1. Examination of the Breasts and Axillae Dr. Maysa Almomani Fall 2015 Chapter 10

2. Anatomy of the Breast §located on the anterior chest wall §superficial to the pectoralis major and inferior margion, the serratus anterior muscles §female breast composed of gland, fiber and fat with proportions dependent on age, genes, nutrition and childbearing §Cooper suspensory ligaments, attached to underlying muscle, provide support along with the layer of subcutaneous fibrous tissue

3. Anatomy of Breast (cont.) §divided into 4 quadrants and a tail §the upper outer quadrant contains the most glandular tissue §breast tissue extends from the upper outer quadrant into the axilla, forming the tail of Spence §in the axillae, the mammary tissue is in direct contact with the axillary lymph nodes

6. The Breast: Lymphatic Drainage §Each breast contains a lymphatic network that drains the breast radially and deeply to underlying lymphatics. §The axillary nodes are more superficial than others draining the breasts and are therefore more accessible and relatively easy to palpate.

7. The Axillary Lymph Nodes §Anterior axillary (pectoral) l along lower border of pectoralis major §Posterior axillary (subscapular) l along the lateral border of the scapula §Central l high in the axilla close to the ribs §Lateral axillary l along the upper humerus, drain most of the arm

10. Breast Anatomy: Variations l Menopause & Older Adults some premenopausal decrease in tissue after menopause, glandular tissue atrophies, replaced by fat inframammary ridge thickens, suspensory ligaments loosen, and nipples become smaller, flatter and less erectile skin may become thin & dry and axillary hair may decrease

11. Breast and Axillae Assessment: History Review §Present Problem (common symptom) l breast pain or discomfort l breast mass or lump: ranging from cyst & fibroadenoma l nipple discharge: spontaneous & after compression of the nipple Galactorrhea: inappropriate discharge of milk containing fluid Common questions: do you examine your breast? How often? §Past Medical History l previous breast disease l surgeries l menstrual history l pregnancy l lactation l hormonal medications

12. . §Family History l breast cancer l other breast disease in female and male relatives §Personal & Social History l age l cyclic & noncyclic changes in breast characteristics l menstrual or menopausal status l breast self-examination l self care l hormonal meds l risk factors for cancer

13. Breast Cancer: Risk Factors §General l age (80% occur after age 40) l gender: female l personal history of breast cancer l personal history of ovarian, endometrial, colon or thyroid cancer §Specific Risks for Women l family history of breast cancer mother, sister, grandmother, or aunt l early menarche (<12) l late menopause (>55) l nulliparity l birth of first child after age 30

15. Physical Examination §Patient disrobed to waist §Good light §Matter-of-fact attitude §Thorough exam (don’t rush it!) §Small pillow or folded towel §Glass slide and fixative (cytology) §Teach BSE / Review technique

16. Objective Data/ Inspection §General appearance: pt. in sitting position -Color/ redness from local infection or inflammatory carcinoma -Skin/ thickening accompany lymphatic obstruction §Size of the breasts §Symmetry of the breasts §The contour of the breasts such as masses, dimpling, flattening, retraction in 4 views §The charac. of the nipples including size, shape, ulceration or rashes or discharge

17. Inspection Positions: Arms over head Dimpling or retraction/ cancer Hands pressed against hips For benign lesions e.g. mammary ducts ectasia Leaning forward for asymmetry Retraction of the nipple & areola/cancer Arms at sides: color, thickening of the skin, Size, symmetry, contour, change in nipple.

18. Palpation Methods:

19. Palpation §Consistency of the tissues ( tender cords suggest mammary duct ectasia) §Tenderness (premenstrual fullness) §Nodules/Lump: Assess for -Location by quadrant or clock -Size in cm -Shape: round or cystic, or irregular in contour -Consistency :soft, firm or hard -Delimitation: circumscribed or not -Tenderness -Mobility: dimpling, cysts §Nipple: elasticity §Retraction: dimpling, altered contour §Peau d’orange sign §Associated lymphadenopathy

20. Abnormal Breast Findings: §Dimpling§Inflammatory cancer

21. Abnormal Breast Findings: §Peau d’orange

22. Abnormal Breast Findings: §Breast cancer, lump & nipple retraction

23. The Male Breast §Inspect the nipple and areola for nodules, swelling or ulceration §Palpate the areola & breast tissue for nodules. §Abnormalities: -Gynecomastia: firm disk of grandular enlargement -Carcinoma

24. The Axillae §Inspection: - Rash -Infection -Unusual pigmentation §Palpation -Central nodes -Lateral nodes (brachial) -pectoral nodes (Anterior) --Subscapular nodes (Posterior)

25. Mammogram §is an X-ray test that produces an image of the inner breast tissue on film. This technique, called mammography, is used to visualize normal and abnormal structures within the breasts. Mammography, therefore, can help in identifying cysts, calcifications, and tumors within the breast. It is currently the most efficient screening method to detect early breast cancer.

26. §The American Cancer Society recommends that a woman obtain her first baseline mammogram between the ages of 35 to 40. After the age of 40, she should receive a yearly mammogram. Women who are at high risk for developing breast cancer may need to obtain mammograms earlier than these recommendations and at more frequent intervals.

30. الفحص السريري الدوري بدنا ااياك سالمة 80% من الاورام هي اورام حميدة 30

31. Breast Self-Exam §The breast self-exam is a way that female can check her breasts for changes (such as lumps or thickenings). It includes looking at and feeling her breast. Any unusual changes should be reported to the doctor. When breast cancer is detected in its early stages, the chances for surviving the disease are greatly improved

32. قومي بإجراء هذا الفحص وأنت مستلقية على ظهرك. ضعي وسادة أو منشفة مطوية تحت الكتف جهة الثدي الأيسر، وضعي يدك اليسرى أجري الفحص باليد اليمنى وباستخدام باطن الأصابع الثلاث الوسطى ( البصمات ) افحصي ثديك الأيسر، بضغط دائري خفيف، ومن ثم متوسط ومن ثم عميق لكل بقعة، والانتقال من بقعة لبقعة دون رفع أصابعك. كرّري ذلك بشكل دائري حيث تبدئين بفحصه من دائرة الثدي الكبرى باتجاه دائرة الحلمة دون أن تتركي أي جزء دون فحص، وأخيراً عليك فحص تحت الإبط. وأخيراً عليك فحص تحت الإبط يمكنك إعادة الفحص خلال الاستحمام، حيث أن الصابون يخفف الاحتكاك وقد يعمل على تسهيل عملية الاحساس بالكتل. 32 الفحص باللمس

33. Breast Biopsy §A procedure in which a sample of a suspicious breast growth is removed and examined, usually for the presence of cancer. The sample is suctioned out through a needle or removed surgically. The setting depends on the size and location of the growth, the patient's general health, and the type of biopsy performed.

34. §Among the most common benign growths in the breast are cysts (sacs filled with fluid or semisolid material), intraductal papillomas (small wart-like growths that project above a tissue surface), and lumps formed by fat necrosis (the death of tissue often as a result of trauma to the breast).