Breast

Question 1

Anatomy of the breast

Answer 1

The 2 mammary glands are highly developed apocrine sweat glands.
They develop embryologically along 2 lines extending from the axillae to the groin- the milk lines.
In humans, only 1 gland develops on each side of the thorax although extra nipples with breast tissue may sometimes occur.
The breasts extend from the 2nd to the 6th ribs and transversely from the lateral border of the sternum to the midaxillary line.
For the purposes of examination, each breast may be divided into 4 quadrants by horizontal and vertical lines intersecting at the nipple.
An additional lateral extension of breast tissue (the axillary tail of Spence) stretches from the upper outer quadrant towards the axilla.
Each mammary gland consists of 15-20 lobes separated by loose adipose tissue and subdivided by collagenous septa.
Strands of connective tissue called the suspensory ligaments of the breast (Cooper’s ligaments) run between the skin and deep fascia to support the breast.
Each lobe is further divided into a variable number of lobules composed of grape-like clusters of milk-secreting glands termed alveoli and is drained by a lactiferous duct that opens onto the nipple.
Myoepithelial cells surround the alveoli which contract and help propel the milk towards the nipples.
The nipple is surrounded by a circular pigmented area called the areola and is abundantly supplied with sensory nerve endings.
The surface of this area also contains the ‘sebaceous glands of Montgomery’ which act to lubricate the nipple during lactation.

Question 2

Lymphatic drainage of the breast

Answer 2

Lymphatic drainage from the medial portion of the breast is to the internal mammary nodes.
The central and lateral portions drain to the axillary lymph nodes which are arranged into 5 groups.

Question 3

Breast physiology: normal breast changes in women

Answer 3

Puberty
The menstrual cycle
Pregnancy
Post-natal
Menopause

Question 4

Breast physiology: normal breast changes in women, puberty

Answer 4

During adolescence, oestrogen promotes the development of the mammary ducts and distribution of fatty tissue while progesterone induces alveolar growth.

Question 5

Breast physiology: normal breast changes in women, the menstrual cycle

Answer 5

Towards the 2nd half of the menstrual cycle, after ovulation, the breasts often become tender and swollen.
They return to their ‘resting’ state after menstruation.

Question 6

Breast physiology: normal breast changes in women, pregnancy

Answer 6

High levels of placental oestrogen, progesterone, and prolactin promote mammary growth in preparation for milk production.

Question 7

Breast physiology: normal breast changes in women, postnatal

Answer 7

The sharply declining levels of oestrogen and progesterone permit prolactin to stimulate the alveoli and milk is produced.
Suckling stimulates secretion of prolactin as well as releasing oxytocin which stimulates myoepithelial cells to contract.

Question 8

Breast physiology: normal breast changes in women, menopause

Answer 8

The breasts become softer, more homogenous, and undergo involutional changes including a decrease in size, atrophy of the secretory portions, and some atrophy of the ducts.

Question 9

Important breast symptoms: focused history

Answer 9

Begin by establishing a menstrual history.
Determine the date of the last period of menstruation.
Pre-existing disease in the breast is likely to become more noticeable during the 2nd half of the menstrual cycle- lumps often get bigger or become more easily palpable.
Breast pain (mastalgia)
Nipple discharge
Breast lumps
Gynaecomastia
Galactorrhoea

Question 10

Important breast symptoms

Answer 10

Breast pain (mastalgia)
Nipple discharge
Breast lumps 
Gynaecomastia
Galactorrhoea

Question 11

Important breast symptoms: breast pain (mastalgia)

Answer 11

SOCRATES.
Is the pain unilateral or bilateral?
Is there any heat or redness at the site?
Are there any other visible skin changes?
Is the pain cyclical or constant- and is it related to menstruation?
Is there a history of previous similar episodes?
Is the patient breast-feeding?
Is the patient on any hormonal therapy (e.g. HRT)?
Commonest cause of mastalgia in premenopausal women is hormone-dependent change.
Other benign causes include mastitis and abscesses.
1% of breast cancers present with mastalgia as the sole symptom.

