Podcast
Questions and Answers
In the context of breast anatomy, which of the following best describes the spatial relationship of the female breast relative to the thoracic wall?
In the context of breast anatomy, which of the following best describes the spatial relationship of the female breast relative to the thoracic wall?
- The breast lies against the anterior thoracic wall, spanning from the clavicle and second rib down to the sixth rib, and from the sternum across to the midaxillary line, overlying the pectoralis major and serratus anterior muscles. (correct)
- The breast adheres directly to the periosteum of the ribs, superficial to the intercostal muscles, reaching from the manubrium to the midclavicular line.
- The breast is superficial to the pectoralis minor muscle, extending from ribs 3 to 7 and the sternal border to the posterior axillary line.
- The breast is positioned deep within the thoracic cavity, anterior to the ribs, and extends from the first to the fifth intercostal spaces.
Within the glandular tissue of the breast, what is the functional significance of the radial arrangement of lactiferous ducts and sinuses?
Within the glandular tissue of the breast, what is the functional significance of the radial arrangement of lactiferous ducts and sinuses?
- It facilitates the convergence of milk from multiple lobes towards the nipple and areola for efficient secretion. (correct)
- It enhances structural integrity by providing a framework for the suspensory Cooper ligaments.
- It ensures uniform distribution of adipose tissue, preventing localized areas of fibrocystic changes.
- It promotes lymphatic drainage towards the axillary nodes, reducing the risk of mastitis.
During lactation, what is the primary physiological role of the oily secretion produced by the sebaceous glands of the areola?
During lactation, what is the primary physiological role of the oily secretion produced by the sebaceous glands of the areola?
- To regulate the pH of the areolar skin, maintaining an optimal environment for lactobacilli.
- To enhance sensory perception, thus optimizing the milk ejection reflex.
- To provide a protective lubricant for the areola and nipple, preventing cracking and irritation. (correct)
- To stimulate local immune responses against bacterial colonization.
In the context of breast anatomy, what is the clinical significance of the 'milk line' regarding the presence of supernumerary nipples?
In the context of breast anatomy, what is the clinical significance of the 'milk line' regarding the presence of supernumerary nipples?
What underlying physiological process accounts for normal physiologic nodularity in the female breast?
What underlying physiological process accounts for normal physiologic nodularity in the female breast?
What is the neurophysiological basis for milk letdown following infant sucking?
What is the neurophysiological basis for milk letdown following infant sucking?
Which of the following anatomical structures defines the lateral border of the pyramidal space that constitutes the axilla?
Which of the following anatomical structures defines the lateral border of the pyramidal space that constitutes the axilla?
The serratus anterior muscle is innervated by which nerve?
The serratus anterior muscle is innervated by which nerve?
A physician palpates enlarged, matted axillary lymph nodes during a clinical breast exam. If the central nodes feel large, hard, and tender, what is the MOST appropriate next step to assess potential lymphatic spread?
A physician palpates enlarged, matted axillary lymph nodes during a clinical breast exam. If the central nodes feel large, hard, and tender, what is the MOST appropriate next step to assess potential lymphatic spread?
What recommendation does the USPSTF give for women aged 40-49 regarding breast cancer screening?
What recommendation does the USPSTF give for women aged 40-49 regarding breast cancer screening?
What is the strongest risk factor for breast cancer?
What is the strongest risk factor for breast cancer?
According to evidence-based guidelines, under what circumstances would the American Cancer Society (ACS) advise annual screening mammography for women aged 45-54?
According to evidence-based guidelines, under what circumstances would the American Cancer Society (ACS) advise annual screening mammography for women aged 45-54?
For a woman at very high risk for breast cancer due to genetic mutations, what specific imaging modalities and frequency are recommended for screening?
For a woman at very high risk for breast cancer due to genetic mutations, what specific imaging modalities and frequency are recommended for screening?
