of a clock + cm distance from nipple
Male Breast
- consists chiefly of small nipple + areola overlying a thin disc of undeveloped breast tissue consisting primarily of ducts
- ductal branching and development of lobules are minimal b/c lack estrogen & progesterone stimulation
- difficult to distinguish male breast tissue from surrounding muscles of chest wall
- firm button of breast tissue 2cm or more in 1:3 adult men
Gynocomastia
- benign breast enlargement in men
- proliferation of palpable glandular tissue
- breast tissue often tender
- not risk factor for cancer
Pseudogynecomastia
accumulation of subareolar fat
Causes of gynocomastia
increased estrogen
decreased testosterone
medication side effects
most lymphatic vessels of the breast drain into:
axillary lymph nodes
most lymphatic vessels of the breast drain into ?
which of these are most likely to be palpable?
axillary lymph nodes
palpable = central nodes (lie along chest wall, usually high in axilla and midway between anterior and posterior folds
3 groups of breast lymph notes that drain into central nodes and are seldom palpable:
- pectoral nodes - anterior: located along lower border of pectorals major inside the anterior axillary fold; drain anterior chest wall and much of breast
- sub scapular nodes - posterior: located along lateral border of scapula; palpated deep in posterior axillary fold; drain posterior chest wall and portion of arm
- lateral nodes: located along upper humerus; drain most of arm
lymph drains from the central axillary nodes to the ? and ?
infraclavicular and supraclavicular nodes
do all lymphatics of the breast drain into the axilla?
no, malignant cells from a breast cancer may spread directly to the infraclavicular nods or into the internal mammary chain of lymph nodes within the chest
Breasts: common or concerning symptoms
breast lump or mass
breast discomfort or pain
nipple discharge
Breast lump reports: ID?
precise location
how long present
change in size or variation within menstrual cycle
Breast Pain (Mastalgia)
most common breast symptoms prompting office visits
breast pain alone w/o mass isn’t breast cancer risk factor
determine if pain is diffuse or focal (focal - may merit diagnostic imaging), cyclic or noncylic, rated to medications
Breast health history: symptom ask
lumps (50% have palpable lumps/nodularity)
discomfort (premenstrual enlargement and tenderness are common)
pain
change in breast contour, dimpling, swelling, puckering of skin over breast
nipple discharge
medications associated with breast pain
hormonal therapy
psychotropic drugs: SSRIs and Haldol
spironolactone
digoxin
Nipple discharge: health history
when it occurs
spontaneous or after nipple compression
- if spontaneous: color (brown, milky, greenish, bloody), consistency, quantity
unilateral or bilateral
causes of Physiologic nipple hypersecretion
pregnancy lactation chest wall stimulation sleep stress
physiologic nipple discharge is usually:
bilateral
multi ductal
prompted by stimulation
ranges in color from white to yellowish or greenish
Galactorrhea
discharge of milk-containing fluid unrelated to pregnancy or lactation
more likely to be pathologic when bloody or serous, unilateral, spontaneous, associated with mass, occurs in women >40
Breasts: important topics for health promotion and counseling
palpable masses of the breast
assessing risk of breast cancer
breast cancer screening
Palpable masses of breast: age 15-25
common lesion = fibroadenoma
characteristics = usually smooth, rubbery, round, mobile, nontender
palpable masses of breast: age 25-50
Cysts - usually soft to firm, round, mobile, often tender
fibrocystic changes - nodular, ropelike
cancer - irregular, firm, may be mobile or fixed to surrounding tissue
palpable masses of breast: age over 50
cancer until proven otherwise
palpable masses of breast: pregnancy
lactating adenomas
cysts
mastitis
cancer
most important risk factor for breast cancer is ?