Question 12

Important breast symptoms: nipple discharge

Answer 12

Important causes of nipple discharge include ductal pathology such as ductal ectasia, papilloma, and carcinoma.
Is the discharge true milk or some other substance?
Colour of the discharge, e.g. clear, white, yellow, blood stained?
Spontaneous or non-spontaneous discharge?
Is the discharge unilateral or bilateral?
Any changes in the appearance of the nipple or areola?
Mastalgia?
Any breast lumps?
Periareola abscesses or fistulae indicating periductal mastitis?- closely linked to smoking in young women.

Question 13

Important breast symptoms: galactorrhoea

Answer 13

After childbearing, some women continue to discharge a small secretion of milk (galactorrhoea).
In rare instances this can be the 1st presenting symptom of a prolactin-secretin pituitary adenoma.
Ask about headaches, visual disturbance, and any other neurological symptoms to rule this out.

Question 14

Important breast symptoms: breast lumps

Answer 14

Most important cause is cancer.
When was the lump first noticed?
Has the lump remained the same size of enlarged?
Does the size of the lump change according to the menstrual cycle?
Is there any pain?
Are there any local skin changes?
Is there a history of breast lumps?- previous biopsies, diagnoses, and operations.
A full systems enquiry should include any other symptoms which might be suggestive of a neoplastic disease (weight loss, appetite loss, fatigue, etc.) and metastatic spread to other organ systems (SOB, bony pain, etc.).
Fibroadenomas common between 20-30 years.
Cysts common between 30-50 years.
Cancer very rare <30 years.

Question 15

Important breast symptoms: gynaecomastia

Answer 15

This is enlargement of the male breast tissue which should not normally be palpable.
There is an increase in the ductal and connective tissue.
Common occurrence in adolescents and the elderly.
Seen in obese men due to increased adipose tissue.
May be drug-related, e.g. oestrogen receptor binders such as oestrogen, digoxin, and marijuana as well as anti-androgens such as spironolactone and cimetidine.
Ask about drug and hormone treatment, e.g. for prostate cancer.
Look for signs of hypopituitarism, chronic liver disease, and thyrotoxicosis.

Question 16

Inspection of the breast: before you start

Answer 16

When examining the female breast, examiners should have a chaperone present.
Ideally, the chaperone should be female.
The patient should be fully undressed to the waist and sitting on the edge of the ed with her arms by her side.
You should be able to see the neck, breasts, chest wall, and arms.

Question 17

Inspection of the breast: general inspection

Answer 17

Stand in front of the patient and observe both breasts.
Size.
Symmetry.
Contour.
Colour.
Scars.
Venous pattern on the skin.
Any dimpling or tethering of the skin.
Ulceration.
Skin texture: e.g. any visible nodularity, peau d'orange caused by local oedema in breast carcinoma and following breast radiotherapy.

Question 18

Inspection of the breast: nipples

Answer 18

Symmetrical.
Everted, flat, or inverted.
Scale: may indicate eczema or Paget’s disease of the breast.
Associated with any discharge: single duct discharge can indicate a papilloma or cancer, multiple duct discharge at the nipple suggests duct ectasia, if abnormalities are present make sure these are a recent or long-standing appearance.

Question 19

Inspection of the breast: axillae

Answer 19

Ask the patient to place her hands on her head and repeat the inspection process.
Pay particular attention to any asymmetry or dimpling that is now evident.
Examine the axillae for masses or colour change.

Question 20

Inspection of the breast: manoeuvres

Answer 20

Finally, dimpling or fixation can be further accentuated by asking the patient to perform the following manoeuvres.
Lean forward whilst sitting.
Rest her hands on her hips.
Press her hands against her hips (pectoral contraction).
Anatomical position, hands on hips, arms crossed above head.