What is the significance of recent nipple retraction during a clinical breast examination?
What is the significance of recent nipple retraction during a clinical breast examination?
During inspection of the breasts, a physician notes skin thickening and prominent pores, creating a peau d'orange appearance, what underlying pathophysiological process should the physician suspect?
During inspection of the breasts, a physician notes skin thickening and prominent pores, creating a peau d'orange appearance, what underlying pathophysiological process should the physician suspect?
During examination of the breasts with the patient's arms at sides, the physician notes asymmetry with a change in nipple direction. Which of the following is MOST likely to be the underlying cause?
During examination of the breasts with the patient's arms at sides, the physician notes asymmetry with a change in nipple direction. Which of the following is MOST likely to be the underlying cause?
To optimize the palpation of the lateral portion of the breast, what specific positioning of the patient is MOST appropriate?
To optimize the palpation of the lateral portion of the breast, what specific positioning of the patient is MOST appropriate?
Which technique is currently considered the most validated for detecting breast masses?
Which technique is currently considered the most validated for detecting breast masses?
During palpation of the breast, the physician encounters a firm, transverse ridge along the lower margin. What is this most likely to be?
During palpation of the breast, the physician encounters a firm, transverse ridge along the lower margin. What is this most likely to be?
A physician palpates a mobile mass in a patient's breast that becomes fixed when the arm is relaxed. What is the MOST likely anatomical attachment?
A physician palpates a mobile mass in a patient's breast that becomes fixed when the arm is relaxed. What is the MOST likely anatomical attachment?
What is suggested by thickening of the nipple with loss of elasticity?
What is suggested by thickening of the nipple with loss of elasticity?
What is indicated by milky nipple discharge unrelated to a prior pregnancy and lactation?
What is indicated by milky nipple discharge unrelated to a prior pregnancy and lactation?
What condition is suggested by the presence of tender subareolar cords?
What condition is suggested by the presence of tender subareolar cords?
Clear, serous, green, black, or nonbloody discharges that are multiductal MOST likely is:
Clear, serous, green, black, or nonbloody discharges that are multiductal MOST likely is:
During examination of the axillae, what is the correct positioning for the patient?
During examination of the axillae, what is the correct positioning for the patient?
During axillary examination, you instruct a patient to relax their arm. What is the primary reason for this?
During axillary examination, you instruct a patient to relax their arm. What is the primary reason for this?
Upon palpation of the axilla, you detect deeply pigmented, velvety axillary skin. What is this MOST indicative of?
Upon palpation of the axilla, you detect deeply pigmented, velvety axillary skin. What is this MOST indicative of?
Enlarged axillary nodes may be due to?
Enlarged axillary nodes may be due to?
What are normal findings in a newborn's breast?
What are normal findings in a newborn's breast?
In premature thelarche, breast development occurs:
In premature thelarche, breast development occurs:
According to Tanner staging, in what stage does projection of areola and nipple to form a secondary mound above the level of breast occur?
According to Tanner staging, in what stage does projection of areola and nipple to form a secondary mound above the level of breast occur?
According to Tanner staging, in what stage does projection of nipple only; areola has receded to general contour of the breast occur?
According to Tanner staging, in what stage does projection of nipple only; areola has receded to general contour of the breast occur?
A patient is found to have pea-size firm masses inferior to the nipple. What statement is MOST accurate about this finding?
A patient is found to have pea-size firm masses inferior to the nipple. What statement is MOST accurate about this finding?
During male breast examination, how can gynecomastia be distinguished from pseudogynecomastia?
During male breast examination, how can gynecomastia be distinguished from pseudogynecomastia?
What is NOT a risk factor for male breast cancer?
What is NOT a risk factor for male breast cancer?
During palpation of the breast, the physician identifies a hard, irregular, eccentric, or ulcerating painless dominant mass. What condition is MOST likely?
