BREAST AND AXILLA EXAMINATION

Breast Anatomy 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

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

Evaluation: History 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

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

Evaluation: Physical Exam 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

Benign Characteristics Malignant Characteristics 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

Breast Disease Benign Malignant Nonproliferative Fibrocystic changes Simple cysts Lactational adenoma Fibroadenoma Hyperplasia without atypia Epithelial hyperplasia Sclerosing adenosis Intraductal papillomas 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

Mastalgia: Incidence 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: Etiology Differential Diagnosis: Cyclic Non-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: Fibrocystic Disease Premenopausal women Premenstrual breast swelling/tenderness Nodules/masses/lumps related to dense breast tissue or cysts Fibrous tissue Cystically dilated ducts + Calcifications + Ductal hyperplasia

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

Breast Mass: Etiology 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: Fibroadenoma Solitary, firm, rubbery, mobile mass Women < 30 yrs Slow growing (? hormonally mediated) Fibroadenoma gross specimen Firm, tan, lobulated Well circumscribed mass Variable size

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

Breast Mass: Evaluation 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

Nipple Discharge: 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

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 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 axillae Deviation from normal Normal 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 Look for any dimpling or unusual skin changes. There should be no visible bumps or bulges of the breast beyond the normal contour. The skin should be a uniform color and not have areas of redness suggesting increased blood flow. The nipples should have no visible secretions or crusting.

Assessing Breasts and axillae Deviation from normal Normal 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 axillae Deviation from normal Normal 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 axillae Deviation from normal Normal 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 axillae Deviation 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 axillae Assessment *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 axillae Deviation from normal Normal findings Assessment -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 Don't use your fingertips...they are too sensitive and you will end up focusing on all the tiny irregularities and nodules that are present in everyone's breasts. Don't use the palms of your hand...they are too insensitive and you can miss something important. Use the middle portions of your fingers...they have just the right sensitivity for finding the lumps or masses you are seeking.

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 Move your hand in small circles while feeling for lumps

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. Using the same circular motions, examine the armpit, feeling for any lumps in the "tail" of the breast or any lymph nodes. Lymph nodes are normally so small they cannot be felt. If enlarged due to infection or inflammation, they grow to about the size of a pencil eraser but are long and narrow rather than round.

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. Using the thumb and fingers, squeeze the breast toward the nipple to try to express any discharge. This stripping of the milk ducts can be useful in identifying early problems with the ducts. You should squeeze not only from side to side, but also from top to bottom and at an angle. In normal breasts, you can, with effort, usually produce a drop or two of clear, milky, or slightly green-tinged discharge. Abnormal findings would be a bloody discharge, or so much discharge that it squirts across the room or consistently stains the inside of your bra.

Assessing Breasts and axillae Deviation from normal Normal findings Assessment 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 axillae Deviation from normal Normal findings Assessment 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.