Breast and Chest Examination

What are the indications for a breast and chest exam?

- specific breast complaint

- follow up to an abdominal examination

- increased risk for breast cancer

- part of an overall health visit for both women and men

What structures are examined during a breast and chest exam?

breast tissue, axilla, lymph chains

What are breasts?

paired mammary glands on the anterior chest wall

What are breasts superficial to?

pectoralis major and serratus anterior muscles

Where do breasts extend to and from (vertically and horizontally)?

from clavicle/2nd rib to 6th & from sternum to mid axillary line

Describe the glandular tissue of the breasts.

- 15-20 lobes per breast radiate about the nipple

- lobes are composed of 20-40 lobules

What do lobules consist of?

milk-producing acini cells

What do lactiferous ducts do?

drain milk from each lobe onto the nipple surface

Describe the fibrous tissue of the breasts.

- subcutaneous

- provides breast support

- suspensory ligaments (Cooper ligaments)

Where do suspensory ligaments (Cooper ligaments) extend from and attach to?

from the connective tissue layer through the breast and attach to the underlying muscle fascia, providing further support

What is beneath the breasts?

underlying muscle

Describe the vascular supply of the breasts.

internal mammary artery & lateral thoracic artery

What supplies the bulk of the breast?

subcutaneous and retromammary fat

What does subcutaneous and retromammary fat vary with?

age, pregnancy, lactation, and genetics

How many segments make up the breast?

five (4 quadrants and a tail)

What are the segments of the breast?

- upper outer quadrant

- upper inner quadrant

- lower inner quadrant

- lower outer quadrant

- tail of Spence

Which segment has the greatest amount of glandular tissue?

upper outer quadrant

Where is the nipple located, and what is it surrounded by?

centrally on the breast, surrounded by the pigmented areola

What is the epithelium of the breast infiltrated with?

smooth muscle fibers

Where do lactiferous ducts empty onto?

nipple

What type of glands are on the areola?

sebaceous glands (Montgomery tubercles)

Describe the lymphatic network of the breast.

- drains breast radially and deeply to underlying lymphatics

- complex of axillary lymph nodes

What do superficial lymphatics drain?

skin

What do deep lymphatics drain?

mammary lobules

Describe the breast in an assigned male at birth?

- small nipple and areola

- thin, undeveloped breast tissue consisting of mostly ducts with minimal to no lobules

What information is important to obtain in the HPI for a breast complaint?

- breast discomfort (associated with cycle?)

- breast mass or lump

- nipple discharge (bilateral/unilateral? associated mass? bloody/serous?)

- breast enlargement in men

What is the most diagnosed cancer in the world?

breast cancer

True or False: Breast cancer is a leading cause of cancer death among women.

True

Risk factors for breast cancer

- increasing age

- first-degree family members with breast cancer

- inherited genetic mutations

- personal hx of breast cancer

- denser breasts on mammography

- high levels of endogenous hormones

Prevention of breast cancer

- physical activity, diet of fruits and vegetables, limit alcohol

- risk tool to screen women for BRCA if family hx of breast, ovarian, tubal, or peritoneal CA

- consider BRCA testing

- prophylactic bilateral mastectomy or chemoprophylaxis

- SERMS (selective estrogen receptor modulators)

Protective factors for breast cancer

- early full-term pregnancy

- breastfeeding

- late menarche and early menopause

- physical activity

- healthy body weight

- limiting alcohol intake

Describe the screening options for breast cancer.

- mammography

- clinical breast exam

- self breast exam

What is the USPSTF screening recommendation for mammography?

Biennial screening mammography ages 40-74 yo

What is the American CA Society screening recommendation for mammography?

- 40-45 optional annual

- 45-54 annual screening

- >55 biennial screening with option for annual screening

What is the ACOG screening recommendation for mammography?

screening at 40-75 with shared decision-making

What is the USPSTF screening recommendation for clinical breast exams?

insufficient evidence

What is the American CA Society screening recommendation for clinical breast exams?

not recommended

What is the ACOG screening recommendation for clinical breast exams?

shared clinical decision making 1-3 years for women aged 25-39 and annually 40 and older

What is the recommendation for self breast exams?

all recommend against teaching breast self-exam, rather supports breast self-awareness

What are the techniques of a breast exam?

- be courteous and respectful

- ask patients what language they prefer for body parts (chest vs breast, nipples vs front chest) and use their pronouns throughout

- explain each step clearly and ask for explicit consent while respecting the patient's privacy and identity

- standardize your approach with each exam

When is the best time for a breast exam?

5-7 days after the onset of menstruation

What position should the patient be in during the breast exam?

seated and arms hanging loosely at the sides

How should you perform an inspection of the breasts?

Inspect both breasts and compare the following:

- size, symmetry, and contour

- retractions or dimpling

- skin color and texture

- venous patterns

- lesions

- supernumerary nipples

What should you inspect and compare on the areolae and nipples?