During palpation of the breast, the physician identifies a hard, irregular, eccentric, or ulcerating painless dominant mass. What condition is MOST likely?
What are the three most important nerves that course through the axilla?
What are the three most important nerves that course through the axilla?
Which of the following is the MOST accurate description of the 'tail of Spence' regarding its anatomical location and clinical significance?
Which of the following is the MOST accurate description of the 'tail of Spence' regarding its anatomical location and clinical significance?
In the context of hormonally mediated breast changes, what specific intracellular signaling cascade is MOST directly responsible for the proliferative effects observed during the luteal phase of the menstrual cycle?
In the context of hormonally mediated breast changes, what specific intracellular signaling cascade is MOST directly responsible for the proliferative effects observed during the luteal phase of the menstrual cycle?
Considering the lymphatic drainage pathways related to breast cancer metastasis, what is the probabilistic distribution of sentinel lymph node involvement, accounting for variance in tumor location and size, and how does this influence surgical planning regarding axillary dissection?
Considering the lymphatic drainage pathways related to breast cancer metastasis, what is the probabilistic distribution of sentinel lymph node involvement, accounting for variance in tumor location and size, and how does this influence surgical planning regarding axillary dissection?
How does the varying expression of estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ) isoforms within different breast tissue compartments (e.g., ductal epithelium vs. stromal fibroblasts) contribute to the heterogeneous response of the breast to hormonal stimuli across the lifespan?
How does the varying expression of estrogen receptor alpha (ERα) and estrogen receptor beta (ERβ) isoforms within different breast tissue compartments (e.g., ductal epithelium vs. stromal fibroblasts) contribute to the heterogeneous response of the breast to hormonal stimuli across the lifespan?
Considering the biomechanical forces acting on Cooper's ligaments, and their susceptibility to neoplastic infiltration, what finite element analysis (FEA) parameters would MOST accurately predict the spatial deformation and tensile strength reduction of these ligaments in the presence of an invasive ductal carcinoma?
Considering the biomechanical forces acting on Cooper's ligaments, and their susceptibility to neoplastic infiltration, what finite element analysis (FEA) parameters would MOST accurately predict the spatial deformation and tensile strength reduction of these ligaments in the presence of an invasive ductal carcinoma?
What are the long-term effects of supernumerary nipples on lactation?
What are the long-term effects of supernumerary nipples on lactation?
In the context of breast physiology, what is the precise mechanism by which tactile stimulation of the nipple induces milk letdown, considering the roles of oxytocin receptor isoforms and downstream signaling pathways in myoepithelial cells?
In the context of breast physiology, what is the precise mechanism by which tactile stimulation of the nipple induces milk letdown, considering the roles of oxytocin receptor isoforms and downstream signaling pathways in myoepithelial cells?
Considering the variations in axillary anatomy, what are the probabilistic constraints on the safe placement of a subclavian central venous catheter, accounting for the anatomical relationships of the axillary vein, axillary artery, and brachial plexus, and how do these constraints vary with patient body mass index (BMI)?
Considering the variations in axillary anatomy, what are the probabilistic constraints on the safe placement of a subclavian central venous catheter, accounting for the anatomical relationships of the axillary vein, axillary artery, and brachial plexus, and how do these constraints vary with patient body mass index (BMI)?
How does the differential expression of neuropeptides, such as calcitonin gene-related peptide (CGRP) and substance P, within the sensory neurons innervating the breast contribute to the perception of breast pain (mastalgia) in premenopausal women, and how is this modulated by hormonal fluctuations during the menstrual cycle?
How does the differential expression of neuropeptides, such as calcitonin gene-related peptide (CGRP) and substance P, within the sensory neurons innervating the breast contribute to the perception of breast pain (mastalgia) in premenopausal women, and how is this modulated by hormonal fluctuations during the menstrual cycle?
