N209 - Breast & Axilla

Exam 3

Tail of Spence

What is the superior lateral corner of breast tissue that projects up and laterally into the axilla?

Montgomery glands

What are the small elevated sebaceous glands located in the areola that secrete a protective lipid material during lactation?

Tail of Spence

Central Axillary Node

#1?

Pectoral (anterior)

#4?

Subscapular (posterior)

#3?

Lateral Axillary Node

#2?

Estrogen

Which hormone is responsible for changes in the breast?

“milk line”

Supernumerary nipple

What are the ventral epidermal ridges that curve down from the axillae to the groin bilaterally? What is a congenital variation that can persist here?

thelarche

= the beginning of breast development

menarche

= the beginning of menstruation

BRCA1 and BRCA2

A mutation in which genes indicates a higher risk for developing breast CA (70%)?

breast CA survival varies by the stage when it’s diagnosed (early detection = greater chance of survival)

Why is it important to have screenings and mammograms?

estrogen receptors & HER-2

What receptors are targeted to prevent the spread of breast CA?

• @ age 40-44

• @ age 45

When should annual screening mammography begin for at risk patients? Definitely?

later stage diagnosis

Why is there racial disparity in breast CA survival?

Less likely to get screened (CA develops to later stages b4 it is detected & the survival rate drops)

How does socioeconomic conditions affect breast CA survival? (e.g., poverty, lower education levels, lack of access to care, lack of health insurance)

• alcohol drinking

• postmenopausal hormone therapy & weight gain

• Decreased physical activity

What are some lifestyle risk factors for developing breast cancer?

Breast cancer

What is the 2nd major cause of death from cancer in women?

• 99%

• 85%

• early detection

5-year survival rate has increased to ____ today & _____ if the CA has spread regionally because of:

>1; there is a higher likelihood of occurrence of breast CA

A relative risk of what indicates a higher likelihood of breast cancer occurrence? What does this mean?

primary purpose = lactation

the breasts are integrated w a women’s self-concept (affects body image)

What is the primary purpose of the female breast? How does this differ from the pt.’s view?

fear, anxiety and panic; they will initially assume the worst

What might a women who has found a lump in her breast feel?

Risk increases w age across all ages until 80

How does age affect the risk for breast CA?

• High waist-hip ratio

• High fat diet

• No breastfeeding and low number of births (1)

• Regular alcohol intake

• Radiation exposure

• Never been pregnant or late age @ 1^st pregnancy (>30)

• Higher education and socioeconomic group

• Taller height

• Physical Inactivity

• age

• gender

• personal Hx of breast CA

• family Hx of breast CA\

• increased exposure to the female hormone estrogen

What are risk factors for breast CA?

c)

Which of the following does NOT pose a higher risk for breast CA?

a) having first period before 11

b) entering menopause after age 55

c) Birth control

d) using estrogen replacement therapy for more than 5 years

mastalgia

What is pain in breast?

milk secretions from the breasts in a non-breastfeeding woman

What is galactorrhea?

using a short gown that is open at the back and lift it up to the shoulders during inspection.

What is an alternative draping method when examining the breasts?

supine

What position should the pt. be in when palpating the breast?

Breast Self-Examination (BSE)

What should be taught after breast examination?

Symmetry is size and shape (slight asymmetry is common)

What is a normal general appearance of the breasts?

Sudden asymmetry/ growth in the breasts

What is an abnormal general appearance of the breasts?

bulging, discoloration or edema

What abnormalities might be found in the lymphatic drainage areas?

• smooth and of even color

• (in pregnant women) fine blue vascular network visible

• (after pregnancy) striae (aka: Strech marks)

What should you normally find when inspecting the skin over the breasts?

• localized areas of redness, bulging or dimpling

• skin lesions or focal vascular patterns

• edema

What would be an abnormal finding when inspecting the skin over the breasts?

• it is fixed (cannot be pulled out)

• it is a recent change to the nipple

What indicates that a nipple inversion is a bad sign?