age
non modifiable risk factors for breast cancer
family history or breast/ovarian cancer
inherited genetic mutations
personal hx of breast cancer or lobular carcinoma in situ
high levels of endogenous hormones
breast tissue density
proliferative lesions with atypic on breast biopsy
duration of unopposed estrogen exposure related to early menarche
age of first full term pregnancy
late menopause
modifiable risk factors for breast cancer
hx of radiation to chest DES exposure breastfeeding <1 yr postmenopausal obesity use or HRT cigarette smoking ETOH physical inactivity type of contraception
Male breast cancer
peaks 60-70 y/o
low incidence: primarily in situ and local-stage tumors
higher incidence: age, black, radiation exposure, BRCA1/2 mutations, Klinefelter syndrome, testicular disorders, family hx, ETOH, cirrhosis, obesity
Risk assessment tools for breast cancer risk
Gail Model & Claus Model (most common) BRCAPRO model (predicts risk of BRCA1or2)
Gail Model
breast cancer risk assessment tool
provides 5 year and lifetime estimates of risk of invasive breast cancer
incorporates age, race, 1st degree relative w/ breast CA, previous breast biopsy and presence of hyperplasia, age at menarche, age at first delivery
best used for >50y/o, no family hx (or just 1 relative w/ hx), get annual screening mammograms
not used for women w/ breast CA hx, radiation exposure, <35y/o
doesn’t determine risk of noninvasive breast CA, paternal dz hx, 2nd degree relatives, age of onset of dz
Claus Model
breast cancer screening tool:
asses risk for high-risk women and incorporates family hx for both female/male 1st and 2nd degree relatives including age of onset
based on current age
expanded version includes family hx ovarian CA
doesn’t include personal, lifestyle, reproductive risk factors
BRCAPRO
breast cancer screening tool for high risk women to assess risk of BRCA1 &2 mutation in a family
incorporates BRCA1/2 mutation frequencies, CA penetration in affected carriers, age of onset in 1st/2nd degree relatives
doesn’t include nonhereditary factors
family history: high risk factors for familial breast cancer
- <50 y/o age of diagnosis
- breast CA in 2 or more individuals in same lineage (paternal or maternal)
- multiple primary or ovarian tumors in 1 person
- breast CA in male relative
- Ashkenazi Jew
- family member w/ known predisposing general (including Li-Fraumeni and Cowden syndromes)
- start screening in 20s
Types of Benign Breast Lesions:
nonproliferation changes - cysts, ductal ectasia, mild hyperplasia, simple fibroadenoma, mastitis, granuloma, diabetic mastopahty
- no increased risk of breast CA
proliferative without atypia - ductal hyperplasia, complex fibroadenoma, papilloma
- small increased risk breast CA
proliferative with atypia - atypical ductal hyperplasia, atypical lobular hyperplasia
- moderate increased risk breast CA
Breast Density
- increasing importance as risk factor for breast CA
- on mammograms stromal & epithelial fibroglandular tissue appears white/dense, fat tissue appears dark
- when radiologic density reaches 60-75% relative risk of breast CA increase 4-6x r/t masking effect of breast density on smaller cancers which have same x-ray attenuation as fibroglandular breast tissue
breast self exam recommendations for average risk females
USPSTF - recommends against
ACA - not recommended d/t lack of evidence
ACOG - encourages
clinical breast exam recommendations for average risk females
USPSTF - >40y/o insufficient evidence
ACA - not recommended d/t lack of evidence
ACOG - 20-39 every 1-3 yrs, >40 annually
mammogram recommendations for average risk females
USPSTF - 50-74 biennially, <50 individualize, >75 no evidence
ACA - 40-45 optional, 45-54 biennial, >55 biennial or annual until life expectancy 10 yrs
ACOG - >40 annually
Digital mammography performs better in:
younger women w/ higher breast density
MRI recommendations for breast cancer screening
USPSTF - no evidence
ACA - MRI + mammogram onset 30y/o for high risk, discuss w/ MD for moderate risk
standardized approach to clinical breast exam
use systematic and thorough search pattern (up and down)
use finger pads
vary palpitation pressures
use circular motion
during clinical breast exam, most important factor in detecting suspicious changes?
length of time spent on palpitations ( 5-10 minutes)
best time of breast exam
5-7 dis after onset of menstruation (breasts tend to swell and become more nodular before menses from increasing estrogen stimulation - nodules appearing during premenstrual phrase should be re-evaluated at a later time)
Breast Inspection 4 views
arms at sides
arms over head
arms pressed against hips
leaning forward
-inspect for skin changes, symmetry, contours, retraction
Breast inspection: sitting up with arms at sides
- appearance of skin (color, thickening, prominent pores)
- size and symmetry of breasts (some differences normal)
- contour of breasts (masses, dimpling, flattening)
- nipple characteristics (size, shape, direction, rashes/ulcerations, discharge)
breast skin redness suggests ?
local infection
inflammatory carcinoma
beast skin thickening and prominent pores suggest ?
breast cancer
flattening of normally convex breast suggests ?
cancer
asymmetry d/t change in nipple direction suggests ?
underlying cancer
eczematous changes w. rash, scaling, or ulceration on the nipple extending to the areola suggests?
