Breasts & Axillae

Question 1

Modifiable Risk Factors for Breast Cancer

Answer 1

• 1st pregnancy after 30 or nulliparity
  
  • Nulliparity: women who’s never given birth to live baby or baby that has gestated for >24 wks
• EtOH: more EtOH you consume ⇒ increases risk for breast cancer
• Hormone Replacement Therapy (HRT) (≥4 yrs combined HRT):
  
  • HRT commonly used for women going thru menopause or premenopausal periods to manage Sxs
  • If you use HRT ≥4 yrs ⇒ increases breast cancer risks
• Obesity
• Inactivity/Sedentary lifestyle
• Radiation to chest well esp

Question 2

Nonmodifiable Risk Factors for Breast Cancer

Answer 2

• Gender: female > male
• Age: older > younger
  
  • Younger breast cancer pts commonly related to genetic mutations or FHx
• Family or personal Hx:
  
  • If you have primary relative w/ breast cancer ⇒ increases risk
  • If you have secondary relatives w/ breast cancer, usually there needs to be a lot of them w/ it to increase your own chances of getting it
• Genetic: BRCA1/2 gene
• Menarche before 12
• Menopause after 55
• Ethnicity: Non-Hispanic white women and non-Hispanic Black women > other ethnicities

Question 3

Breast Cancer Common S&S

Answer 3

• Often asymptomatic
• Breast lump
• Pain
• Edema in affected arm: lymphedema from malignancy to lymph nodes
• Weight loss
• Bone pain: if breast cancer metastasizes ⇒ usually bone is first affected ⇒ bone pain and weight loss as result

Question 4

Breast Exam (When to do, goal, techniques, inspection of, palpation of)

Answer 4

• When to do exam: if pt has specific complaint of breast/axillae issues
• Goal: identify…
  
  • Masses
  • Vascular or skin changes that indicates malignancies
• Use Tanner Staging for children, pts w/ abnormal breast development esp in males
  
  • Tanner Sexual Maturity Rating (TSMR)/Staging: tracks development of secondary sex characteristics in adolescents during puberty for both females and males
• Inspection of: in various postures
  
  • Both breasts
    
    • Don’t expect both breasts to be completely symmetrical
    • Look for differences in vasculature: Extreme vascularization ⇒ sign of cancer
  • Skin of breasts: look for puckering skin
  • Areolae
  • Nipples: look for discharge
  • Axillae
• Palpation of:
  
  • Breasts and axillae
  • Nipples

Question 5

Breast Cancer

Answer 5

• High risk group: white women
• Visible signs of infection and cancer…
  
  • Erythema
  • Peau d’Orange: sign of inflammatory breast cancer (Can also indicate infection, sarcoidosis, scleroderma)
  • Paget’s Disease: can be confused for eczema
  • Nipple retraction and deviation
  • Skin dimpling
  • Abnormal contours
  • Edema of skin
  • Thickening and prominent pores
  • Hard, irregular, poorly circumscribed nodules fixed to skin or underlying tissues

Question 6

Nipple Retraction

Answer 6

• What: nipple pulled inward bc a mass pulls the tissue in
  
  • Recent or fixed flattening or depression of nipple
  • Retracted nipple can also be broadened or thickened
• Can be normal in some ppl and/or sign of aging
  
  • Issue is when someone that didn’t have retracted nipples before now has them

Question 7

Dimpling

Answer 7

• What: retraction of breasts
• Assessment: look for this w/ pt’s arm at rest, during specific positioning, and on moving or compressing breast

Question 8

Mastitis

Answer 8

• What: inflammation and infection of breast tissue
• Cause: bacterial (Staph. aureus)
• S&S:
  
  • Unilateral enlargement
  • Unilateral, persistent breast pain
  • Enlarged axillary lymph nodes
  • Erythema
  • Nipple discharge
  • Edema
  • Very tender
  • Flu-like and other systemic Sxs
• Assessment Steps: Hx → VS → Inspection
• Common in: breast feeding women
  
  • Recommendation is to keep breastfeeding so it doesn’t get engorged more
• Tx: antibiotics

Question 9

Supernumerary Nipples

Answer 9

• What: nipples that occur along “milk line” on image
  
  • Normal variant ⇒ nothing concerning abt it
  • Only nipple and areola usually present ⇒ mistaken for mole
  • May have glandular tissue

