Breast and axillae Flashcards
Colostrum
clear or milky fluid from breast before mild production
Cooper ligament
subcutaneous fibrous tissue that provides support to the breast
Duct ectasia
benign condition of the subareolar ducts that can cause nipple discharge
Fibroadenoma
benign tumor of the breast
Fibrocystic disease
benign condition that presents with fluid-filled cyst due to ductal enlargement that is usually bilateral and multiple
Galactorrhea
lactation not associated with childbearing
Intraductal papillomas
benign tumors of the subareolar ducts that produce a nipple discharge
Mastodynia
breast pain
Montgomery follicles
tiny sebaceous glands on areola
Paget disease
skin manifestations indicative of ductal carcinoma
Peau d’orange
breast skin changes due to edema caused by lymph drainage blockage, associated with breast cancer
Tail of Spence
area where most malignancies of the breast tissue occurs
Thelarche
beginning of female pubertal breast development
Muscles forming floor of the breast
Pec major and minor, Serratus anterior, Lat dorsi, subscapularis, external oblique, rectus abdominus
Lymphatics of breast
drain toward axilla, from central axillary nodes to infraclavicular and supraclavicular nodes, common places for metastases: axillae
***Tanner I
prepubertal, elevation of only papilla
***Tanner II
breast bud stage, elevation of breast and papilla as small mound, enlargement of diameter of areola
***Tanner III
further enlargement of breast areola with no separation of contours
***Tanner IV
areola projected above level of breast as secondary mound
***Tanner V
recession of areola mound to general contour of breast, projection of papilla only
Milk line
vestigial epithelium from axilla to inguinal region; some women have accessory breasts or nipples, most commonly in axilla
Breast inspection
Size best 5-7 days after menses onset Symmetry Alignment Nipple characteristics Shape/type (convex, pendulous, conical) Skin color and texture
Inframammary ridge
normal, transverse ridge of compressed tissue along lower edge of breast, common in pendulous breasts
***Five “D”s for Nipples
Discharge Depression or Inversion Discoloration Dermatologic changes Deviation - compared to opposite
Three broad groups of risk factors for breast cancer
modifiable, non-modifiable, uncertain/controversial/unproven
***Non-modifiable breast cancer risk factors
- gender (100x more female)
- age (most important - 2/3 occur @55yo+)
- genetic (5-10%, BRCA1/2)
- fmhx (1st degree doubles risk, 2 first degree 5x risk)
- pmhx
- race (white more likely to develop, Af. Am. more likely to die)
- dense breast tissue (higher risk)
- previous chest radiation
- Diethylstilbestrol exposure
- menstrual periods (before 12 menarche, after 55 menopause)
- benign breast conditions such as lobular carcinoma in situ
***Modifiable breast cancer risk factors
- post menopausal obesity
- exercise
- alcohol (2-5 daily increases risk)
- hormone replacement (combined HRT increases risk, reversible, not ET therapy alone)
- recent oral contraceptive use (reversible)
- childbirth (breast feeding lowers risk, nullparity increases risk)
***Uncertain/controversial/unproven breast cancer risk factors
- diets and vitamins
- antiperspirants
- bras
- induced abortion
- breast implants (make harder to examine, no higher risk)
- chemicals in environment
- tobacco smoke
- night work
Three breast cancer risk assessment tools
- Gail Model (5 year and lifetime estimates)
- Claus Model (high risk women, uses fmhx of males and females)
- BTCAPRO Model (high risk women, uses BRCA 1/2)
AGOG 2012 recommendations for early detection
- 40yo+ annual mammogram
- CBE (1-3 yrs for young women, annual for 40+)
- BSE
- high risk women: MRI and mammogram yearly
- moderate risk women: consider MRI with PCP
***Fibroadenoma characteristics
- Fibroadenoma: smooth, round, very mobile, nontender, well delineated, no retraction, 15-25yo
- usually bilateral, no variation with menses
***Fibrocystic characteristics
- Fibrocystic changes: nodular, ropelike, 25-50
- usually bilateral, multiple or single, mobile, soft to firm/elastic (spongy)
- no retraction, well defined borders
- variation with menses
***Breast Cyst characteristics
- Cysts: soft to form, round, mobile, often tender, well delineated, no retraction, 25-50yo
***Breast CA characteristics
- Cancer: irregular/stellate, firm/stone-like, mobile or fixed, not clearly delineated, usually nontender, maybe retraction, 25-50+
- no variation with menses, unilateral, single but may coexist
Montgomery tubercles
normal
Paget’s disease
- retraction or deviation => think cancer
- inversion vs. eversion
- unilateral or bilateral
Assymetric breasts likely means…
Think cancer
Retraction and dimpling likely means…
Recent unilateral inversion of previously everted nipple => malignancy
Peau d’orange
Skin edema around nipple at first
Associated with cancer
Three types of malignant tumors and age groups
- Infiltrating ductal
- 30-80yo, single mass
- irregular/stellate, hard/stone
- fixed
- most common type - Inflammatory
- lymphatic involvement frequent
- poor prognosis - Paget’s disease
- eczematous nipples
- rare form
- nipple redness/burning
- skin biopsy to dx
Normal variations of breasts
- size: often one is larger
- contact dermatitis: differentiate from paget’s with skin biopsy
- dermal cyst of nipple
Benign tumors
- cystosarcoma phyllodes: large bulky mass of cysts & CT, rapidly growing
- fibroadenoma: most common tumor <25yo, small/movable/firm/no change with menses
- intraductal papilloma: tumor of lactiferous ducts, nipple discharge
Menstruation and breasts
- do not examine breasts during menstruation
- breasts enlarge 3-5 days prior to menses
- increased nodularity and fluid buildup
- BEST to inspect breasts 5-7 days after onset
***Pregnancy and breasts
- fuller/more firm
- darker areola, enlarged/erect nipples
- colostrum during third trimester, which switches to milk only after birth (24hrs)
Most important symptoms o fbreast disease
- mass
- breast pain
- nipple discharge
- bloody=cancer
- yellow/green=infection
- white=colostrum
Breast mass stats
90% benign
60% discovered by SBE
Breast mass hx questions
- When first notice?
- Change during period?
- Physiologic nodularity?
- Tender?
- Previous mass?
- SKin changes?
- Recent injury?
- Nipple discharge or retraction?
- Pregnant, nursing, post-partum?
- FMHX?
Mastalgia questions and facts
- When did you first feel pain?
- Describe.
- Unilateral/bilateral
- Changes in menses?
- Change with cycles?
- Changes in breasts? - mass, d/c, retraction
- INjury?
Common causes: engorgement during luteal stage of cycle, pregnancy, hematoma, cysts, mastitis, abscess, galatocele, nipple disorder
Facts: rarely associated with breast cancer
Nipple d/c questions
- expressed or spontaneous?
- color?
- unilateral/bilateral?
- first notice?
- menstrual cycle related?
- LMP?
- NIpple retraction, mass, tenderness?
- medications - oral contras?
- if post-partum…any prob w/ delivery?
- FMHX?
Nipple discharge facts
- breast carcinoma
- spontaneous, bloody
- mass associated, single duct in one breast - non-malignant
- only with compression
- multiple ducts, bilateral
Either: fluid can be yellow/clear/white/dark green
Most common cause of cancerous d/c is intraductal papilloma –> ductal ectasia
Common causes of nipple d/c
intraductal papilloma, fibrocystic disease, sclerosing adenosis
less common: chronic cystic mastitis, ductal ectasia, galactocele, papillary cystadenoma, keratosis of nipple, fat necrosis, acute mastitis/abscess