• usually protrude (some are flat and some are inverted)

• symmetric on the same plane on both sides

What should you normally find when inspecting the nipples?

nipple line

an extra nipple along the embryonic “milk line” (congenital)

What is a supernumerary nipple?

milk line

1. raise arms over their head

2. push into their hips

3. lean forward (if breasts are pendulous)

What 3 maneuvers should you have the pt do to screen for retractions?

• changes in appearance (such as retractions, dimpling, or fixation)

• uneven nipple line

What are abnormal findings when performing retraction screenings?

sitting

What position should the pt. be in to examine the axillae?

• lift the arm and support it so that her muscles are loose and relaxed; use right hand to palpate left axillae

• reach fingers high into axillae and move them firmly down in 4 directions

How would you palpate the axillae?

normal, all other nodes should be non palpable

Is it normal or abnormal to feel a small, soft, nontender, node in the central group?

you might feel something deeper that cant be felt with light palpations

Why should you alternate between light, medium and deep palpations?

• 3 fingers held together

• using the flat part of the fingers

• using rotary or circular movements

How should you palpate the breasts?

Supine with the arm over their head and pillow underneath side palpated

have a pt. w pendulous breasts rotate their hips to the opposite side

How should the pt. be positioned when palpating the breasts? What should you add if the breasts are pendulous?

vertical strip pattern

What is the preferred method for palpation patterns to detect breast masses?

vertical strip

start high in the axilla and move down and up medially to the sternal edge

wedge (spokes)

palpating from the nipple to the posterior

circular

palpating in concentric circles out to the periphery

fibrosis in the breast tissue, usually caused by growing neoplasms

What are retractions a sign of?

the position flattens the breast tissue & displaces it medially, making significant lumps more distinct

Why is it important for the pt. to be in the correct position to palpate the breasts?

In a woman with large, pendulous breasts

When would you use the bimanual technique to palpate the breasts?

• gently compress between the thumb and forefinger in all quadrants

• color and consistency of discharge if any

How would you palpate the nipple & areola? What should you note?

physiological (benign)

___________ (________) discharge is usually bilateral.

pathological

____________ discharge is spontaneous, unilateral, has blood or is clear, serous, and is sometimes associated with a mass.

during pregnancy, lactation, and up to a year after weaning.

When would you expect galactorrhea to be present?

intact breast

Which breast is palpated first in a pt. post masectomy?

along the incision line

What is the most common site for reoccurrence of cancer in a post mastectomy patient?

no redness, swelling, or skin lesions noted

What is a normal finding in an incisional site of a post mastectomy pt.?

a flat disk of undeveloped breast tissue beneath the nipple

How would you describe the normal male breast?

gynecomastia

what is a benign growth of breast tissue in males when estrogen levels are greater than testosterone that feels like a smooth, firm, movable disk?

• occurs normally during puberty and is temporary

• occurs in adult males with Cushing’s, adrenal disease, liver cirrhosis, hyperthyroidism, and multiple drugs (alcohol, steroids, cancer treatments)

• Breast mass

• Retractions

• Edema

• Axillary mass

• Scaly nipple

• Tender breast

What are the signs associated with more advanced breast cancer?

• feels smooth, firm and elastic

• tissue is softer and looser

What should a normal breast of a nulliparous woman feel upon palpation? How does this differ after pregnancy?

the woman has never been pregnant

What does it mean to be a nulliparous woman?

progesterone

Increased levels of which hormone in premenstrual women leads to breast engorgement?

• inframammary ridge

• yes

What is the firm transverse ridge of compressed tissue in the lower quadrants called? Is this a normal finding?

• use the breast as a clock face

• describe the distance from the nipple in cm using a ruler

• e.g., “8:00, 2 cm from the nipple”

How would you assess the location of a breast mass?

• judge in 3 dimensions (width x length x thickness)

• e.g. “2 cm wide, 2 cm long, 1 cm thick”

How would you assess the size of a breast mass?

• state whether the lump is round, oval, lobulated, or indistinct

How would you assess the shape of a breast mass?

