Breast And Axillae Flashcards
Where does breast tissue start and stop
Start: clavicle/2nd rib
Stop: 6th rib, sternum, to mid axillary line
What muscles do the breast overlay? And what type of tissues does the breast contain?
- Overlies pectoralis major and serratus anterior msucles
- Consists of
*glandular
*Fibrous
*adipose
What does the glandular tissue contain
It is hormonal sensitive with
1. Tubuloalveolar glands and ductules, arranged in 15 to 20 lobes
*has 20-40 lobules in each lobe
*acini cells are milk producing
*lactiferous ducts drain milk
Where is the greatest concentration of glandular tissue
In the upper outer quadrant
What is the purpose of the fibrous tissue
- Provides support and shape
*has suspensory ligaments (Cooper’s)
What is the purpose of the adipose tissue
Fat tissue (80-85% of the breast)
*surrounds glandular tissue
What are some factors that can affect breast tissue
- Age
*younger = more fibro-glandular
*older = atrophy of glandular tissue - Pregnancy
- Lactation
- Cyclic hormonal changes
What surrounds the nipple
The Areola
*has sebaceous, sweat, and accessory glands
*Montgomery glands which increase in pregnancy, it is an oily substance that protects tissue during lactation
What type of tissue is the nipple made of
Epithelium and smooth muscle
*has a smooth muscle reflex which will make the nipple smaller, firmer, more erect with tactile stimulation
What does the sensory innervation provide to the nipple
Triggers milk letdown
*signals to the brain to have milk come out faster
What are supernumerary nipples
Extra nipples
*located along embryonic milk line
*may be mistaken for a mole
*no pathological significance
What is the vascular supply of the breast
Axillary artery
*superior thoracic
*pectoral branches of the thoraco-acromion artery
*lateral thoracic
Internal mammary artery
*medial
Intercostal perforators
What are the central axiallry lymphatics of the breast
They are palpated most frequently
*along the chest wall, midway between anterior and posterior axillary folds
*can drain to infracalvicular and supraclavicular nodes
What are the pectoral lymphatics of the breast
Drain anterior chest wall and much of the breast
What are the subscapular lymphatics of the breast
Drain posterior chest wall and a portion of the arm
What are the lateral lymphatics of the breast
They are along the upper humerus, and drain most of the arm
What are the components of the male breast
- Consists of small nipple and areola
- Overlies a thin disc of underdeveloped breast tissue
- Has a firm button of tissue 2+cm in diameter
What is the tail of Spence
- Axillary tail of breast tissue
- Extends laterally across the anterior axillary fold
Where does the upper inner quadrant fall between
12 and 3 o’clock
Where does the lower inner quadrant fall between
3 and 6 o’clock
Where does the lower outer quadrant fall between
6 and 9 o’clock
Where does the upper outer quadrant fall between
9 and 12 o’clock
*area has the most breast tissue
What are stage 1 and 2 of tanner stages (breast development)
Stage 1: preadolescent: elevation of nipple only
Stage 2: breast bud stage-elevation of breast and nipples as a small, mound enlargement of areola diameter
What are stage 3 and 4 of tanner stages (breast development)
3: further enlargement of the breast and areola with no separation of contours
4: projection of areola and nipple to form a secondary mound above the level of breast
What is stage 5 of the tanner stages (breast development)
5: mature-projection of nipple only, areola recedes to general contour of breast
What must happen if you found a breast mass or lump/
Must always be carefully assessed
What is galactorrhea
- Inappropriate discharge of milk-containing fluid
*abnormal if occurs 6 months or more after childbirth or cessation of breast feeding
What should be included in the PMH of a woman
- Previous breast disease
- Surgeries
*breast biopsy
*implants
*reduction/augmentation - menstrual history
- Pregnancy
- Lactation
What is the most common cause of cancer in women worldwide
Breast cancer
US: 12% 1 in 8 women have a risk to develop
*African American women have a higher incidence of breast cancer before 45
What are the modifiable risk factors for breast cancer
- Post menopausal obesity
- Use of HRT
- Alcohol ingestion
- Physical inactivity
- breast-feeding choices
What are the non-modifiable risk factors for breast cancer
- Age/Gender
- Personal history of breast cancer
- Breast tissue density
- Proliferative lesion with atypical on breast biopsy
- Duration of estrogen exposure
*early menarche
*age of first full-term pregnancy >30
*late menopause >55
How do BRCA1 and BRCA2 mutation relate to cancer
Autosomal dominant
BRCA1 have a 85% risk of developing breast cancer
BRCA2 have a 31-51% risk
Are breast self-examinations recommended?