Considering a patient presenting with suspected lymphatic metastasis from a primary breast carcinoma, what specific combination of immunohistochemical markers and flow cytometric analysis would provide the HIGHEST sensitivity and specificity for detecting occult micrometastases within sentinel lymph nodes?
Considering a patient presenting with suspected lymphatic metastasis from a primary breast carcinoma, what specific combination of immunohistochemical markers and flow cytometric analysis would provide the HIGHEST sensitivity and specificity for detecting occult micrometastases within sentinel lymph nodes?
What is the mechanism of action by which the long thoracic nerve injury leads to a winged scapula?
What is the mechanism of action by which the long thoracic nerve injury leads to a winged scapula?
In the context of axillary lymph node dissection following neoadjuvant chemotherapy for breast cancer, what statistical modeling approach BEST predicts the likelihood of residual nodal disease based on pre-treatment imaging characteristics and pathological response in the primary tumor?
In the context of axillary lymph node dissection following neoadjuvant chemotherapy for breast cancer, what statistical modeling approach BEST predicts the likelihood of residual nodal disease based on pre-treatment imaging characteristics and pathological response in the primary tumor?
A 42-year-old woman presents with a palpable axillary mass. After a thorough workup, the biopsy reveals metastatic adenocarcinoma of unknown primary. Given the lymphatic drainage patterns of the breast, which of the following imaging modalities would be MOST sensitive for detecting occult primary breast malignancy?
A 42-year-old woman presents with a palpable axillary mass. After a thorough workup, the biopsy reveals metastatic adenocarcinoma of unknown primary. Given the lymphatic drainage patterns of the breast, which of the following imaging modalities would be MOST sensitive for detecting occult primary breast malignancy?
How do the recommendations of The American Cancer Society (ACS) differ from those of the USPSTF regarding the initiation and frequency of screening mammography for women aged 40-49, and what is the rationale for these differences in terms of balancing benefits and harms?
How do the recommendations of The American Cancer Society (ACS) differ from those of the USPSTF regarding the initiation and frequency of screening mammography for women aged 40-49, and what is the rationale for these differences in terms of balancing benefits and harms?
What are the potential mechanisms, beyond direct DNA damage, through which high-dose radiation exposure to the chest at a young age increases the risk of subsequent breast cancer development, considering the roles of epigenetic modifications and alterations in the tumor microenvironment?
What are the potential mechanisms, beyond direct DNA damage, through which high-dose radiation exposure to the chest at a young age increases the risk of subsequent breast cancer development, considering the roles of epigenetic modifications and alterations in the tumor microenvironment?
Considering a patient with recent nipple retraction, what would be the MOST appropriate sequence of diagnostic investigations to differentiate between benign etiologies (e.g., mammary duct ectasia) and underlying malignancy?
Considering a patient with recent nipple retraction, what would be the MOST appropriate sequence of diagnostic investigations to differentiate between benign etiologies (e.g., mammary duct ectasia) and underlying malignancy?
What is the underlying pathophysiological mechanism responsible for the peau d'orange appearance of the breast skin in inflammatory breast cancer (IBC), and how does this differ from the skin changes observed in non-inflammatory breast malignancies?
What is the underlying pathophysiological mechanism responsible for the peau d'orange appearance of the breast skin in inflammatory breast cancer (IBC), and how does this differ from the skin changes observed in non-inflammatory breast malignancies?
What is the clinical significance of observing asymmetry in nipple direction during breast examination, and what specific anatomical structures are MOST likely to be implicated in causing this finding in the context of underlying malignancy?
What is the clinical significance of observing asymmetry in nipple direction during breast examination, and what specific anatomical structures are MOST likely to be implicated in causing this finding in the context of underlying malignancy?
In order to optimize palpation, how should a physician position a patient to examine the lateral portion of the breast?
In order to optimize palpation, how should a physician position a patient to examine the lateral portion of the breast?
What are the comparative advantages and disadvantages of the vertical strip pattern versus the circular pattern for breast palpation, considering the sensitivity and specificity for detecting small, non-palpable masses in women with varying breast densities?