Question 10

Fibrocystic Breast Changes

Answer 10

• What: multiple types of benign masses in breast
• Cause: ductal enlargement and cyst formation
• S&S:
  
  • One or more palpable mass that fluctuates w/ menstrual cycle
  • Tender
  • Enlarged ducts
  • Usually BIL

Question 11

Types of Fibrocystic Breast Changes

Answer 11

• Fibroadenoma
• Galactorrhea
• Gynecomastia

Question 12

Fibroadenoma

Answer 12

• What: benign breast mass consisting of both glandular and fibrous tissue
• S&S: unilateral mass and doesn’t fluctuation w/ menstrual cycle
• Common in: young women

Question 13

Galactorrhea

Answer 13

• What: milky nipple discharge unrelated to breastfeeding ⇒ sign of underlying problem
• Causes:
  
  • Hypothalamus or pituitary disorder ⇒ leads to increases in prolactin
  • Medication side-effect
  • Breast stimulation
• Can occur in men and women

Question 14

Gynecomastia

Answer 14

• What: development of breast tissue in males ⇒ indicates underlying hormonal imbalance
• Can lead to: psychosocial implications
• Can occur in any age
• Assessment: hormone lvls tests
• Txs: monitoring → meds → surgery depending on severity (mastectomy)

Question 15

Documentation of EtOH to Breast Cancer

Answer 15

• Women who drink 3-6 drinks/wk = 15% higher risk of developing breast cancer
• Women who drink 2 drinks/day = 50% increased risk of developing breast cancer
• “Safe EtOH” consumption for women: 1 drink/day
• Some data show that small amts of EtOH can decrease risk of cardiovasc disease ⇒ up to pts to look at their own FHx to decide their own EtOH consumption habits

Question 16

Tanner Sexual Maturity Ratings in Girls: Breasts

Answer 16

• Stage 1: small elevated nipples (pre-adolescents)
• Stage 2:
  
  • Breast bud stage
  • Small amt mound of breast and nipple develops
  • Areola widens
  • Norm in: 11 - 12 yo
• Stage 3:
  
  • Breast and areola enlarge
  • Nipple is flushed w/ breast surface
  • Norm in: 12 -13 yo
• Stage 4:
  
  • Areola and nipple form secondary mound over breast
  • Norm in: 13 - 15 yo
• Stage 5:
  
  • Mature breast
  • Only nipple protrudes
  • Areola flushed w/ breast contour (Areola may continue as secondary mound in some women)
  • Norm in: >15 yo

Question 17

Documentation of Breast Exam Quadrants

Answer 17

• If you see or palpate something on breasts ⇒ identify region
• Tail of spence: common place for masses ⇒ examine thoroughly !

Question 18

Breast Mass Documentation

Answer 18

• Location
• Size
• Shape
• Consistency: concerning if hard consistency and feels like pebble or rock 🚩
• Tenderness concerning 🚩
• Mobility: concerning if mass stays fixed/adheres to underlying tissues 🚩
• Borders: concerning if jagged 🚩
• Retractions: does the skin come bc the mass is pulling it in?
  
  • Concerning if skin is puckering/retracting in 🚩

Question 19

Nipple Discharge Documentation (Color + Possible Causes)

Answer 19

• Serous (yellow): Usually norm
• Serosanguineous (straw colored mix of yellow discharge and blood): Carcinoma or Ductal Ectasia
• Sanguineous (bloody): Carcinoma, Intraductal papilloma, Ductal ectasia, Prepartum women from vascular engorgement
• Clear (watery) 🚩: Carcinoma
• Milky: Pituitary adenoma, Galactorrhea, Med side-effects
• Purulent (pus): Infection or Ductal Ectasia
• Multicolored (green, gray, brown): Fibrocystic changes, Carcinoma, Infection, Ductal ectasia

Question 20

Red Flags

Answer 20

• Breast Mass…
  
  • Consistency: hard consistency and feels like pebble or rock
  • Tender
  • Non-Mobile: stays fixed/adheres to underlying tissues
  • Borders: jagged
  • Retraction of nipple and puckering of skin bc mass is pulling them in
• Clear (watery) nipple discharge
• Unilateral, persistent breast pain ⇒ may indicate infection, breast cancer, cyst