Dr. Plundo *'d slides_Breasts & Axilla

Question 1

Stages of Breast Development (Tanner Stages)First 3 stages

Answer 1

Thelarche stages:Breast developmentTanner I: PrepubertalElevation of only papillaTanner II: Breast bud stageElevation of breast and papilla as a small moundEnlargement of diameter of areolaTanner III:Further enlargement of breast and areola with no separationof contours

Question 2

Last Stages & Onset

Answer 2

Tanner IV:Areola projected above levelof breast as a secondary moundTanner V: Mature stageRecession of areola mound to the general contour of thebreastProjection of papilla onlyOnset of breast development occurs approximately:1 year prior to onset of pubichair development2 years prior to menarcheComplete process usually occurs over a 4 year period

Question 3

Five “D’s” related to Nipples

Answer 3

žDischargežDepression or InversionžDiscolorationžDermatologic changesžDeviationCompare to opposite side

Question 4

Breast Cancer Risk factors and their relative risk

Answer 4

žGroups:ModifiableNon-modifiableUncertain,Controversial or Unproven

Question 5

Non-modifiable (factors you can not change)

Answer 5

Gender100 times more common in women than menAgeMOST IMPORTANT2 of 3 invasive breast cancers women 55 or olderGenetic5-10% thought hereditaryBRCA1 & BRCA2 most common causeRisk as high as 80%, tend to occur in younger women andaffect both breastFamily HistoryFirst degree doubles risk, two first degree increase risk fivefoldPersonal HistoryIncrease risk a new cancer in other or same breastRaceWhite more likely to developAfrican-American more likely to dieDense breast tissueHigher riskPrevious chest radiationVaries with age, chemotherapy.DES (Diethylstilbestrol) Exposure:May increase the risk of breast cancer in the users of DES and in their daughters.Used 1940’s-70’s decrease miscarriageMenstrual periods:Menarche prior to age 12Menopause after age 55Certain benign breast conditionsLobular carcinoma in situ

Question 6

Modifiable: (Life style related, changeable)

Answer 6

Postmenopausal ObesityExercise§Lack of physical activityAlcohol§ Increases with 2 to 5 drinks a dayHormone replacement§Combined HRT increases risk, return normal 5 years after stop§ET alone does not seem to affect risk, increase if used more 10 yearsRecent oral contraceptive use§Slightly higher than those that never used§Return to normal after stoppingChildbirth§Breast feeding§Nulliparity or late age at birth of first child

Question 7

Uncertain, controversial, or unproven

Answer 7

Diet and vitamin intake§Conflicting§American Cancer Society recommends healthy diet, plant sourcesAntiperspirants§Internet rumor…ConflictingBras§Internet rumorInduced abortion§Strong data to neither induced or spontaneous increaseBreast implants§Do not increase§May make harder to examineChemicals in environment§Certain substances found in animal studies§Research does not prove in humansTobacco smoke§Some do and some do not§Second hand ???Night work:§May increase, recent finding, needs more study

Question 8

SIGNS & symptoms of breast masses

Answer 8

Fibrocystic Changesž20-50 yearsžUsually bilateralžMultiple or singležRoundžSoft to firm; usually elasticžMobiležNo retractionžOften tenderžWell defined bordersžVariation with Menses,žExcept with estrogen therapyFibroadenomaž15-25 years, up 55žUsually bilateralžSingle; may be multipležRound, disc like, or lobularžUsually firm, rubberyž Very mobiležNo retractionžUsually nontenderžWell defined bordersžNo variation with mensesCancerž30-90 years, most common over 50žUsually unilateralžSingle, may coexistžIrregular or stellatežFirm, hard, stonelikežFixedžUsually have retractionžUsually nontenderžPoorly defined borders, irregularžNo variation with menses

Question 9

Visible signs of breast cancer

Answer 9

Table 10-2 Retraction signs As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue produces dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia. Abnormal contours:

