L14: The Breast

Question 1

Lymphatics of breast

Answer 1

Question 2

Tanner stages of breast development

Answer 2

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

Question 3

Timing of breast development

Answer 3

• 1 year prior to onset of pubic hair development, 2 years prior to menarche, complete process over a 4 year period

Question 4

What is the milk line?

Answer 4

• 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

Question 5

Quadrants of breast

Answer 5

• Upper/lower and inner/outer quadrants - Tail of Spence = extension of upper outer lobe towards axilla

Question 6

Shapes of breasts

Answer 6

• Convex - Pendulous - Conical

Question 7

Are breasts symmetrical?

Answer 7

• Not necessarily, most don’t match (often larger on right)

Question 8

Various arm positions with breast exam?

Answer 8

1.) Arms over head 2.) Hands pressed against hips or pressing hands together 3.) Seated and leaning forward from waist

Question 9

When palpating breasts, what position should pt be in? Three ways to palpate, what is best practice?

Answer 9

• 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

Question 10

In what location do breast malignancies frequently/commonly occur?

Answer 10

• Upper outer quadrant

Question 11

What is an inframammary ridge?

Answer 11

• Transverse ridge of compressed tissue along lower edge of breast that is a normal finding

Question 12

Five Ds related to nipple

Answer 12

• Discharge - Depression/inversion - Discoloration - Dermatologic changes - Deviation (compared to opposite)

Question 13

Areola

Answer 13

• pigment surrounding nipple, can darken during pregnancy and post-natally

Question 14

Colostrum

Answer 14

• Clear milky fluid expressed from breast before milk production (typically seen in third trimester)

Question 15

Galactorrhea

Answer 15

• Lactation not associated with childbearing

Question 16

Gynecomastia

Answer 16

• abnormal large mammary glands in male, sometimes excrete milk

Question 17

Mastitis

Answer 17

• inflammation of breast

Question 18

Mastodynia

Answer 18

• pain in breast

Question 19

Risk factors for breast cancer groups

Answer 19

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

Question 20

Modifiable breast CA factors

Answer 20

• 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)

Question 21

Uncertain/controversial/unproven breast CA factors

Answer 21

• Diet and vitamin intake - Antiperspirants - Bras - Induced abortion - Breast implants - Chemicals in environment - Tobacco smoke - Night work

Question 22

Breast CA risk assessment tools

Answer 22

• Gail Model - Claus Model - BTCAPRO Model

Question 23

According to ACOG, who should be getting mammograms or CBE (clinical breast exam) and how often

Answer 23

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

Question 24

Why is mammogram not helpful in young women?

Answer 24

• Breast tissue can be dense. MRI as alternative

Question 25

Should a breast exam be done in a menstruating patient?

Answer 25

• Examinations are best done 5-7 days after onset of menses when estrogen stimulation is lowest

Question 26

Three common kinds of breast masses. Age of onset, both / single breast, number of masses, shape, consistency, delineation, mobility, tenderness, retraction, variation with menses?

Answer 26

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

Question 27

What are Montgomery tubercles?

Answer 27

• Normal finding, elevated areolar glands associated with pregnancy

Question 28

What is Paget’s disease of breast?

Answer 28

• Uncommon form of breast CA that starts with scaly, eczemalike lesion that may weep, crust or erode

Question 29

Inversion or eversion to nipples – normal?

Answer 29

• Can be normal if bilateral or unilateral. Retraction or deviation would be concern for cancer

Question 30

What is Peau d’orange?

Answer 30

• Edema of skin, which is associated with cancer, often appearing first around nipple

Question 31

Types of malignant breast tumors

Answer 31

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

Question 32

Using venous drainage to assess for malignancy

Answer 32

• Unilateral dilation may indicate malignancy

Question 33

Benign breast tumor types

Answer 33

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

Question 34

Duct ectasia

Answer 34

• Benign condition of the subareolar ducts that can cause a nipple discharge

Question 35

Fibrocystic disease

Answer 35

• benign condition that presents with fluid-filled cyst due to ductal enlargement that is usually bilateral and multiple

Question 36

Thelarche

Answer 36

• beginning of female pubertal breast development