Breast Anatomy: Surface, Internal, and Lymphatics

Surface Anatomy

• Breasts are located anterior to the pectoralis major and serratus anterior muscles
• They are situated between the second and sixth ribs and extend from the side of the sternum to the midaxillary line
• The Tail of Spence is located at the superior lateral corner, projecting up and laterally into the axilla
• The areola surrounds the nipple
• Montgomery's Glands: Small elevated sebaceous glands that secrete protective lipid material during lactation

Internal Anatomy

• Breasts are composed of glandular, fibrous, and adipose tissue
• The glandular tissue has 15 to 20 lobes radiating from the nipple and composed of lobules
• Cooper's ligaments are fibrous bands that extend vertically from the surface to attach to chest wall muscles
• Lobes are embedded in adipose tissue
• The breast may be divided into four quadrants via imaginary horizontal and vertical lines intersecting at the nipple

Lymphatics

• The breast has extensive lymphatic drainage
• Four groups of axillary nodes are present: central, pectoral(anterior), subscapular (posterior), and lateral axillary nodes
• Drainage flows from the central axillary nodes up to the infraclavicular and supraclavicular nodes

Aging Woman

• After menopause, decreased secretion of estrogen and progesterone leads to atrophy of breast glandular tissue
• The inner structures become more prominent and breast size decreases
• A breast lump may have been present for years but is suddenly palpable
• Lactiferous ducts around the nipple are more palpable, feeling firm and stringy due to fibrosis and calcification
• Axillary hair decreases

Male Breast

• The male breast is a rudimentary structure consisting of a thin disk of undeveloped tissue underlying the nipple
• Gynecomastia is common during adolescence, leading to temporary enlargement of breast tissue, usually unilateral and temporary
• Reassurance is necessary for adolescent males
• Gynecomastia may reappear in aging males due to testosterone deficiency

Genetics and Environment: Breast Cancer

• Statistics on breast cancer morbidity, mortality, and prognosis should be reviewed
• Mutations in BRCA1 and BRCA2 should be considered
• Estrogen receptor and HER-2 as target cell surface receptors should be taken into account
• Racial disparity and socioeconomic conditions affecting access to health care should also be considered
• Screening mammography recommendations and lifestyle risk factors, such as alcohol dose-dependent effect, postmenopausal weight gain, and decreased physical activity, should be reviewed

Subjective Data: Breast

• Pain, lumps, and discharge should be taken into account
• Rash, swelling, and trauma should be noted
• A History of breast disease and surgery or radiation should be taken into account
• Medications and patient-centered care should be noted
• If the patient preforms Breast self-examination/last mammogram should also be taken into consideration

Subjective Data: Axilla

• Tenderness, lumps, or swelling should be noted
• Any rash should be noted

Culture and Women Regarding Breast Cancer

• Female breasts signify more than their primary purpose of lactation in many cultures
• Body image, societal influence, and media response can all affect this
• This is integrated with women's self-concept
• Feelings of fear, anxiety, and panic may be a result from finding a breast lump
• Even though many breast lumps are benign, assume the worst possible outcome, including cancer, disfigurement, and death
• Be sensitive to each women's individual's perception of female body image

Questions to Ask. Pain

• Any pain or tenderness in breasts?
• Note the Onset
• Pain location
• Determine if it is Localized or diffuse
• Is painful spot sore to touch?
• Determine if the patient feels a burning or pulling sensation?
• Find out if the pain is cyclic
• Is there Any relation to menstrual cycle?
• Precipitating factors may include things like, Brought on by strenuous activity, Change in activity or Sexual manipulation?

Questions to Ask. Lump

• Determine the location of the lump, ask if they have Ever noticed a lump or thickening in breast?, and where
• Note the Onset and find out When they first noticed it? if it has Changed at all since then?
• Check the Appearance and ask them if it has Any relation to the menstrual period?
• Ask if they have Noticed any change in overlying skin like, Redness, warmth, dimpling, and swelling?

Questions to Ask. Discharge

• Note the Onset: and ask if there is Any discharge from the nipple?
• When did they first notice the discharge?
• Find out the Characteristics: such as, the color of discharge? and is it consistency thick or runny? and what the odor is like?

Questions to Ask. Rash

• Ask about the Appearance of the Rash and find out if they have Any rash on breast?
• Find out the Onset and ask them When they first noticed this?
• Ask them for the Location and Where did it start?
• Find out if it is On nipple, areola, or surrounding skin?

