• BREAST AND AXILLA• EXAMINATION

Primarily adipose tissue, glandular tissue, and suspensory ligaments

Composed of 15-25 radially arranged lobes of parenchyma, each associated with a major lactiferous duct

Each major duct extends from the nipple to terminate in a “terminal duct-lobular unit” via branching ducts of diminishing caliber

Breast Anatomy

• A ducts• B lobules• C dilated section of duct

to hold milk• D nipple• E fat• F pectoralis major muscle• G chest wall/rib cage

Breast Anatomy

Ruan, W, Kleinberg, DL. Endocrinology 1999; 140:5075. Copyright © 1999 The Endocrine Society.

Microscopic

• Glands,• Dense stroma• Interlobular stroma

History: Change in general appearance of breast (size, symmetry) New or persistent skin changes New nipple inversion Breast pain (cyclic vs. noncyclic, duration, location in breast) Breast mass (how it was discovered, duration, change in size, location) Relationship of mass to menstrual cycles Nipple discharge (unilateral vs. bilateral, color) Medications (e.g. hormones) Risk factors for breast cancer

Evaluation: History

• Risk factors• BRCA1 and BRCA2• 1˚ relative with breast or

ovarian cancer• Personal history of breast

disease• Age > 70 yrs• Age at menarche < 12 yrs• Nulliparous or age at first

birth > 30 yrs• Never breastfed• Age at menopause > 55 yrs

• Protective factors• Breastfeeding• Parity• Recreational exercise• Postmenopause BMI <

23• Oophorectomy at < 35

yrs• Aspirin

Clinical Breast Exam: Inspect (relaxed, arms raised, hands on hips)

Breast symmetry Skin changes (dimpling, retraction, edema, ulceration) Nipples (symmetry, inversion/retraction, discharge)

Palapation (breasts, axillae, entire chest wall) Pain Masses Regional lymph nodes (Axillary and Supraclavicular)

Documentation “Clock” system Location of concern and abnormality Distance from areola Size of mass

Evaluation: Physical Exam

Benign vs. Malignant

Chief Complaint Benign Characteristics Malignant Characteristics

Breast mass Multiple lesions Single lesion

“Rubbery” Hard

Mobile Immovable

Well circumscribed border Irregular borders

Nipple discharge Bilateral Unilateral

Multiductal Uniductal

Milky Bloody, Clear, or Colored

Spontaneous

Persistent

Skin changes Retraction

Dimpling

Thickening

Benign Nonproliferative

Fibrocystic changes Simple cysts Lactational adenoma Fibroadenoma

Hyperplasia without atypia Epithelial hyperplasia Sclerosing adenosis Intraductal papillomas

Breast Disease

Malignant Ductal carcinoma Lobular carcinoma Tubular carcinoma Mucinous carcinoma Micropapillary carcinoma Metaplastic carcinoma Inflammatory carcinoma

• Irregular thickening in the breast-fibrocystic disease,

• Areola changes-Paget’s disease of the breast,• Pus- duct ectasia

Approximately 45% of women have mild breast pain, and 21% have severe breast pain in their lifetime

Breast cancer is found in 1.2 – 6.7% of women presenting with breast pain

Mastalgia: Incidence

Differential Diagnosis: Cyclic

Cyclic mastalgia Fibrocystic disease

Non-cyclic Large pendulous breasts Diet, lifestyle Mastitis Hormone replacement therapy Ductal ectasia Inflammatory breast cancer

Extramammary (non-breast) pain

Mastalgia: Etiology

Fibrocystic disease Premenopausal women Premenstrual breast swelling/tenderness Nodules/masses/lumps related to dense breast tissue or cysts

Mastalgia: Fibrocystic Disease

Fibrous tissue Cystically dilated ducts + Calcifications + Ductal hyperplasia

Inflammatory breast cancer

Mastalgia: Inflammatory Breast Cancer

Peau d’orange-dimpling of involved skin due to retraction caused by lymphatic involvement and obstruction

Associated erythema Cellulitis may mimic inflammatory carcinoma

More than 90% of palpable breast masses in women in their 20’s to early 50’s are benign

