Breast and Regional Lymphatics

Question 1

The breasts lie anterior to the _______ major and serratus _______ muscles. Located between 2nd and ____ rib.

Answer 1

pectoralis
anterior
6th

Question 2

The superior lateral corner of breast tissue, called the axillary ___ __ ______, projects up and laterally into the axilla.

Answer 2

tail of spence

Question 3

In the areola are small elevated sebaceous glands, called _______ glands. These secrete a protective lipid material during lactation.

Answer 3

montgomery

Question 4

The breast is composed of 1.) ______ tissue, 2.) Fibrous tissue including supsensory ligaments and 3.) adipose tissue

Answer 4

glandular-contains 15-20 lobes radiating from the nipple, and these are composed of lobules. each lobe are clusters of alveoli that produce milk.

Question 5

The suspensory ligaments, or ______ ligaments, are fibrous bands extending vertically from the surface to attach on chest wall muscles.

Answer 5

Cooper’s- these become contracted in cancer of the breast, producing pits or dimples in the overlying skin.

Question 6

The lobes are embedded in _____ tissue, provide for most of the bulk of the breast.

Answer 6

adipose

Question 7

What are the 4 groups of axillary lymph nodes?

Answer 7

1. ) Central axillary nodes-high up in the middle of the axilla, over the ribs and sarratus anterior muscle. these receive lymph from the other three groups of nodes
2. ) Pectoral: (anterior) along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold.
3. ) Subscapular: (posterior) along the lateral edge of the scapula, deep in the posterior axillary fold.
4. ) Lateral: along the humerus, inside the upper arm

Question 8

Subjective data of the breast includes pain, lumps, ______, rash, swelling, _____, history of breast disease, surgery, self-care behaviors

Subjective data for the axilla include ________, lumps, or swelling, and _____

Answer 8

discharge
trauma
tenderness
rash

Question 9

Any pain or tenderness in the breasts?
When did you notice it?
Localized or all over?
Is the pain cyclic? any relation to menstrual cycle?
Is the pain brought on by activity, exercise, sex etc?

Answer 9

• Mastalgia occurs with trauma, inflammation, infection, and benign breast disease.
• Cyclic pain is common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease
• is the pain related to a specific cause?

Question 10

Ever noticed a lump or thickening in the breast? where?
Onset?
Any change in the overlying skin? (redness, warmth, dimpling, swelling)

Answer 10

Carefully explore the presence of any lump. a lump presents for many years and exhibiting no change may not be serious but still should be explored. approach recent change or new lump with suspicion

*The upper outer quadrant is the site of most breast tumors

Question 11

Any discharge from the nip?
Onset?
What color?
Consistency-thick or runny?
Odor?

Answer 11

Galactorrhea. Note medications that may cause clear nipple discharge; oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers.

Bloody of blood tinged discharge always is significant. any discharge with a lump is significant.

Question 12

Any rash on the breast?
Onset?
Where did it start? on the nipple, areola, or surrounding skin?

Answer 12

Paget’s disease starts with a small crust on the nipple apex and then spreads to areola.

Eczema or other dermatitis rarely starts at the nipple unless it is due to breast feeding. it usually starts on the areola or surrounding skin and then spreads to the nipple.

Question 13

Any trauma or injury to the breast?

Did it result in any swelling, lump, or break in skin?

Answer 13

A lump from an injury is due to local hematoma or edema and resolves shortly. Or, trauma may cause a woman to feel the breast and find a lump that really was there before.

Question 14

Any history of breast disease? 
What type? how was it diagnosed?
Onset?
How is it/was being treated? 
Any in your family? what age? 

Ever had surgery? Biopsy? results?

Answer 14

• Past breast cancer increases risk for recurrent cancer.
• The presence of benign breast disease makes the breasts harder to examine; the general lumpiness conceals a new lump.
• Breast cancer occurring before menopause in certain family members increases risk for this woman

Question 15

Self care behaviors:

• Have you ever been taught a breast self-exam?
• If so- how often do you perform it? Ask for pt to show you there technique
• if not-This can be an excellent way to take care of your own health, after the exam I will teach you the technique.
• Ever had a mammography?

Answer 15

• The american cancer society recommends that women ages 20-39 years should perform a BSE and have a CBE every 3 years.
• women ages 40 yrs and older should perform BSE, with an annual mammogram and an annual CBE conducted close to the same time.

Question 16

History for the menopausal woman: any change in breast contour, size, or firmness?