What are the comparative advantages and disadvantages of the vertical strip pattern versus the circular pattern for breast palpation, considering the sensitivity and specificity for detecting small, non-palpable masses in women with varying breast densities?
During deep palpation, a physician mistakes a normal rib for a hard breast mass, what technique should the physician use to ensure correct diagnostic practices?
During deep palpation, a physician mistakes a normal rib for a hard breast mass, what technique should the physician use to ensure correct diagnostic practices?
If a mobile mass in a patient's breast becomes fixed when the arm is relaxed, which anatomical structures would be MOST likely attached to?
If a mobile mass in a patient's breast becomes fixed when the arm is relaxed, which anatomical structures would be MOST likely attached to?
What are the differential diagnostic considerations for nipple thickening and loss of elasticity, and what specific histopathological features would distinguish these conditions from underlying malignancy?
What are the differential diagnostic considerations for nipple thickening and loss of elasticity, and what specific histopathological features would distinguish these conditions from underlying malignancy?
What are the potential implications of milky nipple discharge unrelated to a prior pregnancy and lactation (nonpuerperal galactorrhea), and what is the MOST appropriate initial step to determine the etiology?
What are the potential implications of milky nipple discharge unrelated to a prior pregnancy and lactation (nonpuerperal galactorrhea), and what is the MOST appropriate initial step to determine the etiology?
What is the appropriate terminology to describe the characteristics of clear, serous, green, black, or nonbloody nipple discharges and what underlying conditions should be included in the differential diagnosis?
What is the appropriate terminology to describe the characteristics of clear, serous, green, black, or nonbloody nipple discharges and what underlying conditions should be included in the differential diagnosis?
To optimize the examination, how should a physician position a patient while examining the axillae?
To optimize the examination, how should a physician position a patient while examining the axillae?
Why is it important to instruct a patient to relax their arm during axillary examination?
Why is it important to instruct a patient to relax their arm during axillary examination?
Deeply pigmented, velvety axillary skin may be indicative of what underlying conditions?
Deeply pigmented, velvety axillary skin may be indicative of what underlying conditions?
What are potential causes of enlarged axillary nodes and how can they be differentiated based on clinical examination?
What are potential causes of enlarged axillary nodes and how can they be differentiated based on clinical examination?
What are the expected normal findings in a newborn's breast examination, and what hormonal influences contribute to these findings?
What are the expected normal findings in a newborn's breast examination, and what hormonal influences contribute to these findings?
What are the underlying hormonal mechanisms responsible for premature thelarche, and how does this condition differ clinically and endocrinologically from true precocious puberty?
What are the underlying hormonal mechanisms responsible for premature thelarche, and how does this condition differ clinically and endocrinologically from true precocious puberty?
According to Tanner staging, what are the precise morphological characteristics that define stage 4 of breast development, and how does this stage correlate with hormonal and reproductive milestones in adolescent girls?
According to Tanner staging, what are the precise morphological characteristics that define stage 4 of breast development, and how does this stage correlate with hormonal and reproductive milestones in adolescent girls?
According to Tanner staging, what are the key distinguishing features of stage 5 breast development, and how does this stage relate to the overall maturation process in adolescent females?
According to Tanner staging, what are the key distinguishing features of stage 5 breast development, and how does this stage relate to the overall maturation process in adolescent females?
A patient is found to have pea-size firm masses inferior to the nipple, which statement is MOST accurate?
A patient is found to have pea-size firm masses inferior to the nipple, which statement is MOST accurate?
Flashcards
Location of the Female Breast
Location of the Female Breast
The female breast extends from the clavicle and 2nd rib down to the 6th rib, and from the sternum across to the midaxillary line.