Question 21

Palpation of the breast: before you start

Answer 21

Palpation of the breast should be performed with the patient lying at about 45 degrees on the bed.
Initially, the patient should have her hands by her sides.
Examination of the upper-outer quadrant is best performed with the hand on the side to be examined placed behind her head.
Ask the patient if there is any pain or tenderness, and examine that area last.
Ask her to tell you if you cause any pain during the examination.
Begin the examination on the asymptomatic side, allowing you to determine the texture of the normal breast first.

Question 22

Palpation of the breast

Answer 22

Should be performed by keeping the hand flat and gently rolling the substance of the breast against the underlying chest wall.
Most breasts will feel ‘lumpy’ if pinched.
Proceed in a systematic way to ensure that the whole breast is examined.
Start below the areola and work outwards in a circumferential pattern, ensuring that all quadrants have been examined.
Alternatively, examine the breast in 2 halves working systematically down from the upper border.
Do not forget to examine the axillary tail of Spence stretching from the upper-outer quadrant to the axilla.

Question 23

Palpation of the breast: lumps

Answer 23

If you feel a lump, describe it thoroughly noting especially: position, colour, shape, size, surface, nature of the surrounding skin, tenderness, consistency, temperature and mobility.
Next, ascertain its relations to the overlying skin and underlying muscle.
You must decide whether you are feeling a lump or a lumpy area.

Question 24

Palpation of the breast: skin tethering

Answer 24

A lump may be described as tethered to the skin if it can be moved independently of the skin for a limited distance but pulls on the skin if moved further.
Tethering implies that an underlying lesion has infiltrated Cooper’s ligaments which pass from the skin through the subcutaneous fat.
On inspection at rest, there may be puckering of the skin surface as if being pulled from within, or there may be no visible abnormality.
To demonstrate tethering, move the lump from side to side and look for skin dimpling at the extremes of movement. Ask the patient to lean forwards whilst sitting. Ask the patient to cross her arms above the head.

Question 25

Palpation of the breast: skin fixation

Answer 25

This is caused by direct, continuous infiltration of the skin by the underlying disease.
The lump and the skin overlying it cannot be moved independently.
It is on a continuum with skin tethering.
This may be associated with some changes of skin texture.

Question 26

Palpation of the breast: the relation of a lump to the muscle

Answer 26

The lump may be tethered or fixed to the underlying muscle, e.g. pectoralis major.
Lumps that are attached to the underlying muscle can be moved to some degree if the muscle is relaxed but are less mobile if the muscle is tensed.
Ask the patient to rest her hand on her hip with the arm relaxed.
Hold the lump between your thumb and forefingers and estimate its mobility by moving it in 2 planes at right angles to each other (e.g. up/down, left/right).
Ask the patient to press her hand against her hip causing contraction of the pectoralis major. Repeat the mobility exercise.

Question 27

Palpation of the breast: immobile lumps

Answer 27

If a lump is immobile in all situations, it may have spread to involve the bony chest wall, e.g. in the upper half of the breast or axilla, or may be a lump arising from the chest wall.

Question 28

Palpation of the breast: the nipple

Answer 28

If the patient complains of nipple discharge, ask her to gently squeeze and express any discharge, noting colour, presence of blood and smell.
Milky, serous, or green-brown discharges are almost always benign.
A bloody discharge may indicate neoplasia (e.g. papilloma or cancer).

Question 29

Examining beyond the breast: lymph nodes

Answer 29

Support the patient’s arm to examine the lymph nodes in the axillae.
When examining the right axilla, abduct the patient’s right arm gently and support it at the wrist with your right hadn’t whilst examining the axilla with your left hand.
Examine the main sets of axillary nodes including: central, lateral, medial (pectoral), infraclavicular, supraclavicular, apical.
If you feel any lymph nodes, consider site, size, number, consistency, tenderness, fixation, and overlying skin changes.
Palpate for lymph nodes in the lower deep cervical lymph chain at the same time as the supraclavicular nodes.