Paget disease of the breast, associated w/ underlying ductal or lobular carcinoma
nipple pulled inward, tethered by underlying ducts signals?
nipple retraction from a possible underlying cancer - the retracted nipple may be depressed, flat, broad, or thickened
Inverted nipple
depressed below areolar surface, may be enveloped by folds of areolar skin but can be moved out from its sulcus
- normal variant of no clinical importance
- possible difficulty breast feeding
breast dimpling or retraction may suggest?
underlying cancer - cancers w/ fibrous strands attached to skin and fascia over the pectoral muscles may cause inward dimpling of the skin during muscle contraction
benign conditions: post traumatic fat necrosis or mammary duct ectasia
Breast Palpation
- supine position
- palpate rectangular area from lavicle to inframammary fold and midsternal line to posterior axillary line and into axilla for the tail of the breast
- thorough exam takes 3 min per breast
- use finger pads of 2nd,3rd,4th fingers
- use vertical strip pattern
- palpate in small concentric circles w/ light, medium, deep pressure
- examine entire breast including periphery, tail, and axilla
Breast Palpation: lateral portion
- ask pt to roll onto opposite hip, hand on forehead w. shoulder pressed against exam table
- flattens lateral breast tissue
- begin palpation in axilla moving straight down to bra line, do vertical strip pattern until reach nipple
Breast Palpation: medial portion
- ask pt to lie w/ shoulders flat against exam table
- place hand at her neck and lift up her elbow until its even with her shoulders
- palpate in straight line down from nipple to bra line continuing in vertical strip pattern to midsternum
nodules in tail of spence can be mistaken for?
enlarged axillary lymph nodes
Breast Palpation: examine Breast tissue for
- consistency of tissues (normal varies on proportions of firmer glandular tissue and soft fat and physiologic nodularity, note firm inframmary ridge which is transverse ridge of compressed tissue along lower margin of Brest especially I large breasts - ridge sometimes mistaken for tumor)
- tenderness
- nodules (any lump or mass different or large than rest of breast tissue - dominant mass)
Breast Nodule: assess and describe
location (quadrant or clock w/ cm from nipple)
size (cm)
shape (round or cystic, dislike, irregular in contour)
consistency (soft, firm, hard)
delimitation (well circumscribed or not)
tenderness (check for cysts and inflamed areas - some cancers may be tender)
mobility (in relation to skin, pectoral fascia, chest wall - move breast near mass for dimpling)
tender cords in breast suggest ?
mammary duct ecstasies (benign but painful condition of dilated ducts w/ surrounding inflammation and associated w/ menses)
hard irregular poor circumscribed nodule fixed to skin or underlying tissues suggests ?
cancer
Positions to palpate breast nodules
supine
relaxes arm
pressed hand on hip
mobile mass that becomes fixed when the arm relaxes is attached to ?
fixed when hand is pressed against the hip ?
ribs and intercostal muscles
attached t pectoral fascia
thickening of nipple and loss of elasticity suggests ?
underlying cancer
Nipple Palpation
- elasticity
- determine origin of discharge by compressing areola w. index finger in radial positions
milky discharge unleaded to prior pregnancy and lactation is ?
non puerperal galactorrhea
causes include hyperthyroid, pituitary prolactinoma, dopamine antagonists (psychotropics and phenothiazines)
spontaneous unilateral blood discharge from one or two ducts warrants further eval for ?
intraductal papilloma, ductal carcinoma in situ, or Paget’s disease
(clear, serous, green, black, non bloody discharges that are multiductal are usually benign)
Exam of male breast
inspect nipple and areola for nodules, swelling, ulceration
palpate areola and breast tissue for nodules
if breast is enlarged: distinguish between soft, fatty enlargement of obesity (pseudogynecomastia) and the firm disc of glandular enlargement (gynecomastia)
male breast: hard, irregular, eccentric, ulcerating painless dominant mass suggests ?
breast cancer
The axilla: inspection
sitting position preferred (can be lying)
note: rash, infection, unusual pigmentation
sweat gland infection from follicular occlusion suggests ?
hidradenitis suppurativa
deeply pigmented velvety axillary skin suggests ?
acanthuses nigricans - associated w/ diabetes, obesity, PCOS, malignant paraneoplastic disorders
the axilla: palpation
Left
-ask pt to relax w/ left arm down
-cup together fingers of R hand & reach as high as possible toward apex of axilla
-fingers should lie directly behind pectoral muscles, toward mid clavicle
press fingers toward chest wall and slide them down
-try to feel central nodes against chest wall (one or more soft <1cm contender nodes is normal)
(opposite for R)
enlarged axillary nodes may suggest ?
