PD E3- Breast Exam

What organ?

• secondary sex characteristic

• physiologic function is mild secretion to feed infants

Breast

What nodes drain the anterior chest wall & most of the breast tissue?

Pectoral nodes

What nodes drain the posterior chest wall and a portion of the arm?

Subscapular nodes

What nodes collect from the pectoral (anterior) and sub scapular (posterior) nodes?

Central axillary nodes

What nodes collects lymphs from the central nodes?

Supraclavicular & infraclavicular nodes

What supplies the superomedial portion of the breast (60% of total breast blood supply)?

Internal mammary vessels

Where is the sensory of the breast mainly derived from?

Anterolateral & anteromedial branches of thoracic intercostal nerves T3-T5

Where is nipple sensation derived from?

Lateral cutaneous branch of T4

What tanner stages does menstruation begin?

III or IV

From tanner stage II, how long until menarche begins?

2 years

In what family members should you be asking about a history of breast cancer?

Blood related FEMALE relatives (mother, sister, maternal grandmother & aunts)

What is polythelia?

Extra nipples

What is polymastia?

Accessory breasts

Where is breast tissue located?

Anywhere along milk lines (axillar to groin)

In what positions should the breasts be inspected?

Sitting w/ arms over head or pressed on hips: dimpling & retraction

Sitting leaning forward: asymmetry, retraction of nipple / areola

What does retraction of the nipple or areola suggest?

Cancer

What are possible causes of peau d’orange?

Breast cancer, mastitis, & lymphedema

What would nipple inversion (if previously everted) along with signs of itching & pain be a sign of?

Inflammatory breast cancer

How should breast normally appear to palpation?

Firm w/o masses, tenderness or warmth, no nipple dc, & smooth axillae w/ non palpable nodes

*use pads of middle 3 fingers held together w/ metacarpal-phalangeal joint slightly flexed

What is NOT a useful prognostic indicator for cancer?

Squeezing the nipple to assess dc

How should axillae me palpated?

R hand for L axilla & vice versa; point fingers toward mid clavicle & press fingers toward chest wall & slide downward

What do large axillary nodes > 1 cm suggest?

Malignancy

What age does male breast cancer peak?

71 y/o

What are RF for male breast cancer?

BRCA2, obesity, FHx, testicular disorders, work exposure to high temps, exhaust emission

What must you distinguish in a male has enlarged breasts?

Obesity vs gynecomastia

What is postpartum enlargement (1-1.5 cm) of infant breasts & production of “witch’s milk” due to?

*resolves in 2 wks - 3 mos

Estrogen transfer

What imaging do you do for a suspicious mass in an adolescent female?

US

How are geriatric breasts anatomically different?

Flatter, elongated, loosely suspended, granular feel, smaller flatter nipples, breasts cysts if on HRT

What should UL bloody discharge form 1-2 ducts of the nipple be further evaluated for?

Intraductal papilloma, DCIS, paget’s disease

What kind of nipple discharge requires reassurance?

Clear, serous, green, black or non bloody that is multi-ductal

What is nonpuerpal galactorrhea?

Milky dc unrelated to pregnancy & lactation → hypothyroidism, hypoglycemia, cushings, pituitary prolactinoma, antihypertensives, TCAs, estrogens, DA agonists, psychotropic agents, & phenothiazines

When should BSEs be performed?

Monthly at the end of menses in all menstruating women

What is the most sensitive screening tool for breast cancer?

Mammogram

What is roentgenography of breasts without injection of contrast medium?

Mammogram

Screening or diagnostic mammogram?

• look for breast disease in women who appear to have no breast problems

Screening

Screening or diagnostic mammogram?

• Find breast disease in women who have sx or found a lump or abnormal radiological changes

Diagnostic

What should you do if an area of concern is found on mammogram?

Biopsy

When should screening for breast cancer be performed < 40 years/o?

Extensive Fhx breast/ovarian cancer at young age, exposed to chest wall radiation at young age, ADH or LCIS, BRCA 1 or 2 mutations, Phx of breast cancer at young age, pre-operatively for pts requiring breast reduction surgery

What is the presence of a painless, firm, solitary, mobile, slowly growing lump in the breast of a woman of childbearing years?

*MC young women, 1-3 cm, no menstrual cycling; 2nd MCC of benign breast problems

FIbroadenoma

What breast condition?

• long follicular or luteal phase of cycle

• fluid filled cysts, BL, multiple, tender

• MC 30-55 y/o

Fibrocystic disease

What kind of breast disease?

• lumps

• retractions

• asymmetry

• nipple abnormalities, inversion

• prominent veins, discoloration, skin surface changes, peau d’orange

Malignant breast tumor

What breast disease is a firm irregular discolored mass that is a response to injury?

Fat necrosis

What are 2-3 cm tumors of subareolar ducts that cause serous or bloody discharge?

Intraductal papilloma / papillomatosis

What condition?

• benign breast condition → NOT a disease

• exaggerated response to hormones (cyclic BL pain & engorgement)

  • diffuse, may radiate to shoulders or upper arms

• changes most prominent just prior to menses

Fibrocystic changes

When is fibrocystic changes MC?

Premenstrual time frame, nulliparous women, non uses of hormonal contraceptives, mid 20s - early 30s, high caffeine or nicotine intake

What is the treatment for fibrocystic changes?

OCs, DMPA, NSAIDs, dietary changes- low fat, caffeine free, vits E & B, & stop smoking

What is the workup for fibroadenoma?

PE, mammo/ US, tissue sample w FNA or excision, cystic aspiration (therapeutic and diagnostic)

What does straw colored fluid on cyst aspiration indicate?

Fibrocystic

What does dark brown or green fluid on cyst aspiration indicate?

Cyst has been present for a while

What is the treatment for adult gynecomastia?

Plastic surgery

What causes adult gynecomastia?

Hormone secretion tumor of testicles or pituitary, cancer, liver failure, antihypertensive meds, steroids, estrogens, marijuna use

What might premature thelarche be due to?

Possible link to estrogen producing tiny cysts found on ovaries by US; benign

What are blocked subareolar ducts that are painful, tender, inflamed, & have nipple dc?

Mammary duct ectasia

What is a non-tender fatty tumor that often requires biopsy or excision to distinguish from malignancy?

Lipoma

What condition?

• ductal obstruction & inflammation during or soon after lactation that often becomes infected

• swelling, tenderness, redness, warmth, chills, fever

• MC d/t staph

• tx: abx, heat, I&D or excision

Mastitis

Can a mammogram alone prove that an area of concern is breast cancer?

No

What can Paget’s disease present with?

Invasive breast cancer or ductal carcinoma in situ

What does persistent redness, scaling, crusting on nipple or areola that is unilateral usually indicate?

Paget’s disease