Female Breast Glandular Tissue
Female Breast Glandular Tissue
Glandular tissue divided into 15 to 20 lobes, converging as lactiferous ducts/sinuses, which open on the nipple/areola. Each lobe drains into 20-40 smaller lobules of milk-secreting glands.
Areola Surface Anatomy
Areola Surface Anatomy
Small elevations on the areola's surface are formed by sebaceous glands (Montgomery glands), sweat glands and accessory areolar glands.
Supernumerary Nipples
Supernumerary Nipples
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Normal Breast Texture
Normal Breast Texture
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Axilla Boundaries
Axilla Boundaries
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Axilla Nerves
Axilla Nerves
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Axillary Lymph Nodes
Axillary Lymph Nodes
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Breast Cancer Risk Factors
Breast Cancer Risk Factors
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Breast Palpation Technique
Breast Palpation Technique
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Nodule Characteristics to Assess
Nodule Characteristics to Assess
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Nipple Discharge Assessment
Nipple Discharge Assessment
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Axillary Exam Technique
Axillary Exam Technique
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Suspicious Nodes
Suspicious Nodes
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Axillary Node Groups
Axillary Node Groups
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Newborn Breast Findings
Newborn Breast Findings
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Male Breast Exam
Male Breast Exam
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Gynecomastia Cause
Gynecomastia Cause
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Suggestive Mass for Breast Cancer in Males
Suggestive Mass for Breast Cancer in Males
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Symptoms that merit breast cancer screening
Symptoms that merit breast cancer screening
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Cooper's Ligaments
Cooper's Ligaments
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Axillary Tail of Breast / Tail of Spence
Axillary Tail of Breast / Tail of Spence
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Physiologic Nodularity
Physiologic Nodularity
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Mammography
Mammography
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Mammography for Women Ages 50-74
Mammography for Women Ages 50-74
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Breast Inspection
Breast Inspection
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Redness of Breast Skin
Redness of Breast Skin
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Peau d'Orange
Peau d'Orange
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Nipple Retraction
Nipple Retraction
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Breast Palpation Patient Position
Breast Palpation Patient Position
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Examination Time
Examination Time
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Breast Tissue Consistency
Breast Tissue Consistency
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Inframammary Ridge
Inframammary Ridge
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Reach of the Apex
Reach of the Apex
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Acanthosis Nigricans
Acanthosis Nigricans
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Gynecomastia
Gynecomastia
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Study Notes
Female Breast Anatomy
- The female breast extends from the clavicle and second rib down to the sixth rib, and from the sternum across to the midaxillary line.
- The breast overlies the pectoralis major and serratus anterior muscles.
- Glandular tissue is divided into 15 to 20 lobes, converging as lactiferous ducts and sinuses.
- Each lobe drains into 20 to 40 smaller lobules with milk-secreting glands.
- Adipose tissue surrounds the breast, predominantly in the superficial and peripheral areas.
- The areola has small elevations formed by sebaceous glands (Montgomery glands), sweat glands, and accessory areolar glands.
- The areola often has a few hairs.
- Sebaceous glands produce an oily secretion during pregnancy for lubrication during lactation.
- Superficial fascia lies deep to the dermis
- Deep fascia lies anterior to the pectoralis major muscle.
- Suspensory Cooper ligaments attach the breast to the skin.
- Supernumerary nipples can occur along the "milk line" and may contain glandular tissue.
- Usually consists of a small nipple and areola, often mistaken for a common mole.
- May be familial.
- Rarely associated with other congenital anomalies in the absence of associated glandular tissue.
- Containing glandular tissue may show increased pigmentation, swelling, tenderness, or even lactation during puberty, menstruation, or pregnancy and can be associated with other congenital anomalies, mainly renal and thoracic.
- Treatment is recommended if there is diagnostic ambiguity, cosmetic concerns, or possible pathology.
- Breast quadrants are based on horizontal and vertical lines crossing at the nipple.
- The axillary tail of Spence extends laterally across the anterior axillary fold.