- shape

- symmetry

- color

- smoothness

- size

- nipple inversion, eversion, or retraction

What additional positions should you inspect the breasts in?

- arms extended over head or flexed behind neck

- hands pressed on hips with shoulders rolled forward

- seated and leaning forward from waist

How should the patient be positioned during palpation?

seated position & supine position

What should be palpated during a SEATED breast exam?

- chest wall sweep

- bimanual digital palpation

- lymph node palpation

- palpation of the axillary and infraclavicular areas (nodes should NOT be palpable)

What should be palpated during a SUPINE breast exam?

- use a systematic up-and-down search pattern

- vary palpation pressure, use circular motion with finger pads of 2nd, 3rd, and 4th fingers

- all areas of breast tissue for lumps or nodules

What should you do if a breast mass is felt?

Note characteristics and palpate its tenderness, consistency, and nodules

What should documentation of a breast mass include?

- location

- size and shape

- consistency

- tenderness

- mobility

- borders

- retraction

What should you palpate for in the tail of Spence?

- both axillae and lymph nodes

- masses

What should you palpate for in the nipples?

depression into well behind the areola

What should you note about discharge (if present)?

- not if spontaneous, unilateral, from a single duct

What type of discharge should you further evaluate for intraductal papilloma?

spontaneous, unilateral, and bloody

What should you expect to feel during palpation of an assigned male and birth?

a thin layer of fatty tissue overlying muscle

What will gynecomastia feel like on palpation?

firm disk of glandular tissue can be felt in some men

What will pseudo-gynecomastia feel like on palpation?

obese men may have a somewhat thicker fatty layer, giving the appearance of breast enlargement

What should you document for a breast exam?

- Breasts symmetric and smooth without nodules or masses. Nipples without discharge. No axillary lymphadenopathy.

- "Pendulous breasts"

- "Diffuse fibrocystic changes"

- Size fo mass, location, mobile/immoble, tender/non-tender, overlying skin changes

What are fibrocystic changes?

benign fluid-filled cyst formation caused by ductal enlargement

What is the age range for fibrocystic changes?

22-50 yo

What do fibrocystic changes feel like?

nodular, rope-like densities, may be tender, benign

What is a fibroadenoma?

single, benign tumor

What is the age range for fibroadenoma?

15-25 yo MC, up to 55 yo

What does a fibroadenoma feel like?

- round, disc-like, or lobular

- firm, very mobile, nontender

What is the age range fo rmalignant breast tumors?

> 50 yo MC, can be seen 30-90 yo

What does a malignant breast lump feel like?

- usually singular, irregular/stellate

- firm/hard

- not clearly delineated from surrounding tissue

- may be fixed, nontender, may have associated signs of retraction

What is fat necrosis?

benign breast lump that occurs as an inflammatory response to local injury

What are visible signs of breast cancer?

- retraction signs

- abnormal contours

- skin dimpling

- nipple retraction and deviation

- edema of the skin (Peau D'Orange)

- Paget disease of the nipple

What is galactorrhea?

discharge of milk-containing fluid (unrelated to pregnancy or lactation)

What is galactorrhea most commonly caused by?

hyperprolactinemia

What is mastitis?

inflammation of breast tissue associated with lactation

What is a common history associated with mastitis?

most commonly occurs in the first 4-6 weeks of feeding

What are common physical exam findings for mastitis?

- localized pain, swelling, redness

- fever/malaise/flu-like illness

What can mastitis progress to?

abscess - severe focal tenderness and erythema

Where do implants in breast augmentation go?

subglandular or submuscular

True or False: Patients with a mastectomy still require breast examinations.

True

How should you perform a breast exam in a patient with a mastectomy?

Inspect scar and axilla for masses, irregularities, inflammation, or infection --> can suggest recurrence of CA

What may be present in a patient with a mastectomy?

lymphedema

Considerations for breast exam in a transgender patient.

- Physical examination should only be relevant to the anatomy that is present

- Use gender-affirming care

- Only examine body parts that pertain to the specific visit

- Use patient-preferred language or gender-neutral language (chest, genitalia)

Considerations for breast exam in a transgender woman.

- hormone therapy - breast development (typically underdeveloped)

- increased likelihood of dense breasts

- may have undergone breast augmentation surgery

Breast cancer screening considerations in transgender women.

- transgender women have an increased risk of breast cancer compared to cisgender men, but a lower risk than cisgender women

- consider BRCA family hx for genetic counseling

- mammography every two years

- >50 or > 5-10 years of feminizing hormone use

Considerations for breast exam in transgender men.

- hormone therapy (may slightly decrease breast size due to fat loss)

- may have undergone gender affirmation surgery (top surgery or breast reduction)

- ensure proper documentation of surgery to understand risks

Breast cancer screening considerations in transgender men.

- same recommendations as non-transgender women for trans men who have not undergone a bilateral mastectomy or only breast reduction

- no reliable recommendations for trans men who have had a mastectomy