Answer 16

Decreased estrogen level causes decreased firmness. rapid decrease in estrogen level causes actual shrinkage

Question 17

Breast cancer risk factors that cannot be changed

Answer 17

• Female gender > 50 yrs
• personal history of breast cancer
• mutation of BRCA 1 and BRCA 2 genes
• first degree relative with breast cancer
• high breast tissue density
• biopsy confirmed atypical hyperplasia
• high dose radiation to chest
• early menarche (55 yrs)

Question 18

Breast cancer lifestyle related risk factors

Answer 18

• first child after age 30
• recent oral contraceptive use
• never breastfed a child
• recent and long term use of estrogen and progestin
• alcohol intake of more than 1 drink daily
• obesity (esp. after menopause) and high fat diet
• physical inactivity
• ** best way to detect a person’s risk is by asking the right history questions, use these to guide your exam.
• *be aware that most breast cancers occur in women with no identifiable risk factors except gender and age.

Question 19

Inspect the breasts and note symmetry of size and shape. It is common to have a slight asymmetry in size; often the left breast is slightly larger than the right.

Answer 19

A sudden increase in the size of one breast signifies inflammation or new growth

Question 20

Inspect the skin and not that it is normally smooth and of even color. Note any localized areas of redness, bulging, or dimpling. Normally no edema is present.

Answer 20

• Look for hyperpigmentation
• redness and heath with inflam
• Unilateral dilated superficial veins in a nonprego woman

Question 21

A ________ nipple is normal and common variation. It is an extra nipple along the embryonic “milk line” on the thorax or abdomen and is a congenital finding.

Answer 21

supernumerary

• rarely a additional glandular tissue, called a supernumarary breast is present.

Question 22

*To screen for retraction:
Ask the woman to change position by lifting her arms slowly over her head. *Both breasts should move symmetrically.

Now, ask her to push her hands onto her hips and push two palms together. these contract the pectoralis major muscle. a slight lifting of both breasts will occur.

Then, ask the women with large breasts to lean forward while you support her forearms. note the symmetric free forward movement of both breasts

Answer 22

• Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms. the fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue. -Note a lag in the movement of one breast.
• Note a dimpling or a pucker, which indicated skin retraction
• Note fixation to chest wall or skin retraction

Question 23

Examine the axilla while the woman is sitting. inspect skin for any rash or infection.

*lift the woman’s arm and support it yourself, so that her muscles are loose and relaxed and palpate in 4 directions (down a line from the middle of axilla, anterior, posterior, and inner aspect of upper arm).

Answer 23

Usually nodes are not palpable, although you may feel a small, soft, non-tender node in the central group. expect some tenderness when palpating high in the axilla.

**Nodes enlarge with any local infection of the breast, arm, or hand and with breast cancer metastases

Question 24

While palpating the breasts; move pt to a supine position, ask to raise arm over head. these will flatten the breast tissue and displace it medially.

Answer 24

Any significant lumps will then feel more distinct. *for the pendulous breasts, distribute the tissue medially across the chest wall by asking the woman to rotate her hips opposite to the side you are palpating.

Question 25

Continue to palpate the breast by using the pads of your first three fingers and make a gently rotary motion. vary pressure. The ______ strip pattern currently is recommended as the best way to detect a breast mass. *Two other patterns are common- (from nipple out to periphery (like a car hubcap), and around nipple and out (circular motion)

Answer 25

Vertical

Question 26

In nulliparous women, normal breast tissue feels firm, smooth and ______.

Answer 26

elastic

Question 27

Premenstrual engorgement is normal from increasing ________ , this consists of a slight enlargement, a tenderness to palpation, and a generalized nodularity

Answer 27

progesterone

Question 28

Normally, you may feel a firm transverse ridge of compressed tissue in the lower quadrants. This is the _________ ______, and it is especially noticed in large breasts.

Answer 28

inframammary ridge *do not confused with an abnormal lump.

Question 29

After palpating over the 4 breast quadrants, palpate the nip, note any induration or ________ mass. * Use your thumb to gently depress the nipple tissue into the wall. Should move inward easily. If there is discharge, note its color and _______. * For women with large breasts, palpate by using a _______ technique (sitting position, leaning forward)

Answer 29

subareolar consistency bimanual

Question 30

If the pt mentions a breast lump that they discovered themselves, examine the ________ breast first to learn a baseline. if you do feel a lump or mass, note these characteristics: 1. )___________- using the breast as a clock, describe in cm the distance from the nipple 2. ) _______-judge in cm in three dimensions (width x length x height) 3. ) ______- state whether the lump is oval, round, lobulated or indistinct 4. ) ________- note whether it is soft, firm, or hard 5. ) Movable- freely or fixed? 6. ) Distinctness-is the lump solitary or multiple? 7. ) _______- displaced or retracted 8. ) Note the skin over the lump- is it erthymatous, dimpled, or retracted? 9. ) Tenderness 10. ) lymphadenopathy- are any regional lymph nodes palpable?