Question 30

Examining beyond the breast: the rest of the body

Answer 30

If cancer is suspected, it is worth performing a full general examination, keeping in mind the common sites of metastasis of breast cancer.
Examine especially the lungs, liver, skin, skeleton, and CNS.

Question 31

Breast examination: skills station, model technique

Answer 31

Clean your hands.
Introduce yourself.
Explain the purpose of examination, obtain informed consent.
‘The examiner will act as your chaperone’.
Ask for any painful areas you should avoid.
Ask the patient to undress to the waist and to sit upright facing you.
Look for asymmetry, swellings, ulceration, skin changes, scars.
Repeat the inspection with the patient’s arms crossed over her head and tensed at her hips.
Ask the patient to lie back on the bed.
Using the palmar surface of your first 3 fingers, gently palpate the entire breast, remembering the axillary tail.
Elevate the breast and inspect and palpate below.
Palpate the nipple between index finger and thumb. Massage to express any discharge and carefully collect in a universal container.
Palpate the axillary lymph nodes.
Palpate the supraclavicular and cervical lymph nodes.
Examine the opposite side.
Thank the patient and ask them to redress.

Question 32

Breast cancer: background

Answer 32

1/9 women will develop breast cancer in their lifetime (most >50).
Breast cancer is the most common cancer in women worldwide.
It accounts for about 25% of all female malignancies, with a higher proportion in developed countries.
Male:female ratio is 1:100.
Male patients present with the same physical signs and have the same prognosis as female patients.
Over 1 million new cases occur each year worldwide.

Question 33

Breast cancer: risk factors

Answer 33

Female.
Increasing age (80% of cases occur in postmenopausal women).
Previous history of breast cancer, previous benign breast disease.
Not breastfeeding long term.
Use of hormone replacement therapy or oral contraceptives.
Family history of breast cancer.
No children or few children.
Having children late (especially over 30).
Early puberty, late menopause.
Obesity (for postmenopausal women only).
High consumption of alcohol.
Geographical (e.g. higher in Northern Europe, USA).

Question 34

Breast cancer: symptoms

Answer 34

75% symptomatic, 25% present through screening.
Patients may present reporting a breast lump, nipple changes, skin changes, or symptoms of metastases.
1% of patients present with pain as the only symptom.

Question 35

Breast cancer: triple assessment

Answer 35

All suspected breast cancer cases should have 'triple assessment'.
Clinical history and examination.
Radiological examination (e.g. mammography, ultrasound).
Pathological examination (e.g. fine needle aspiration/biopsy).

Question 36

Breast cancer: inflammatory breast cancer

Answer 36

Presents with oedematous, indurated, and inflamed skin.
Skin may be red, hot, and itchy (easily misdiagnosed as mastitis).
Accounts for 1-5% of all breast cancers.
Prognosis is very poor (5-year survival 25-50%).
Not usually associated with a lump and may be difficult to diagnose by mammography or ultrasound- MRI may be useful.

Question 37

Breast cancer: examination findings, inspection

Answer 37

There may be no features visible on inspection.
Mass or dimpling.
When there is lymphatic invasion the overlying skin has an oedematous look or pea d’orange (orange peel).
In late disease ulceration may be present.
Nipples may be normal or show inversion, destruction, deviation, or be associated with a bloody discharge.
Paget’s disease of the nipple/areola looks like eczema.

Question 38

Breast cancer: examination findings, palpation

Answer 38

Hard, non-tender lump (may be impalpable), 50% occur in the upper outer quadrant.
Indistinct surface with exact shape often difficult to define.
The lump can be tethered or fixed to the skin, surrounding breast tissue, or chest wall.
Look for axillary or supraclavicular lymphadenopathy.
May present with lymphoedema of the affected arm.

Question 39

Breast cancer: nipple discharge

Answer 39

10% due to neoplasia (papilloma or cancer).
Commonest symptom of cancer after ‘lump’.
Beware of neoplasia if discharge is blood-stained, persistent, and from a single duct.
Multiple duct creamy discharge is often due to duct ectasia.
Bilateral galactorrhea is usually medication-induced in the absence of pregnancy or beyond 6 months post-partum.
The most common pathological cause is pituitary tumour.