infection from hand or arm
recent immunizations or skin tests
generalized lymphadenopathy
(check epitrochlear nodes medial to the elbow & other groups of lymph nodes)
nodes that are large (>1-2cm) and firm or hard, matted together, or find to skin or underlying tissues suggests ?
malignancy
if central nodes feel large, hard, tender or suspicious lesion in drainage areas for axillary nodes, palpate these other nodes:
pectoral - grasp anterior axillary fold between thumb and fingers, w. fingers palpate inside border of pectoral muscle
lateral - from high in axilla, feel along upper humerus
subscapular - step behind pt and w/ fingers feel inside muscle of posterior axillary fold
infraclavicular and supraclavicular
post mastectomy: masses, modularity, and change in color or inflammation in incision line suggest ?
recurrence of breast cancer
Breast Exam of mastectomy or breast augmentation pt
inspection: inspect scare and axilla for masses, unusual modularity, signs of inflammation or infection
- lymphedema may be present in axilla and upper arm from lymph drainage interrupted by surgery
palpation: palpate gently along scare (may be sensitive), palpate tissue along scar, use circular motion w/ 2or3 fingers, pay attention to upper outer quad and axilla for enlarged lymph nodes
instructions for breast self exam
times 5-7 days after menses with hormonal stimulation of breast tissue is low
- lying: place pillow under same shoulder w/ same arm behind head, 3 middle fingers - dime size circular motions in vertical strip pattern from out to in w/ varying pressure (firmer closer to chest/ribs), firm ridge in lower curve normal
- standing: look in mirror w/ hands on hips for size, shape, contour, dimpling; examine each underarm w/ arm slightly raised(if too high tissue is to tight to examine)
3 most common breast masses
fibroadenoma
cyst
cancer
Fibroadenoma: AGE: NUMBER: SHAPE: CONSISTENCY: DELIMITATION: MOBILITY: TENDERNESS: RETRACTION:
AGE: 15-25 y/o (puberty-young adult) but up to 55 NUMBER: usually single, may be multiple SHAPE: round, dislike, lobular; small 1-2cm CONSISTENCY: may be soft, usually firm DELIMITATION: well delimitated MOBILITY: very mobile TENDERNESS: usually nontender RETRACTION: absent
Breast Cyst characteristics: AGE: NUMBER: SHAPE: CONSISTENCY: DELIMITATION: MOBILITY: TENDERNESS: RETRACTION:
AGE: 30-50y/o, regress after menopause except w/ estrogen therapy NUMBER: single or multiple SHAPE: round CONSISTENCY: soft to firm, usually elastic DELIMITATION: well delimitated MOBILITY: mobile TENDERNESS: often tender RETRACTION: absent
Breast Cancer characteristics: AGE: NUMBER: SHAPE: CONSISTENCY: DELIMITATION: MOBILITY: TENDERNESS: RETRACTION:
AGE: 30-90, most common >50
NUMBER: single, may coexist w/ other nodules
SHAPE: irregular or stellate
CONSISTENCY: firm or hard
DELIMITATION: not clearly delineated from surrounding tissues
MOBILITY: may be tied to skin or underlying tissues
TENDERNESS: usually non tender
RETRACTION: may be present
Visible signs of breast cancer: retraction signs
other causes of retraction?
fibrosis (scar tissue) = shortening of tissue = dimpling, changes in contour, retraction/deviation of nipple
other causes of retraction include: fat necrosis and mammary duct ectasia
Visible signs of breast cancer
retraction: -abnormal contours -skin dimpling -nipple retraction and deviation skin edema Paget disease of nipple
Visible signs of breast cancer: nipple retraction and deviation
flattened, pulled inward, broadened, feels thickened
points toward underlying cancer
visible signs of breast cancer: skin edema
orange peel sign (peau d’orange)
- produced by lymphatic blockade
- appears thickened skin w/ enlarged pores
- often first seen in lower portion of breast or areola
visible signs of breast cancer: Paget’s disease
uncommon form of breast cancer that usually starts as a scaly, eczema like lesion on nipple - may weep, crust, erode
- breast mass may be present
- suspect in any persisting dermatitis of nipple and areola
- often presents w/ underlying in situ to invasive ductal or lobular carcinoma