Answer 30

``` unaffected location size shape consistency nipple ``` **premenopausal women at midcycle often have tissue edema and mastalgia (pain) that make it hard to detect a lesion. if your findings are in questions, as pt to return for a follow up the first week after her menses when hormone levels are lower and edema is not present

Question 31

In males, _________ is a benign growth of the breast tissue making it distinguishable from the other tissues in the chest wall. it feels like a smooth, firm, movable disk. occurs primarily during puberty. can be uni or bilateral

Answer 31

Gynecomastia * reassure that this change is normal, common and temporary * this also occurs with anabolic steroids, some meds and some disease states.

Question 32

In the aging women, a yearly _____ is very important since increasing age is a primary risk factor for breast cancer. * On inspection, breasts look pendulous, flattened, and sagging * nipples may be retracted but can be pulled outward * on palpation, the breasts feel more granular and the terminal ducts around the nipple feel more prominent and stringy. * thickening of the inframammary ridge at the lower breast is normal * reinforce SBE-suggest aids such as talcum powder that helps fingers glide over skin to help with arthritis, limited ROM

Answer 32

CBE **because atrophy causes a shrinkage of normal glandular tissue, cancer detection is somewhat easier. any palpable lump that cannot be positively identified as a normal structure should be referred.

Question 33

The shallow _____ (also called a skin tether) is a sign of skin retraction.

Answer 33

dimple *cancer causes fibrosis, which contracts the suspensory ligaments. the dimple may be apparent at rest, with compression, or with lifting of the arms. also note the distortion of the areola as the fibrosis pulls the nipple toward it

Question 34

______ d'orange is when lymphatic obstruction produces edema. this thickens the skin and exaggerates the hair follicles, giving a pigskin or "orange peel" look. this condition suggest _______. edema usually begins in the skin around and beneath the areola. the most depended area of the breast. also note nipple _______.

Answer 34

peau cancer infiltration

Question 35

_______is asymmetry, distortion, or decreased mobility with the elevated arm maneuver. As cancer becomes invasive, the fibrosis fixed the breast to the underlying pectoral muscles.

Answer 35

Fixation

Question 36

Solitary, unilateral, non-tender mass. single focus in one area, although it may be interspersed with other nodules. Becomes solid, hard, dense, and fixed to underlying tissue or skin as _______ becomes invasive. * boarders are ________ * As cancer advances, signs include firm or hard irregular axillary nodes; skin dimpling; nipple retraction, _______, and discharge.

Answer 36

Cancer irregular elevation

Question 37

Benign tumors, most commonly present as self detected in late adolescence. solitary nontender mass that is solid, firm, rubbery, and elastic. 1-5 cm, freely movable, slippery. Usually no axillary lymphadenopathy. Diagnose by triple test (palpation, ultrasound, and needle biopsy)

Answer 37

Fibroadenoma

Question 38

______ breast diease: Multiple tender masses. "fibrocystic disease-former name" Based on 6 criteria: 1. ) swelling and tenderness 2. ) _______ -severe 3. ) nodularity 4. ) dominant lumps (including cysts and fibroadenomas) 5. ) nipple _______ (including intraductal papilloma and duct ectasia) 6. ) infections and inflammations (including subareolar absess, lactational mastitis, breast absess, and mondor's disease

Answer 38

Benign breast disease mastalgia discharge

Question 39

Paste like matter in subareolar ducts produces sticky, purulent discharge that may be white, gray, brown green, or bloody. - caused by stagnation of cellular debris and secretions in the ducts, leading to obstruction, inflammation and infection - Occurs in women who have lactated, usually occurs in perimenopause.

Answer 39

Mammary duct estasia * itching, burning or drawing pain occurs around nipple. erythema & swelling * non malignant but need biopsy

Question 40

Serous or serosanguineous drainage, which is spontaneous, unilateral, or from a single duct. lesion consists of tiny tumors, 2-3 mm. often there is a palpable nodule in the underlying duct.

Answer 40

Intraductal papilloma *affect women 40-60 yrs; most are benign. refer any bloody discharge for careful eval, including biopsy, to rule out cancer

Question 41

Blood nipple discharge that is unilateral and from a single duct requires further investigation. Mammography reveals a 1cm, centrally located, ill-defined mass.

Answer 41

Carcinoma

Question 42

Early lesions has unilateral, clear, yellow discharge and dry, scaling crusts, friable at nipple apex. Spread outward to areola with erythematous halo on areola and crusted, eczematous, retracted nipple. *later lesion shows nipple reddened, excoriated, ulcerated, with blood discharge when surface is eroded, with a erythematous plaque surrounding the nipple: symptoms include tingling, burning, itching.

Answer 42

Paget's disease (intraductal carcinoma) * Except for the redness and occasional cracking from initial breastfeeding, any dermatitis of the nipple are must be carefully explored and referred immediately

Question 43

Male breast cancer usually presents as a painless palpable mass; hard irregular, fixed to area, may have nipple retraction

Answer 43

Nipple discharge, with or without a palpable mass is a significant warning of early breast cancer. Early spread to axillary lymph nodes because of minimal breast tissue.