Breast Anatomy

Learning Objectives

  • Briefly review physiology and anatomy of the breasts

  • Breast assessment skills

  • Pertinent history taking for breast complaints

  • Brief overview of common breast conditions clinical presentation and physical examination findings

PHYSIOLOGY AND ANATOMY

Basic Anatomy
Male Breast

  • Clavicle

  • Pectoralis major muscle

  • 1st rib

  • Interlobular adipose tissue

Female Breast

  • Clavicle

  • Pectoralis major muscle

  • 1st rib

  • Supporting fibro-adipose tissue

  • Nipple

  • Subareolar breast duct (each leading to a lobe)

  • Areola

    • Blind ducts extending a short distance, rarely beyond the boundary of the areola. Some ducts may be solid cords of cells.

  • Lobe

  • Terminal duct lobular unit (lobule)

HISTORY/ROS

Patient History
Chief Complaint

  • Patient presents with a chief complaint, summarized in 1-2 words (e.g., "Breast lump").

History of Present Illness (HPI)

  • OLD CARTS (Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments, and Severity)

Review of Systems (ROS)

  • Example ROS for breast lump:

    • General: Denies fevers, night sweats, weight loss

    • Breast: Reports lump; denies nipple discharge, increased breast size, pain

    • Cardiac: Denies chest pain, tachycardia

    • Respiratory: Denies shortness of breath

    • Skin: Denies skin redness, pain, wound or rash

    • Lymphatic: Denies enlarged lymph nodes

Past Medical/Surgical History (PMH/PSH)

  • Inquire about any prior breast biopsies, lumpectomies, or breast cancer.

  • Concurrent issues such as diabetes and obesity.

  • Last menstrual period (LMP) and pregnancy history in females.

Medications & Allergies

  • Awareness of medications that could cause galactorrhea or gynecomastia.

  • Consult Torre, D.L., & Falorni, A. (2007) on pharmacological causes of hyperprolactinemia.

Immunizations
Family History

  • History of cancers: breast, ovarian, colon.

  • Family history of BRCA mutations or Lynch syndrome.

Social History

  • Usage of nicotine and caffeine, which can exacerbate fibrocystic changes.

PHYSICAL EXAM

Consent Process

  • Clear explanation of what will be done and why.

  • Chaperones recommended for sensitive examinations.

  • Obtain patient’s clear permission to proceed with the exam.

Inspection

  • Patient should undress down to waist for breast exposure.

  • Steps in Inspection:

    • Patient seated upright, hands on thighs to relax pectoral muscles.

    • Note the following:

    • Scars

    • Asymmetry

    • Masses

    • Nipple abnormalities (especially inversion or discharge)

    • Skin abnormalities such as scaling, erythema, puckering, and peau d’orange.

  • Repeat inspection while patient presses hands on hips to contract pectoralis muscles. Assess any movement of noted masses.

  • Final position: patient puts hands behind head and leans forward, accentuating asymmetry, dimpling, or puckering.

Palpation

  • Patient should lie back with head of bed (HOB) slightly elevated, arm behind head on side being examined.

  • Begin with the asymptomatic breast, utilizing a systematic approach:

    • Methods of Palpation:

    • Clock face method

    • Spiral method (personal preference)

    • Vertical strip method

  • Use pads of the three middle fingers to compress tissue against the chest wall, feel for masses, including the axillary tail.

Characteristics of a Detected Mass

  • If a mass is detected, note the following characteristics:

    • Location (quadrant and position)

    • Size

    • Shape

    • Consistency

    • Mobility

    • Fluctuance

    • Overlying skin appearance

Lymph Node Examination

  • Inspect the underside of the breast if needed, lifting breast as required.

  • Palpate lymph nodes, focusing on:

    • Anterior (pectoral)

    • Central (medial)

    • Posterior (subscapular)

    • Lateral (humoral)

    • Apical groups of lymph nodes.

  • Include:

    • Cervical

    • Supraclavicular

    • Infraclavicular

    • Parasternal groups in examination.

Nipple-Areolar Assessment

  • Compress the nipple with three middle fingers to assess for discharge.

  • If unable to express discharge but patient reports it, assess the characteristics of the discharge upon patient’s comfort:

    • Discharge Characteristics:

    • Milky: Normal during pregnancy/breastfeeding; consider prolactinoma otherwise.