Questions to Ask. Swelling

• Ask about the Location and note if they have Any swelling in breasts?, is it One spot or all over?
• Check the Appearance, and see of its r/t their menstrual period, pregnancy, or breastfeeding?
• Ask if there has been Any change in bra size?

Questions to Ask. Trauma

• Inquire if there have been Any trauma or injury to the breasts?
• Ask about the Presentation and Did it result in any swelling, lump, or break in skin?

Questions to Ask. History of Breast Disease

• Ask if they have Any personal history of breast disease?
• Note the Diagnosis of What type?, and How was it diagnosed?
• Check the Medical management, find out When did this occur?, and How is it treated?
• Note the Family history of Any breast cancer in their family?, Who? (Sister, mother, maternal grandmother, maternal aunts, daughter?)
• Ask them At what age did this relative have breast cancer?

Questions to Ask. Surgery or Radiation

• Check if they have had any Surgical intervention: such as a Biopsy and look at the results
• Look for a Mastectomy, Mammoplasty, augmentation, or reduction?
• Find out if Radiation was given as part of any therapy
• See Imaging studies: and if a Mammography, and screening x-ray examination of breasts? Was done, and when was the last x-ray?

Questions to Ask. Medication

• Ask them if they Have you taken oral contraceptives? and For how long?
• Inquire if the Where on HRT and for How long? and what type of Estrogen/Progesterone? where they on
• Note the Different Types of medications they take (Rx and OTC)

Questions to Ask. Self-Breast Exam (BSE)

• See if they have any knowledge about and Ask about self-breast exam (BSE)
• Take an opportunity to teach moment to review basics of examination

Questions to Ask. Screening Guidelines

• Review screening guidelines recommendations based on age and patient history
• American Cancer Society - No recommendation for a Complete Breast Examination (CBE)
• Can begin at ages 40 to 44, screening mammography
• Annual mammography from ages 45 to 54
• Biennial mammography over age 55 or continuation of annual

Questions to Ask. Axilla

• Ask about Tenderness, lumps, or swelling
  • Note the Appearance- such as Any tenderness or lump in the underarm area?
  • Determine the Location.
  • Where did you first notice this?
• Note the potential Rash
  • Look for any axillary rash?
  • Find out if the rash Seem to be a reaction to deodorant?
  • Precipitating factor

Risk Profile for Breast Cancer

• Breast cancer is the 2nd leading cause of cancer-related deaths in women
• Early detection and improved treatment methods lead to increased rates of survival
• RR above 1 indicates a higher likelihood of occurrence among exposed than unexposed persons

Objective Data: Preparation

• Woman is sitting up facing examiner
• Short gown, open at back, and lift it up to woman's shoulders

Objective Data During Palpation

• When woman is supine, cover one breast with gown while examining other
• Use a sensitive but matter-of-fact approach because Many women are embarrassed to have their breasts examined

Objective Data Equipment Needed

• Small pillow
• Ruler marked in centimeters
• Pamphlet or teaching aid for breast self-examination (BSE)

General Appearance of Breasts Inspection

• Symmetry of size and shape
• Slight asymmetry in size

Skin Inspection

• Normally smooth and of even color
• Note any localized areas of redness, bulging, or dimpling
• Look for any skin lesions or focal vascular pattern
• Fine blue vascular network visible during pregnancy
• Pale linear striae, or stretch marks follow pregnancy
• No edema is present

Nipple Inspection

• Symmetric on same plane on both breasts
• Nipples usually protrude, although some are flat, and some are inverted
• Normal nipple inversion is unilateral or bilateral and can be pulled out
• Look for any dry scaling, any fissure or ulceration, and bleeding or other discharge
• Supernumerary nipple is a normal variation
• Extra nipple a congenital finding

Check Breast and Skin

• Perform sequence of maneuvers to assess for this abnormality

Inspect and Palpate the Axillae

• While Woman sitting, inspect the skin, noting any rash or infection
• Lift woman's arm and support to keep the muscles loose and relaxed
• Palpate for any Enlarged and tender lymph nodes
• Reach fingers high into axilla, and move firmly down in four directions
• Move the arm through range-of-motion to increase surface area
• Nodes are usually non-palpable, but may feel a small, soft, nontender node in central group

