Week 9 - Breast and Axilla

Question 1

What is the milk line? What is its significance?

Answer 1

The imaginary line (generally along ST channel) from LU-1 to LR-10 along which supernumerary
nipples are found.

Question 2

What is galactorrhea? When is it abnormal?

Answer 2

Galactorrhea is the inappropriate discharge of milk-containing fluid. It is abnormal if it occurs six or
more months after childbirth or cessation of breast feeding.

Question 3

Name the palpable masses of the breast at different ages. What are the characteristics of each?

Answer 3

Age 15-25: Fibroadenoma - usually smooth, rubbery, round, mobile, non-tender

Age 25-50: Cysts - usually soft to firm, round, mobile, tender
Fibrocystic changes - nodular, ropelike
Cancer - Irregular, firm, may be mobile or fixed to surrounding tissue

Over 50: Cancer until proven otherwise

Pregnancy / lactation: lactating adenomas, cysts, mastitis, cancer

Question 4

What are the risk factors for breast cancer with relative risk >4.0?

Answer 4

female
age >65
BRCA1 and/or BRCA2
two or more 1st degree relatives w/ breast cancer at early age
personal history of breast cancer
high breast tissue density
biopsy confirmed atypical hyperplasia

Question 5

What are the risk factors for breast cancer with relative risk 2.1 - 4.0?

Answer 5

One 1st degree relative w/ breast cancer
High dose radiation to chest
High bone density (post menopausal)

Question 6

What are the risk factors for breast cancer that affect circulating hormones?

Answer 6

Late age at first full-term pregnancy >30
Early menarche <12
Late menopause >55
No full-term pregnancies
Never breast fed a child
Recent oral contraceptive use
Recent and long term use of HRT
Obesity (post menopausal)

Question 7

What are other risk factors for breast cancer?

Answer 7

Personal history of endometrium, ovary, colon cancer
Alcohol consumption
Tall height
High socioeconomic status
Jewish heritage

Question 8

What are the risk factors of breast cancer which can be modified? What is a protective factor
of breast cancer?

Answer 8

Modifiable risk factors include postmenopausal obesity, use of HRT, alcohol use, and physical inactivity.

Breast feeding decreases risk.

Question 9

What are BRCA-1 and BRCA-2 genes? What are the criteria for identifying women at risk for
mutation of these genes necessitating referral for genetic testing?

Answer 9

BRCA genes code for proteins that suppress tumors in breast and ovarian tissue.
Risk criteria for referring for genetic testing of BRCA gene mutation are:
▪ First-degree relative with a known BRCA1 or 2 mutation
▪ ≥ 2 relatives with a diagnosis of breast cancer before age 50, and ≥ 1 is a first-degree
relative
▪ ≥ 3 relatives with a diagnosis of breast cancer, and ≥ occurred before age 50
▪ ≥ 2 relatives with a diagnosis of ovarian cancer
▪ ≥ 1 relative with a diagnosis of breast cancer, and ≥ 1 relative has a diagnosis of ovarian
cancer.

Question 10

What is the relation of mammographic breast density with causation of breast cancer?

Answer 10

Breast density is a strong independent risk factor even after adjusting for the effects of other risk factors.

Question 11

What are the recommendations of screening mammography, CBE, and BSE?

Answer 11

Mammography
▪ Women 40-50 years old: every 1 to 2 years
▪ Women over 50 years old: annual screening

Clinical Breast Exam (CBE)
▪ Women 20-40 years old: every 3 years
▪ Women over 40 years old: annual screening

Breast Self-Examination (BSE)
▪ Women over 20 years old: monthly exam, 5-7 days after menstruation begins

Question 12

What are the four views of inspection of the breast?

Answer 12

Four breast inspection views:
▪ Arms at sides
▪ Arms over head
▪ Arms pressed against hips
▪ Leaning forward

Question 13

What are the causes of redness, thickening and prominent pores in the skin, and flattening of
the normal convex breast?

Answer 13

Redness may be from local infection or inflammatory carcinoma.
Thickening and prominent pores suggest breast cancer.
Flattening of the normally convex breast suggests cancer

Question 14

What is nipple retraction? What is its significance?

Answer 14

Recent or fixed flattening or depression of the nipple suggest nipple retraction. Long-standing inversion
is of no clinical significance. A retracted nipple may also be broadened and thickened, suggesting an
underlying cancer.

Question 15

What causes dimpling of the breast? What is its significance?

Answer 15

Dimpling or retraction of the breasts suggest an underlying cancer. When a cancer or its associated
fibrous strands are attached to both the skin and fascia overlying the pectoral muscles, pectoral
contraction can draw the skin inward, causing dimpling

Question 16

What are the different findings on palpation of breast in breast cancer?