Differential Diagnosis: Fibrocystic changes Fibroadenoma Fat necrosis Phyllodes tumor Intraductal papilloma Breast cancer

Breast Mass: Etiology

Fibroadenoma Solitary, firm, rubbery, mobile mass Women < 30 yrs Slow growing (? hormonally mediated)

Breast Mass: Fibroadenoma

Fibroadenoma gross specimen Firm, tan, lobulated Well circumscribed mass Variable size

Fat Necrosis Caused by trauma Tender, firm mass with indistinct borders May appear suspicious on physical exam Benign breast calcification seen on mammography

Breast Mass: Fat Necrosis

Fat necrosis manifesting as a spiculated mass

Densely calcified 3-cm area of fat necrosis 2 years after blunt trauma to the breast.

Breast Ultrasound

Initial evaluation < 30 yr – Diagnostic ultrasound + Diagnostic mammogram > 30 yr – Diagnostic mammogram

Further evaluation Simple cyst

Symptomatic – Aspirate Asymptomatic – Observe for 2-4 months

Complicated cyst – Ultrasound-guided aspiration Solid mass – Core needle biopsy (CNB) or Excision No specific findings – Re-examine after two cycles

Breast Mass: Evaluation

History Unilateral vs. bilateral Spontaneous vs. provoked discharge Appearance of discharge Medications (e.g. antipsychotics, antidepressants) History of trauma History of amenorrhea History of hypogonadism (e.g. hot flashes, vaginal dryness)

Clinical breast exam Attempt to elicit discharge, identify involved duct(s) Evaluate discharge for gross blood or guaiac positivity

Nipple Discharge: Evaluation

Mamogram

• Fibroadenoma • Breast cancer

A 42 year old lady see her physician due to• Odd changes in the breast and felt small

lump, while showering,• thickening in the breast,• No nipple discharge, no trauma and no pain.

Case studies

• A 22 year old lady noticed small mobile round• Lump in her breast,• ------------------------------

• 39 year old lady, irregular small multiple lumps, firm ,tender more during mid cycle.

• -----------------------------------

• 41 year old lady 2 axillary lymph nodes, non tender, no barest mass ,mild weight loss.

• ---------------------------------• 39 year diffuse firm left breast and FNAC

abnormal• --------------------------------26 year old lady with firm irregular 5mm lump----------------------------

Medication history (e.g., oral contraceptives, steroids, and diuretics) may cause nipple discharge.

Risk factors (e.g., mother, sister, aunt with breast cancer, alcohol consumption, high fat diet, obesity, use of oral

contraceptives, menarche before age 12, menopause after age 55, age 30 or more at first pregnancy

Inquire if the client performs breast self examination, technique used, and when performed in relation to the menstrual cycle.

Estrogen replacement therapy may be associated with the development of cyst or cancer.

Assessing Breasts and axillaeDeviation from

normalNormal findings Assessment

-Recent change in breast size, swelling, marked asymmetry.

Female: rounded shape, slightly unequal in size, generally symmetric.

Male: breasts even with the chest wall, if obese may be similar in shape to female breasts.

Inspect the breasts for:•Size.•Symmetry.•Shape.While the client is in a sitting position

Inspect for:

• Skin changes• Redness• Visible bumps• Nipple crusting• Symmetry

Assessing Breasts and axillaeDeviation from

normalNormal findings Assessment

-Localized discolorations or hyperpigmentation.-Retraction or dimpling.-Unilateral localized hypervascular areas.-Swelling or edema appearing as pig skin or orange peel due to exaggeration of the pores.

Skin : uniform in color and skin is smooth and intact.Striae, moles and nevi.

*Inspect the skin for localized hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema.

Assessing Breasts and axillaeDeviation from

normalNormal findings

Assessment

Breasts should rise evenly Watch for dimpling or retraction

*Emphasize any retraction by having the client:-Raise the arms above the head.-Push the hands together, with elbows flexed.-Press the hands down on the hips.

Assessing Breasts and axillaeDeviation from

normalNormal findings Assessment

Any a symmetry, mass, or lesion.

-Rounded or oval bilaterally the same,--Color varies from light pink to dark brown.-Irregular placement of sebaceous glands on the surface of areola.