Palpate the Breasts

• Vertical strip pattern is used to detect breast masses
• from the nipple palpating out to periphery as if spokes on a wheel
• Palpating in concentric circles out to periphery
• Nulliparous women- normal breast tissue feels firm, smooth, and elastic
• Pregnancy- tissue feels softer and looser
• Premenstrual- engorgement is normal from increasing progesterone
• Inframammary ridge- normal finding

Palpate Nipple

• After palpating over four breast quadrants, palpate nipple
• Note any induration or subareolar mass
• Thumb and forefinger gently depress nipple tissue into well behind areola
• Tissue should move inward easily

Check for Nipple Discharge

• Press areola inward with your index finger
• Repeat from a few different directions; note color and consistency of any discharge
• Check if its physiologic (benign) discharge which is usually bilateral
• Look for Galactorrhea: white, milky during pregnancy and breastfeeding, which can occur up to 1 year after weaning

Breast Lumbs

• Examine unaffected breast first to learn a baseline of normal consistency.

Characteristics of Lump Location

• Determine as with clock face, the distance in centimeters from nipple
• Diagram breast in woman's record and mark in location of lump

Characteristics of Lump Size

• Judge in centimeters in three dimensions: width, length, and thickness

Characteristics of Lump Shape

• Determine if its oval, round, lobulated, or indistinct

Characteristics of Lump Consistency

• Check if it's soft, firm, or hard

Characteristics of Lump Movable

• Check to see of It is freely movable or fixed when you try to slide it over chest wall

Characteristics of Lump Distinctness

• Is it solitary or multiple?

Characteristics of the Nipple

• Is it displaced or retracted?

Skin Over Lump

• Is it erythematous, dimpled, or retracted?

Tenderness

• Is lump tender to palpation?

Lymphadenopathy

• Are any regional lymph nodes palpable?

Breast Self-Examination (BSE) Teaching

• Keep Teachings Simple
• Simpler the plan, the more likely the person is to comply
• Describe the correct technique and rationale and expected findings
• Teach woman to inspect her own breasts while disrobed to waist in front of a mirror
• Can start palpation in the shower with soap and water
• Perform palpation while lying supine
• A model as well as pamphlets may be helpful
• Encourage the woman to palpate her own breasts while you monitor her technique

Examining a Patient After Mastectomy

• Be aware of the concerns of the patient for a return of cancer
• Inspect the anterior chest, incisional site, noting stage of healing
• Palpate the intact breast first, then the mastectomy area
• Finger pads apply circular motion
• Palpate the axilla and explore ROM on the affected side

Male Breast Examination

• Can be abbreviated, but do not omit
• Contains a normal flat disk of undeveloped breast tissue beneath the nipple

Male Breast Gynecomastia

• Benign growth of this breast tissue distinguishes it from other chest wall tissues
• Feels like a smooth, firm, movable disk
• The patient is acutely aware, it Occurs normally during puberty and is temporary
• Reassure the patient that this change is normal, common, and temporary

Developmental Competence: Aging Women

• On inspection, breasts look pendulous, flat, and sagging
• There are Changes to be noted on breast tissue with aging
• Annual CBE required Women over 50 years old have increased risk for breast cancer

Abnormal Findings: Signs of Retraction and Inflammation

• Dimpling
• Nipple retraction
• Edema (Peau d'Orange)
• Fixation
• Deviation in nipple pointing

Abnormal Findings: Breast Lumps

• Benign ("Fibrocystic") Breast Disease
• Cancer
• Fibroadenoma
• Differentiating breast lumps

Differentiating Breast Lumps

• Age
• Shape, consistency, and demarcation
• Number, mobility, and tenderness
• Skin retraction, pattern of growth, and risk to health

Abnormal Findings: Abnormal Nipple Discharge

• Mammary Duct Ectasia
• Intraductal Papilloma
• Ductal Carcinoma in Situ (DCIS)
• Paget Disease (Intraductal Carcinoma)

Abnormal Findings Disorders

• Disorders occurring during lactation:
  • Mastitis, Breast Abscess, Plugged Duct
• Male breast abnormalities:
  • Gynecomastia, Male Breast Cancer

Summary Checklist: Breasts and Regional Lymphatics

• Inspect the breasts as the woman sits, raises arms overhead, pushes hands on hips, and leans forward
• Inspect the supraclavicular and infraclavicular areas
• Palpate the axillae and regional lymph nodes
• With woman supine, palpate the breast tissue, including tail of Spence, the nipples, and areolae
• Teach BSE