• look for any variation in the normal convexity of each breast, and compare one side with the other. Special positioning may again be useful. Flattening of the quadrants. Skin dimpling
• look for this sign w/the patient’s arm at rest, during special positioning, and on meoving or compressing the breast. Nipple Retraction and Deviation:
• A retracted nipple is flattened or pulled inward. It may also be broadened, and feels thickened. When involement is radially asymmetric, the nipple may deviate or point in a different direction from its normal counterpart, typically toward the underlying cancer. Edema of the skin:
• edema of the skin is produced by lymphatic blockade. It appears as thickened skin w/enlarged pores–the so called peau d’orange (orange peel) sign. It is often seen first in the lower portion of thebreast or areola. Paget’s Disease of the Nipple
• This uncommon form of breast cancer usually starts as a scaly, eczemalike lesion that ay wep, crust, or erode. A breast mass may be present. Suspect Paget’s disease in any persisting dermatitis of the nipple and areola. Can present w/invasive breast cancer or ductal carcinoma in situ. Nipple & Areola Montgomery tubercles
• A normal finding. Elevated areolar glands usually associated with pregnancy
• Normal Crusting and flaking
• considerPaget’s Disease Eversion verses Inversion: unilateral or bilateral Retraction or deviation: consider cancer Retraction & Dimpling Ask if new onset…recent unilateral inversion of a previously everted nipple suggests malignancy Peau d’orange Edema of the skin which is associated with cancer, often appearing first around the nipple

Question 10

Normal changes of the breast

Answer 10

Menstruation: Enlargement can occur 3-5 days prior to menstruationDO NOT examine breasts at this time

• due to an increase in nodularity from fluid build-up
• increased pain and tenderness¡Best time to evaluate breasts is 5-7 days after onset of mensesPregnancy: Fuller and more firm
• breasts can change two cup sizes during pregnancy & lactation Nipple changes
• areola darken
• nipples enlarge & become erect Third trimester
• ​colostrum: thin yellowish secretion FYI: After the baby is born, secretion of colostrum will stop and milk production begins if the mother begins nursing within 24 hours

Question 11

Palpable masses of the breastAge 15-25

Answer 11

Table Page 410Age: 15-25Common Lesion: FibroadenomaCharacteristics: Usually smooth, rubbery, round, mobile, often tender

Question 12

Palpable masses of the breast–Age 25-50

Answer 12

Table Page 410Age: 25-50Common Lesion: CystsCharacteristics: Usually soft to firm, round, mobile; often tenderCommon Lesion: Fibrocystic changesCharacteristics: Nodular, ropelikeCommon Lesion: CancerCharacteristics: Irregular, firm, may be mobile or fixed to surrounding tissue

Question 13

Palpable masses of the breast–Age Over 50

Answer 13

Table Page 410Age: Over50Common Lesion: Cancer until proven otherwiseCharacteristics: Irregular, firm, may be mobile or fixed to surrounding tissue

Question 14

Palpable masses of the breast–Pregnancy/lactation

Answer 14

Common Lesion: Lactating adenomas, cysts, mastitis, and cancer

Question 15

Common breast masses (3 common)

Answer 15

Table 10-1Fibroadenoma (a benign tumor)CystsBreast cancer

Question 16

Common breast masses (fibroadenoma)

Answer 16

FibroadenomaUsual age: 15-25, usually puberty and young adulthood, but up to age 55Number: usually single, may be multipleShape: round, disclike, or lobularConsistency: may be soft, usually firmDelimitation: well delineatedMobility: very mobileTenderness: usually nontenderRetraction Signs: absent

Question 17

Common breast masses (cysts)

Answer 17

CystsUsual age: 30-50, regresses afte rmenopause except with estrogen therapyNumber: single or multipleShape: roundConsistency: soft to firm, usually elasticDelimitation: well delineatedMobility: mobileTenderness: often tenderRetraction Signs: absent

Question 18

Common breast masses (cancer)

Answer 18

CancerUsual age: 30-90, most common over age 50Number: usually single, although may coexist with other nodulesShape: irregular or stellateConsistency: firm or hardDelimitation: not clearly delieated from surrounding tissuesMobility: may be fixed to skin or underlying tissuesTenderness: usually nontenderRetraction Signs: may be present