- Findings can be localized as the time on the face of a clock and the distance in centimeters from the nipple.
Physiology
- The female breast is hormonally sensitive and changes with monthly cycling and aging.
- Normal physiologic nodularity is common, and may increase before menses.
- Breast composition varies with age, nutritional status, pregnancy, hormone use, and other factors.
- After menopause, glandular tissue atrophies, and the number of lobules decreases.
- Smooth muscle in the nipple and areola contracts to express milk.
- Sensory innervation triggers milk letdown during breastfeeding.
- Tactile stimulation makes the nipple smaller, firmer, and more erect.
- The areola puckers and wrinkles due to smooth muscle reflexes.
Axilla
- The axilla is a pyramidal structure defined by the axillary vein superiorly, the latissimus dorsi muscle laterally, and the serratus anterior muscle medially.
- Key nerves include the thoracodorsal, long thoracic, and intercostobrachial nerves.
- The thoracodorsal nerve supplies the latissimus dorsi muscle.
- The long thoracic nerve innervates the serratus anterior muscle.
- The intercostobrachial nerve is a sensory nerve for the axilla and upper medial arm.
- Axillary lymph nodes are arranged in six groups along the chest wall.
- The central nodes are the most likely to be palpable.
Breast Cancer Screening
- Breast cancer is the most commonly diagnosed cancer in the world.
- Leading cause of cancer death among women.
- In 2015, 2.4 million women were diagnosed with breast cancer worldwide, with >500,000 deaths.
- A female born now in the United States has about a 1 in 8 lifetime risk of developing invasive breast cancer and a 1 in 38 lifetime risk of eventually dying from it.
- Approximately 80% of new breast cancer diagnoses occur after age 50.
- Median age at diagnosis is 62.
- Risk factors include increasing age, family history, genetic mutations, personal history, dense breasts, radiation exposure, and high hormone levels.
- Mammography is the primary screening modality.
- Concerning findings may be further evaluated with special mammographic views, breast ultrasound, MRI, or digital breast tomosynthesis (DBT).
- Greatest mortality benefits are for women in their 60s.
- Women in their 40s are most likely to have false-positive results.
- The USPSTF recommends biennial mammography screening for women ages 50 to 74 (Grade B).
- Average risk women (no previous breast cancer or high-risk lesion, no genetic mutation, and no history of chest radiation at a young age).
- Individualized decision-making (Grade C recommendation) for women between 40 and 49.
- grade I recommendation (insufficient evidence) for women 75 and older.
- Experts suggest women with moderately increased risk begin screening earlier, annually, and with DBT.
- Moderately increased risk due to increased breast density or a family history of one or two relatives with breast cancer.
- Women at very high risk should undergo annual screening with mammography and MRI starting 10 years before the youngest family member was diagnosed (but not before age 30).
- Very high risk due to genetic mutations.
- Those who received thoracic radiation are advised to begin annual screening with mammography and MRI 10 years after completing radiation, but not before age 30.
- Male breast cancer accounts for less than 1% of cases.
- Risk factors for men include increasing age, radiation exposure, BRCA gene mutations, Klinefelter syndrome, testicular disorders, alcohol use, liver disease, diabetes, and obesity.
Clinical Breast Examination
- Includes inspection and palpation of the breasts.
- Inspection involves noting skin changes, symmetry, contours, and retraction in four views: arms at sides, arms over head, arms pressed against hips, and leaning forward.
- Arms at Sides:
- Appearance of the skin, including color.
- Skin thickness and prominence of pores, which may accompany lymphatic obstruction.
- Size and symmetry of the breasts. Some differences in the size of the breasts and areolae are common and usually normal.
- Contour of the breasts. Look for changes such as masses, dimpling, or flattening. Compare one side with the other.
- Characteristics of the nipples. Note size and shape, direction in which they point, any rashes or ulceration, or any discharge.