Question 40

Breast fibroadenoma: background, epidemiology and symptoms

Answer 40

Benign tumours that represent a hyper plastic or proliferative process in a single terminal ductal unit.
The cause is unknown.
Reducing incidence with increasing age, majority occur before the age of 30.
Higher incidence in those taking the oral contraceptive pill.
May involute in postmenopausal women.
May grow rapidly during pregnancy, HRT, or immunosuppression.
Most stop growing after they reach 2-3cm.
Often asymptomatic.

Question 41

Breast fibroadenoma: examination findings

Answer 41

Typically a smooth, mobile, palpable lump.
No fixation to the skin or deep tissues.
May occur in any area of the breast, but especially upper outer quadrant.
Non-tender.
Normally solitary but may be multiple.
No lymphadenopathy.

Question 42

Breast cysts: background and epidemiology

Answer 42

Can appear suddenly and cause pain.
Commonest palpable lump in women aged 30-50 years.
Subareolar main duct cysts may occurring those aged 10-20 years.
Related to oestrogen metabolism.
Can be perpetuated by HRT in women >50.
Can coexist with cancer.

Question 43

Breast cysts: symptoms

Answer 43

Often asymptomatic and incidentally picked up on imaging.

Patient may complain of a palpable, visible, or painful lump.

Question 44

Breast cysts: examination findings

Answer 44

Round, smooth, symmetrical, discrete lump.
May be mobile or tender.
May range from soft to hard.
It is rare to be able to elicit fluctuance, fluid thrill, or transillumination.

Question 45

Fat necrosis of the breast

Answer 45

This can occur after trauma and the physical signs can mimic cancer (e.g. a firm hard lump with skin tethering).

Question 46

Breast abscesses

Answer 46

Mainly occur during the childbearing years and are often associated with trauma to the nipple during breastfeeding.
Present with a painful, spherical lump with surrounding oedema.
Often show constitutional symptoms such as malaise, night sweats, hot flushes, and rigors.
Most recurrent or chronic breast abscesses occur in association with duct ectasia or periductal mastitis.
The associated periductal fibrosis can often lead to nipple retraction.

Question 47

Abnormal nipple and areola

Answer 47

Disease of the nipple are important because they must be differentiated from malignancy and cause concern to patients.
Unilateral retraction or distortion of a nipple is a common sign of breast carcinoma, as is blood-stained nipple discharge.
Blood-stained nipple discharge suggests an intraductal carcinoma or benign papilloma.
A unilateral, red, crusted and scaling areola suggests an underlying carcinoma (Paget’s disease of the breast) or, more commonly, eczema.

Question 48

Puerperal mastitis

Answer 48

Most commonly seen in the first 6 weeks of breastfeeding.

Caused by staphylococcal infection of the ducts.

Question 49

Periductal mastitis

Answer 49

Mean age is 32 years and there is an increased incidence in smokers.
Recurs in up to 50% due to persistence of underlying diseased duct.
Mammary duct fistula: communication between the skin and a major subareolar breast duct, develops in 1/3 of non-lactating periareolar abscesses.

Question 50

Non-puerperal mastitis

Answer 50

In many cases, starts as non-bacterial inflammation.
Risk of recurrence, secondary to infection, and abscess formation is high.
Risk factors: smoking, diabetes, trauma, hyperprolactinaemia.

Question 51

Mastitis: symptoms

Answer 51

Pain, tenderness, swelling (80%).
Redness (80%).
Lump or diffuse swelling of the breast.
Systemic features of infection.

Question 52

Mastitis: examination findings

Answer 52

Skin of affected area is red, hot, and tender.
A cracked nipple may be evident.
There may be a discrete tender lump or diffuse swelling.
There may be ipsilateral tender axillary lymphadenopathy.
If there is abscess formation, this may be evident as a firm, tender lump initially which may then develop into a fluctuant swelling.