    • Purulent: Consider mastitis or central breast abscess.

    • Watery or Bloody: Several possible causes; critical to rule out ductal carcinoma in situ.

COMMON DISEASES

Mastitis

  • Inflammation of breast parenchyma, not always indicating infection.

  • Can occur during or outside of lactation.

  • Clinical Manifestations:

    • Firm, red, swollen, painful area of the breast.

    • Systemic complaints may include fever, chills, and flu-like symptoms.

    • Usually unilateral.

    • If symptoms persist despite treatment, consider inflammatory breast cancer.

Breast Abscess

  • Presentation similar to mastitis; mastitis can progress to an abscess.

  • Defined as a localized area of inflammatory exudate in breast tissue.

  • Clinical Manifestations:

    • Swollen, painful area of breast with possible overlying erythema and warmth.

    • Systemic symptoms may include fever, chills, and malaise.

    • On physical examination, presents as a fluctuating, tender, palpable mass, differentiated by a discrete area of fluctuance.

    • Confirmed via ultrasound when indicated.

Fibroadenoma

  • A benign breast tumor consisting of glandular and stromal tissue; most common benign breast mass.

  • Typically occurs in ages 15-35.

  • Clinical Presentation:

    • Non-tender mass that is movable.

  • Physical Exam Findings:

    • Firm, rubbery, highly mobile, and non-tender mass.

    • Ultrasound preferred as diagnostic modality, especially in younger women with denser breast tissue.

Fibrocystic Breast Changes

  • Benign condition characterized by fibrosis and fluid-filled cysts, common between ages 30-50.

  • Approximately 50% of reproductive-aged women exhibit fibrocystic changes.

  • Clinical Presentation:

    • Painful breast tissue; size and severity fluctuate with menstrual cycle.

  • Physical Exam:

    • Diffuse, nodular areas, usually bilateral but not necessarily symmetric.

Gynecomastia

  • A benign condition characterized by proliferation of glandular tissue of the male breast, often due to hormonal imbalance.

  • May be attributable to:

    • Medication use (e.g., ketoconazole, nifedipine, omeprazole, cimetidine, estrogens, recreational drugs such as THC, alcohol, amphetamines, heroin, and spironolactone).

    • Hyperthyroidism

    • Hypogonadism

    • Chronic kidney disease (CKD)

    • Malignancies

    • Cirrhosis

  • Physical Exam:

    • Palpate disc of glandular tissue underneath the areola greater than 0.5 cm.

    • Distinguish between true gynecomastia (glandular tissue) and pseudo-gynecomastia (due to obesity).

    • Typically bilateral and symmetric.

Breast Cancer

  • Risk Factors:

    • Family history: 2 times increased risk with one first-degree relative with breast cancer, 3 times with two or more.

    • Advancing age.

    • Dense breast tissue: diagnosed via mammogram.

    • Hormonal risk: both endogenous and exogenous estrogen/progesterone.

    • Higher number of menstrual cycles, indicated by early menarche, late menopause, and null parity.

    • Genetic predisposition with BRCA1 or BRCA2 mutations.

  • Clinical Presentation:

    • Hard, immobile, irregular mass.

    • Physical Exam Findings:

    • Axillary lymphadenopathy in 85% of cases.

    • Retraction of the nipple.

    • Erythema, particularly in inflammatory breast cancer.

    • Skin changes including peau d’orange (orange peel appearance).

    • Nipple discharge, atopic dermatitis-like presentation (not atopic dermatitis) in Paget disease (characterized by an itchy, red rash on nipple and areola).

References

  • Bickley, L. S. (2023). Lippincott Connect for Bates' Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health. https://lippincott-connect.vitalsource.com/books/9781975210557

  • Moore, K.L. & Dalley, A.F. (1999) Clinically Oriented Anatomy, 4th ed. Baltimore, MD: Lippincott Williams & Wilkins.

  • Potter, L. (2023, November 6). Breast Examination – OSCE Guide. GeekyMedics. https://geekymedics.com/breast-examination-osce-guide/

  • Torre, D.L., & Falorni, A. (2007). Pharmacological causes of hyperprolactinemia. Therapeutics and Clinical Risk Management, 3, 929 - 951.