- Arms Over Head; Hands Pressed Against Hips; Leaning Forward:
- To bring out dimpling or retraction that may otherwise be invisible, ask the patient to raise her arms over her head, then press her hands against her hips to contract the pectoral muscles.
- If the breasts are large or pendulous, it may be useful to have the patient stand and lean forward, supported by the back of the chair or the examiner’s hands.
- Arms at Sides:
- Palpation is best performed with the patient supine.
- Palpate the rectangular area extending from the clavicle to the inframammary fold or bra line and from the midsternal line to the posterior axillary line and well into the axilla to ensure that you examine the tail of the breast.
- A thorough examination takes at least 3 minutes for each breast.
- Use the vertical strip pattern with the pads of the second, third, and fourth fingers.
- Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point.
- Press more firmly to reach the deeper tissues of a large breast.
- Examine the entire breast, including the periphery, tail, and axilla, for consistency, tenderness, and nodules.
- To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table.
- To examine the medial portion of the breast, ask the patient to lie with her shoulders flat against the examining table, and then slide up her flexed elbow until it is at the level of her shoulder.
- The tail of Spence can be mistaken for enlarged axillary lymph nodes.
- Assess any nodule's location, size, shape, consistency, delimitation, tenderness, and mobility.
- Thickening of the nipple and loss of elasticity suggest an underlying cancer.
- Milky discharge unrelated to pregnancy and lactation is nonpuerperal galactorrhea.
Examination of the Axillae
- Inspect the skin of each axilla for rash, irritation, infection, or unusual pigmentation.
- Palpate the left axilla using your right hand, supporting the patient's left wrist with your left hand.
- Palpate the central nodes against the chest wall, noting their size, shape, delimitation, mobility, consistency, and tenderness.
- Enlarged axillary nodes may result from infection, immunizations, skin tests, or lymphadenopathy.
- Nodes that are large firm or hard, matted together, or fixed suggest malignancy.
- If the central nodes feel large, hard, or tender, palpate the other groups of axillary lymph nodes: anterior (pectoral), lateral (humeral), posterior (subscapular), infraclavicular, and supraclavicular.
- Use your right hand to examine the left axilla.
- Ask the patient to relax with the left arm down and warn the patient that the examination may be uncomfortable.
- Support the patient’s left wrist or hand with your left hand.
- Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla.
- Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle.
- Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall.
- Of the axillary nodes, the central nodes are most likely to be palpable.
- One or more soft, small (<1-2 cm), nontender nodes are frequently felt.
Newborn's Breast
- The breasts of newborns can be enlarged due to maternal estrogen effect, lasting several months.
- Breasts may be engorged with a white liquid ("witch's milk"), lasting 1 or 2 weeks.
- Premature thelarche is breast development between 6 months and 2 years without other signs of puberty.
Tanner Staging
- Breasts progress through five Tanner stages during puberty.
- Stage 1: Preadolescent, elevation of nipple only.
- Stage 2: Breast bud stage, elevation of breast and nipple as a small mound, with enlargement of areolar diameter.
- Stage 3: Further enlargement of elevation of breast and areola, with no separation of their contours.
- Stage 4: Projection of areola and nipple to form a secondary mound above the level of breast.
- Stage 5: Mature stage, projection of nipple only, areola has receded to the general contour of the breast (although in some normal individuals the areola continues to form a secondary mound).
- Breast buds are common among both girls and boys entering puberty and are benign.
Male Breast
- Examination of the male breast involves inspection and palpation for nodules, swelling, or ulceration.
- Differentiate between pseudogynecomastia (soft fatty enlargement) and gynecomastia (benign firm disc of glandular enlargement).
- Gynecomastia arises from an imbalance of estrogens and androgens, and breast tissue in gynecomastia is often tender and is not a risk factor for male breast cancer.
- A hard, irregular, eccentric, or ulcerating painless dominant mass suggests breast cancer.
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