Inspect the areola area for size, shape, symmetry, color, surface characteristics, and any masses or

lesions .

Assessing Breasts and axillaeDeviation from normal Normal findings Assessment

-A symmetrical size and color.

-Presence of discharge, crusts, or cracks.

-Recent inversion of one or both nipples.

-Rounded, everted and equal in size.-Similar in color, smooth, soft, both nipples point in same direction.- No discharge, except from pregnant or breast feeding females.-Inversion of one or both nipples that is present from puberty.

Inspect the nipples for size, shape, position, color, discharge, and lesions.

Assessing Breasts and axillaeAssessment

*Palpate the axillary, subclavicular, and supraclavicular lymph nodes.

Client position: sits with arms abducted and supported on the nurse’s forearm.

Use the flat surfaces of all fingertips to palpate the four areas of axilla:

• The edge of the greater pectoral muscle.• The thoracic wall in the midaxillary area.• The upper art of the humerus.• The anterior edge of the latissimus dorsi muscle along the posterior axillary line.

Assessing Breasts and axillaeDeviation from normal Normal

findingsAssessment

-Tenderness, masses, nodules, or nipple discharge.

If a mass was detected, record the following data:

A-Location and distance from the nipple in cm.

No tenderness, masses, nodules, or nipple discharge.

Palpate the breasts for masses, tenderness, and any discharge from the nipples.

Client position: supine Rationale: The breasts flatten evenly against the chest wall, facilitating palpation

Use the Middle of Your Fingers• Fingertips are too

sensitive (all breasts are somewhat lumpy)

• Palm is too insensitive• Middle portion of

fingers is just right

Move your hand in small circles

• Stay in one place• Press in while circling

with your hand• Feel for thickenings the

size of a marble

Feel the Armpit• Use the same circular

motions.• Feel for breast lumps and

lymph nodes.• Normal lymph nodes

cannot be felt.• Enlarged lymph nodes

are about the size of a pencil eraser, but longer and thinner.

Try to Express Nipple Discharge• Strip the ducts towards

the nipple.• Normally, one or two

drops of clear, milky or green-tinged secretions.

• Should not be bloody or in large quantity, squirting out or staining the inside of a bra.

Assessing Breasts and axillaeDeviation from normal Normal

findingsAssessment

B-Size: the length, width, and thickness of the mass in cm.

C-Shape: round, oval, lobulated, indistinct, or irregular.

D-Consistency: hard or soft mass.

For patients who have a past history of breast masses, who are at high risk for breast cancer, examination in both a Supine and a Setting

position is recommended .

Assessing Breasts and axillaeDeviation from normal Normal

findingsAssessment

E- Mobility: movable or fixed.

F-Skin over the lump: is reddened, dimpled, or retracted.

G-Nipple: whether it is displaced or retracted.

H-Tenderness: whether palpation is painful.

If the client reports a breast lamp, start with the “normal” breast to obtain baseline ass.

For palpation choose one of three patterns:

1- Concentric circles.

Assessment

2-Hands-of-the-clock or spokes-on-a-wheel

3-Vertical strips pattern:• Start at one point for palpation, and move

systematically to the end point to ensure that all breast surfaces are assessed.

• Teach the client the technique of breast self examination.

• Document findings.

Bottom Line Concepts It is important to evaluate breast complaints thoroughly to ensure that breast

cancers, as well as benign breast lesions, are diagnosed and treated promptly.

Evaluation of a woman presenting with a breast complaints requires careful assessment of symptoms and risk factors for developing breast cancer.

The clinical breast exam include inspection and palpation of the breast tissue, chest wall, and regional lymph nodes. Documentation should included both positive and negative findings.

Women with breast problems can present with any combination of symptoms including breast mass or thickening, breast pain, nipple discharge, or skin changes.

Typically, women presenting with a suspicious breast mass who are > 30 yrs should receive a diagnostic mammogram, whereas women younger than 30 should receive a diagnostic ultrasound.

Negative imaging should not stop further investigation is a suspicious lump is felt on clinical exam.

Masses that are solid on ultrasound imaging require biopsy to exclude cancer and provide a histological diagnosis.