No
*be self aware of breasts
When are mammograms recommended
Around age 40ish
*strongly recommend at age 50 and older
What are some things to mention to a patient for breast self-awareness
Have the be aware of changes n breast
1. Lump, hard knots or thickening inside the breast
2. Swelling, warmth, redness or darkening
3. Change in the size or shape
4. Dimpling or puckering of the skin
5. Pulling in of the nipple
What to teach for patients who are interested in a BSE
- Should be done monthly
- 5 to 7 days after menses
- Can be taught as early as age 20
What is the optimal time complete a clinical breast exam
5 to 7 days after onset of menses
How to inspect the breast
Assess at the four views
1. Arms at sides
2. Arms over head
3. Arms pressed against hips
4. Leaning forward
How to palpate the breasts
- Have the patient in the supine position
- Have patient place arm behind head (flattens lateral aspect)
- Start at the tail of Spence (mid axillary line)
- Use finger pads of 2,3,4
- Use the vertical strip patterns
- Palpate using small, circles
How to position the patient for the medial breast palpation
Arms at side, palms on table
What areas of the breast tissue will be palpated for a thorough exam
- Clavicle
- Inframammary fold
- Posterior axillary line
- Mid sternal line
How to document any nodules (dominant masses)
- Location quadrant or clock cm from the nipple
- Size in two dimensions cm
- Determine the consistency
- Determine the shape
- Determine if there is any tenderness
What is the significance of palpating each nipple
To determine if their is spontaneous nipple discharge
What are some findings that are consistent with malignancy in a breast mass
- Hard consistency
- Irregular shape
- Dimpling of overlying skin
- Associated retraction of nipple
- Non tender
Palpable lymphadenopathy is commonly due to
A: Infection in the hand or arm
B: Skin testing in the arm
C: Recent immunization in the arm
D: All of the above
*D
Which of the following characteristics of a breast mass is LEAST suggestive of malignancy?
A: Hard consistency
B: Dimpling of overlying skin
C: Tenderness
D: Irregular shape
C
If you have a male patient with enlarged breast what must you determine?
- Soft, fatty enlargement of obesity (pseudogynescomastia)
- Firm disc of glandular enlargement (gynecomastia)
How to position the patient for the axillae exam
Sitting
How to palpate the axilla
Right side
1. Move right arm out the way and use as support
2. Use left hand and reach as high as possible toward the apex of the axilla
3. Press fingers toward chest wall and slide them downward
*one or more soft, small nontender node is normal
4. If central node are large, hard or tender feel for other groups of axillary nodes
How to palpate a post mastectomy
- Inspect along the scar and axilla for masses
- Palpate the entire chest area, especially along the scar
*use same circular motion
How to palpate a patient with breast implants
- Use same circular method
- Rippling is common along edges
- Contracture will have a hard consistency `
What are sub-glandular and sub-muscular implants
Sub-glandular
*above the muscle
Sub-muscular
*below the muscle
What is fibroadenoma
- Common benign neoplasm frequently in young women
- Hormonal relationship is likely they can increase in size during pregnancy and regress after menopause
- Round, firm, discrete, relatively moveable, non tender max 1 to 5 cm in diameter
What are the fibrocytic breast changes
- Painful, often multiple, usually bilateral mobile masses in the breast
- Rapid fluctuation in the size of the masses
- Most common age is 30 to 50 years old
*occurrence is rare in postmenopausal women
What is Paget’s disease of the breast
- Eczematoid eruption and ulceration that arises from the nipple, can spread to the areola
- Associated with an underlying carcinoma
- Pain, itching and burning
- Superficial erosion or ulceration
What is Peau d’orange
- Caused by blocked lymph drainage from advanced carcinoma
*causes edema - The skin appears thickened with enlarged pores and accentuated skin marking
*orange peel