• state whether the lump is soft, hard or firm

How would you assess the consistency of a breast mass?

• is the lump freely movable or is it fixed when you try to move it over the chest wall?

How would you assess the movability of a breast mass?

• Is it displaced, retracted or inverted (& has it always been)?

How would you assess the nipple of a breast mass?

• Is the lump solitary or multiple?

How would you assess the distinctness of a breast mass?

Is it erythematous (red, hot), thickened, vascular, dimpled or retracted?

How would you assess the skin over the lump of a breast mass?

Is the lump tender to palpation?

How would you assess the tenderness of a breast mass?

Are any regional lymph nodes palpable?

How would you assess the lymphadenopathy of a breast mass?

Age: 20-49

Occurrence: bilateral

Location: UOQ

Nipple discharge: No

Pain or tenderness: yes

#: multiple or single

Shape: rounded

Consistency: soft to firm or tense

Mobility: Mobile

Retractions: absent

Borders: well defined

Variations with menses: yes

Benign (Fibrocystic) Breast Disease

Benign (Fibrocystic) Breast Disease

What is this an image of?

early development of the breasts with no other hormone-dependent signs (pubic hair, menses)

What is premature thelarche?

Age: 15-55

Occurrence: bilateral

Location: no specific

Nipple discharge: No

Pain or tenderness: no

#: single, sometimes multiple

Shape: rounded or discoid

Consistency: firm, rubbery

Mobility: Mobile

Retractions: absent

Borders: well defined

Variations with menses: no

Fibroadenoma

Fibroadenoma

What is this an image of?

Age: 30-80

Occurrence: unilateral

Location: 48% in UOQ

Nipple discharge: bloody or clear if present

Pain or tenderness: no

#: single

Shape: irregular or stellate

Consistency: hard, stonelike

Mobility: fixed

Retractions: present

Borders: poorly defined, irregular

Variations with menses: no

Breast Cancer

Breast Cancer

What is this an image of?

Mammary Duct Ectasia

What occurs when the milk ducts dialate, walls thicken, and the duct fills with fluid?

• Produces sticky, purulent discharge that may be yellow-green or bloody

Intraductal Papilloma

What are discrete benign tumors that arise in papillary duct(s)?

• Can have serous or serosanguineous discharge

Ductal Carcinoma in Situ (DCIS)

What is a noninvasive cancer starting in the cells lining the milk ducts (precursor to invasive CA)?

• Bloody, unilateral discharge

Paget’s Disease

What type of breast cancer involves the nipple & skin around it?

• causes pain, burning sensation, tingling itching, scaling, crusty or hardened skin, lump in the breast and flattening of the nipple and nipple discharge

• unilateral yellow or bloody discharge and dry, scaling crusts at the nipple

• Spreads outward to the areola

How will an early lesion of Paget’s disease appear?

Male Breast CA

• Presents as a painless, palpable mass (hard, irregular, nontender, fixed the area)

• Spreads quicker bc of minimal breast tissue

5

Lack of screening and general awareness for male breast cancer is why men are diagnosed __ years later & @ later stages than women

nipple discharge

What is an early warning sign of male breast cancer?

• enlarged and visible breasts (bc of maternal estrogen crossing the placenta)

• “witch’s milk” secretion

What should you find in regards to the neonate’s breasts?

no, it is not significant and resolves within days or weeks

Is “witch’s milk” a concerning finding in neonates?

• Symmetric, just lateral to midclavicular line, b/t 4^th & 5^th ribs

• Nipple is flat, and areola is darker pigmented

What is the position of nipples on a prepubertal child?

• Blue vascular pattern visible

• Breasts & nipples increase in size (striae may develop)

• Colostrum produced (precursor to breastmilk starting after 1^st trimester)

What should you find in regard to the pregnant woman’s breasts?

• Colostrum changes to milk production around the third postpartum day

• Breast engorgement & nipple soreness can occur (treated w frequent nursing)

What should you find in regard to the lactating woman’s breasts?