L14: The Breast Flashcards
Lymphatics of breast
Tanner stages of breast development
1.) Prepurbertal: elevation of nipple 2.) Breast bud stage: elevation of breast and papilla as small mound, also enlarge diameter of areola 3.) Further enlargement of breast with areola with no separation of contours 4.) Areola projected above level of breast as secondary mound (double mound) 5.) Mature stage: recession of areola mound to the general contour of breast, projection of papilla only
Timing of breast development
- 1 year prior to onset of pubic hair development, 2 years prior to menarche, complete process over a 4 year period
What is the milk line?
- Ridge of vestigial epithelium from axilla (most common site) to inguinal region that may house rudiments of breast tissue, of little clinical significance - 2% of Caucasian women, over 50% cases bilateral
Quadrants of breast
- Upper/lower and inner/outer quadrants - Tail of Spence = extension of upper outer lobe towards axilla
Shapes of breasts
- Convex - Pendulous - Conical
Are breasts symmetrical?
- Not necessarily, most don’t match (often larger on right)
Various arm positions with breast exam?
1.) Arms over head 2.) Hands pressed against hips or pressing hands together 3.) Seated and leaning forward from waist
When palpating breasts, what position should pt be in? Three ways to palpate, what is best practice?
- Pt should be supine with towel/small pillow under scapula Three ways: 1.) Vertical (lawnmower): best practice, best validated 2.) Circular: nipple outwards 3.) Spoke * only compress nipple if it has discharge, don’t forget axilla and nodes
In what location do breast malignancies frequently/commonly occur?
- Upper outer quadrant
What is an inframammary ridge?
- Transverse ridge of compressed tissue along lower edge of breast that is a normal finding
Five Ds related to nipple
- Discharge - Depression/inversion - Discoloration - Dermatologic changes - Deviation (compared to opposite)
Areola
- pigment surrounding nipple, can darken during pregnancy and post-natally
Colostrum
- Clear milky fluid expressed from breast before milk production (typically seen in third trimester)
Galactorrhea
- Lactation not associated with childbearing
Gynecomastia
- abnormal large mammary glands in male, sometimes excrete milk
Mastitis
- inflammation of breast
Mastodynia
- pain in breast
Risk factors for breast cancer groups
1.) Modifiable 2.) Non-modifiable 3.) Uncertain/controversial/unproven Non-modifiable breast CA factors - 100 times more common in women - 2/3 invasive breast CAs in women 55 or older - 5-10% hereditary (BRCA1/2 most common), raises risk 80% - first degree relative doubles risk, two first degree relatives increases risk five fold - self-history increases risk in same or other breast - whites more likely to develop, AA more likely to die - Dense breast tissue higher risk - Previous chest radiation - DES (diethylstilbestrol) exposure: previously given for nausea - Menstrual period prior to age 12, menopause after 55 - Certain benign breast conditions - Lobular carcinoma in situ
Modifiable breast CA factors
- Postmenopausal obesity - Lack of physical activity - Alcohol (with 2+ drinks per day) - Combined ERT (ET alone doesn’t increase risk, unless used for greater than 10 years) - Recent oral contraceptive use - Childbirth (no breast feeding, nulliparity or late age at birth of first child)
Uncertain/controversial/unproven breast CA factors
- Diet and vitamin intake - Antiperspirants - Bras - Induced abortion - Breast implants - Chemicals in environment - Tobacco smoke - Night work
Breast CA risk assessment tools
- Gail Model - Claus Model - BTCAPRO Model
According to ACOG, who should be getting mammograms or CBE (clinical breast exam) and how often
1.) Mammogram: 40 years and older with good health, high risk women should get MRI and mammogram yearly 2.) CBE: 20-39 every one to three years, 40+ yearly
Why is mammogram not helpful in young women?
- Breast tissue can be dense. MRI as alternative
Should a breast exam be done in a menstruating patient?
- Examinations are best done 5-7 days after onset of menses when estrogen stimulation is lowest
Three common kinds of breast masses. Age of onset, both / single breast, number of masses, shape, consistency, delineation, mobility, tenderness, retraction, variation with menses?
1.) Fibroadenoma - 15-25 (up to 55), bilateral, single (may be multiple), round disk-like lobular, firm (may be soft), well delineated, very mobile, usually nontender, absent retraction signs, no variation with menses 2.) Cysts - 30-50, bilateral, single or multiple, round, soft-firm-elastic, well delineated, mobile, often tender, absent retraction signs, variation with menses 3.) Cancer - 30-90 (common over 50), unilateral, single (may coexist with other nodules), irregular/stellate, firm/hard, not clearly delineated, not mobile, nontender typically, retraction signs may be present, no variation with menses
What are Montgomery tubercles?
- Normal finding, elevated areolar glands associated with pregnancy
What is Paget’s disease of breast?
- Uncommon form of breast CA that starts with scaly, eczemalike lesion that may weep, crust or erode
Inversion or eversion to nipples – normal?
- Can be normal if bilateral or unilateral. Retraction or deviation would be concern for cancer
What is Peau d’orange?
- Edema of skin, which is associated with cancer, often appearing first around nipple
Types of malignant breast tumors
1.) Infiltrating ductal - affects 30-80 year olds, single mass, irregular/stellate/hard/stonelike, fixed, most common type of breast cancer 2.) Inflammatory - frequently presents with lymphatic involvement, poor prognosis 3.) Paget’s disease - presents with eczematous patches on nipple, rare form of cancer, can be associated with nipple redness and burning
Using venous drainage to assess for malignancy
- Unilateral dilation may indicate malignancy
Benign breast tumor types
1.) Cystosarcoma phyllodes - Large bulky mass of cysts and CT, rapidly growing 2.) Fibroadenoma 3.) Intraductal papilloma - tumor of lactiferous ducts, presents with nipple discharge
Duct ectasia
- Benign condition of the subareolar ducts that can cause a nipple discharge
Fibrocystic disease
- benign condition that presents with fluid-filled cyst due to ductal enlargement that is usually bilateral and multiple
Thelarche
- beginning of female pubertal breast development