Answer 16

Consistency, Tenderness, and Nodules
▪ Hard, irregular, poorly circumscribed nodules, fixed to the skin or underling tissues,
strongly suggest breast cancer.
▪ A mobile mass that becomes fixed when the arm relaxed is attached to the ribs and
muscles; if fixed with hand pressed against the hip, it is attached to the pectoral fascia.
▪ Thickening of the nipple and loss of elasticity suggest an underlying breast cancer.
15.

Question 17

What is gynecomastia? What are its causes? What are the causes of male breast cancer?

Answer 17

Gynecomastia is glandular enlargement of the male breast. It is caused by an imbalance of estrogens and
androgens.
Male breast cancer risk factors are BRCA2 mutations, obesity, family history of male or female breast
cancer, testicular disorders, and work exposure to high temperatures and exhaust emission.

Question 18

What are the significance of findings on palpation of tender cords and tender nodules?

Answer 18

Tender cords suggest mammary duct ectasia, a benign but sometimes painful condition of dilated ducts
with surrounding inflammation, sometimes associate with masses.
Tender areas are due to cysts, inflamed areas; some cancers may be tender.

Question 19

What are the findings and significance of acanthosis nigricans in the axilla?

Answer 19

Acanthosis nigricans is deeply pigmented, velvety axillary skin. It is associated with internal
malignancy.

Question 20

What are the causes of enlarged axillary lymph nodes? What are the features malignant
axillary lymph nodes?

Answer 20

Enlarged axillary nodes from infection of the hand or arm, recent immunizations or skin tests in the
arm, or part of a generalized lymphadenopathy.
Nodes that are large (≥ 1cm) and firm or hard, matted together, or fixed to the skin or to underlying
tissues suggest malignant involvement.

Question 21

What are the 4 groups of lymph nodes in axilla? What are their locations? What are the areas
of drainage of each? Where they empty their lymph? What other lymph nodes the malignant
cells from breast may metastasize?

Answer 21

Central Nodes
▪ Location: high in the axilla midway between the anterior and posterior axillary folds
▪ Drains From: pectoral, subscapular, and lateral lymph nodes
▪ Drains To: infraclavicular and supraclavicular nodes
Pectoral Nodes
▪ Location: along the lower border of the pectoralis major inside the anterior axially fold
▪ Drains From: anterior chest wall and much of the breast
▪ Drains To: central nodes
Subscapular Nodes
▪ Location: along the lateral border of the scapula in the posterior axillary fold
▪ Drains From: posterior chest wall and a portion of the arm
▪ Drains To: central nodes
Lateral Nodes
▪ Location: along the medial surface of the upper humerus
▪ Drains From: most of the arm
▪ Drains To: central nodes
Malignant cells from breast cancer may metastasize directly to the infraclavicular nodes or into deep
channels within the chest.

Question 22

Define non-puerperal galactorrhea. What are its causes?

Answer 22

Non-puerperal galactorrhea is milky discharge unrelated to a prior pregnancy and lactation.
Causes include: hypothyroidism, pituitary prolactinoma, and dopamine agonists.

Question 23

What are the causes of spontaneous unilateral bloody nipple discharge?

Answer 23

Causes of spontaneous unilateral bloody nipple discharge include intraductal papilloma, ductal
carcinoma in situ, or Paget’s disease of the breast.

Question 24

What are the signs of recurrence of breast cancer after mastectomy?

Answer 24

Masses, nodularity, and change in color or inflammation, especially in the incision line, suggest
recurrence of breast cancer after mastectomy.

Question 25

How will you instruct a patient for breast self-examination?

Answer 25

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Question 26

What are the three most common causes of breast nodules? What are the differences between
them in different aspects?

Answer 26

Fibroadenoma - usually single, well delineated, no retraction

Cysts - single or multiple, well delineated, no retraction

Cancer - usually single, may show retraction

Question 27

What are the retraction signs of breast cancer? What are the other causes of breast retraction?

Answer 27

Retraction signs are due to fibrosis (scar tissue) and may produce dimpling, changes in contour, and
retraction or deviation of the nipple.
Other causes of breast retraction include fat necrosis and mammary duct ectasia.

Question 28

What is the peau d’ orange sign of breast?

Answer 28

Peau d’orange is thickened skin with enlarged pores due to edema of the skin produced by lymphatic
blockage.

Question 29

What is the visible sign in Paget’s disease of the nipple?

Answer 29

Visible signs of Paget’s disease of the nipple starts as a scaly, eczema-like lesion that may weep, crust,
or erode, or with persisting dermatitis of the nipple and areola.