Dr. Plundo Starred Slides_Breast & Axilla Flashcards
Stages of Breast Development (Tanner Stages)
First 3 stages
Thelarche stages:
Breast development
Tanner I: Prepubertal
Elevation of only papilla
Tanner II: Breast bud stage
Elevation of breast and papilla as a small mound
Enlargement of diameter of areola
Tanner III:
Further enlargement of breast and areola with no separation of contours
Last Stages & Onset
Tanner IV:
Areola projected above level of breast as a secondary mound
Tanner V: Mature stage
Recession of areola mound to the general contour of the breast
Projection of papilla only
Onset of breast development occurs approximately:
1 year prior to onset of pubic hair development
2 years prior to menarche
Complete process usually occurs over a 4 year period
Five “D’s” related to Nipples
Discharge
Depression or Inversion
Discoloration
Dermatologic changes
Deviation
Compare to opposite side
Breast Cancer Risk factors and their relative risk
Groups:
Modifiable
Non-modifiable
Uncertain, Controversial or Unproven
Non-modifiable (factors you can not change)
Gender
100 times more common in women than men
Age
MOST IMPORTANT
2 of 3 invasive breast cancers women 55 or older
Genetic
5-10% thought hereditary
BRCA1 & BRCA2 most common cause
Risk as high as 80%, tend to occur in younger women and affect both breast
Family History
First degree doubles risk, two first degree increase risk five fold
Personal History
Increase risk a new cancer in other or same breast
Race
White more likely to develop
African-American more likely to die
Dense breast tissue
Higher risk
Previous chest radiation
Varies 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 miscarriage
Menstrual periods:
Menarche prior to age 12
Menopause after age 55
Certain benign breast conditions
Lobular carcinoma in situ
Modifiable: (Life style related, changeable)
Postmenopausal Obesity
Exercise
§Lack of physical activity
Alcohol
§ Increases with 2 to 5 drinks a day
Hormone replacement
§Combined HRT increases risk, return normal 5 years after stop
§ET alone does not seem to affect risk, increase if used more 10 years
Recent oral contraceptive use
§Slightly higher than those that never used
§Return to normal after stopping
Childbirth
§Breast feeding
§Nulliparity or late age at birth of first child
Uncertain, controversial, or unproven
Diet and vitamin intake
§Conflicting
§American Cancer Society recommends healthy diet, plant sources
Antiperspirants
§Internet rumor…Conflicting
Bras
§Internet rumor
Induced abortion
§Strong data to neither induced or spontaneous increase
Breast implants
§Do not increase
§May make harder to examine
Chemicals in environment
§Certain substances found in animal studies
§Research does not prove in humans
Tobacco smoke
§Some do and some do not
§Second hand ???
Night work:
§May increase, recent finding, needs more study
SIGNS & symptoms of breast masses
Fibrocystic Changes
20-50 years
Usually bilateral
Multiple or single
Round
Soft to firm; usually elastic
Mobile
No retraction
Often tender
Well defined borders
Variation with Menses,
Except with estrogen therapy
Fibroadenoma
15-25 years, up 55
Usually bilateral
Single; may be multiple
Round, disc like, or lobular
Usually firm, rubbery
Very mobile
No retraction
Usually nontender
Well defined borders
No variation with menses
Cancer
30-90 years, most common over 50
Usually unilateral
Single, may coexist
Irregular or stellate
Firm, hard, stonelike
Fixed
Usually have retraction
Usually nontender
Poorly defined borders, irregular
No variation with menses
Visible signs of breast cancer
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 the breast 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.
- Abnormal contours:
- 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.
Nipple & Areola
- Montgomery tubercles
- A normal finding. Elevated areolar glands usually associated with pregnancy
- Normal
- Crusting and flaking
- consider Paget’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
Normal changes of the breast
Menstruation:
- Enlargement can occur 3-5 days prior to menstruation
DO 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 menses
Pregnancy:
- 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
Palpable masses of the breast
Age 15-25
Table Page 410
Age: 15-25
Common Lesion: Fibroadenoma
Characteristics: Usually smooth, rubbery, round, mobile, often tender
Palpable masses of the breast–Age 25-50
Table Page 410
Age: 25-50
Common Lesion: Cysts
Characteristics: Usually soft to firm, round, mobile; often tender
Common Lesion: Fibrocystic changes
Characteristics: Nodular, ropelike
Common Lesion: Cancer
Characteristics: Irregular, firm, may be mobile or fixed to surrounding tissue
Palpable masses of the breast–Age Over 50
Table Page 410
Age: Over 50
Common Lesion: Cancer until proven otherwise
Characteristics: Irregular, firm, may be mobile or fixed to surrounding tissue
Palpable masses of the breast–Pregnancy/lactation
Common Lesion: Lactating adenomas, cysts, mastitis, and cancer
Common breast masses (3 common)
Table 10-1
Fibroadenoma (a benign tumor)
Cysts
Breast cancer
