Chapter 18: Breasts, Axillae, and Regional Lymphatics PDF

Chapter 18 Breasts, Axillae, and Regional Lymphatics Copyright © 2020 by Elsevier Inc. All rights reserved.  Surface Anatomy  Breasts lie anterior to pectoralis major and serratus anterior muscles.  Located between second and sixth ribs, extending...

Chapter 18 Breasts, Axillae, and Regional Lymphatics Copyright © 2020 by Elsevier Inc. All rights reserved.  Surface Anatomy  Breasts lie anterior to pectoralis major and serratus anterior muscles.  Located between second and sixth ribs, extending from side of sternum to midaxillary line  Tail of Spence: Superior lateral corner projects up and laterally into axilla  Areola surrounds nipples.  Montgomery’s Glands: Small elevated sebaceous glands  Secrete protective lipid material during lactation Copyright © 2020 by Elsevier Inc. All rights reserved. Breast Surface Anatomy Copyright © 2020 by Elsevier Inc. All rights reserved.  Internal Anatomy  Breast is composed of  glandular tissue.  fibrous tissue, including suspensory ligaments.  adipose tissue.  Glandular tissue contains 15 to 20 lobes radiating from nipple, and these are composed of lobules.  Cooper’s Ligaments: Fibrous bands extending vertically from surface to attach on chest wall muscles  Lobes are embedded in adipose tissue.  Breast may be divided into four quadrants by imaginary horizontal and vertical lines intersecting at nipple.  Upper outer quadrant is the site of most breast tumors. Copyright © 2020 by Elsevier Inc. All rights reserved. Breast Internal Anatomy Copyright © 2020 by Elsevier Inc. All rights reserved.  Lymphatics  Breast has extensive lymphatic drainage.  Four groups of axillary nodes are present  Central axillary nodes  Pectoral (anterior)  Subscapular (posterior)  Lateral  From the central axillary nodes, drainage flows up to infraclavicular and supraclavicular nodes. Copyright © 2020 by Elsevier Inc. All rights reserved. Regional Lymphatics Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence  During embryonic life, ventral epidermal ridges, or “milk lines,” are present and curve down from axilla to groin bilaterally.  Develops along ridge over thorax, and rest of the ridge usually atrophies.  Supernumerary nipple occasionally persists and is visible along track of mammary ridge.  At birth, the only breast structures present are lactiferous ducts within nipple. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Adolescent  At puberty, estrogen stimulates breast changes.  Temporary asymmetry: Occasionally one breast may grow faster than other  Tanner Staging: Five stages of breast development are included as levels of sexual maturity  Thelarche precedes menarche by about 2 years. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Pregnant Woman  Breast changes start during the second month of pregnancy and are an early sign for most women.  Colostrum may be expressed after fourth month.  Thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat.  Breasts produce colostrum for first few days after delivery.  Rich in antibodies that protect newborn against infection, so breastfeeding is important.  Lactation: Milk production  Begins 1 to 3 days postpartum  Whitish color is from emulsified fat and calcium caseinate. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Aging Woman  After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy.  Decreased breast size makes inner structures more prominent.  A breast lump may have been present for years but is suddenly palpable.  Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification.  Axillary hair decreases. Copyright © 2020 by Elsevier Inc. All rights reserved.  Developmental Competence: Male Breast  Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple.  Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge.  Condition is usually unilateral and temporary.  Reassurance is necessary for adolescent male, whose attention is riveted on his body image.  May reappear in aging male and may be due to testosterone deficiency. Copyright © 2020 by Elsevier Inc. All rights reserved.  Culture and Genetics: Breast Cancer  Review statistics of breast cancer morbidity, mortality, and prognosis.  BRCA1 and BRACA2 mutation  Cumulative risk  Survival varies by stage when diagnosed.  Consider family history, ethnicity, and other environmental variables  Racial disparity in survival  Socioeconomic conditions affecting access to health care  Screening mammography recommendations  Review lifestyle risk factors:  Alcohol dose-dependent effect  Postmenopausal weight gain  Decreased physical activity Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data  Breast  Pain, lump, and discharge  Rash, swelling, trauma  History of breast disease  Surgery or radiation  Medications  Patient-centered care  Perform breast self-examination/last mammogram  Axilla  Tenderness, lump, or swelling  Rash Copyright © 2020 by Elsevier Inc. All rights reserved. Breast Cancer: Culture and Women  In many cultures, female breasts signify more than their primary purpose of lactation.  Affects body image  Influenced by society and media response  Integrated with women’s self-concept  A woman who has found a breast lump may come to you with fear, anxiety, and panic.  Although many breast lumps are benign, women initially assume worst possible outcome, including cancer, disfigurement, and death.  Be sensitive to individual’s perception of female body image. Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Pain  Any pain or tenderness in breasts?  Onset  Pain location  Localized or diffuse  Is painful spot sore to touch? Do you feel a burning or pulling sensation?  Appearance of pain cyclic?  Any relation to menstrual cycle?  Precipitating factors  Brought on by strenuous activity?  Change in activity?  Sexual manipulation? Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Lump and Discharge  Lump  Location: Ever noticed lump or thickening in breast? Where?  Onset: When did you first notice it? Changed at all since then?  Appearance: Does lump have any relation to your menstrual period?  Noticed any change in overlying skin: Redness, warmth, dimpling, swelling?  Discharge  Onset: Any discharge from nipple? When did you first notice this?  Characteristics: What color is discharge? Is consistency thick or runny? Odor? Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Rash and Swelling  Rash  Appearance: Any rash on breast?  Onset: When did you first notice this?  Location: Where did it start? On the nipple, areola, or surrounding skin?  Swelling  Location: Any swelling in breasts? In one spot or all over?  Appearance: r/t your menstrual period, pregnancy, or breastfeeding?  Any change in bra size? Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Trauma and History of Breast Disease  Trauma  Any trauma or injury to the breasts?  Presentation: Did it result in any swelling, lump, or break in skin?  History of breast disease  Any history of breast disease yourself?  Diagnosis: What type? How was this diagnosed?  Medical management: When did this occur? How is it being treated?  Family history: Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter? At what age did this relative have breast cancer? Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Treatment and Medications  Surgery or radiation  Surgical intervention: Biopsy with results  Mastectomy? Mammoplasty, augmentation, or reduction?  Radiation as part of therapy?  Imaging studies: Mammography, a screening x-ray examination of breasts? When was last x-ray?  Medications  Have you taken oral contraceptives? How long?  Have you been on HRT? How long?  Types of medications: Rx and OTC Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Patient-Centered Care  Ask about self-breast exam (SBE)  Teaching moment to review basics of examination  Review screening guidelines recommendations based on age and patient history  American Cancer Society  Begin at ages 40 to 44, screening mammography  Annual mammography from ages 45 to 54  Biennial mammography over age 55 or continuation of annual Copyright © 2020 by Elsevier Inc. All rights reserved.  Subjective Data Questions: Axilla  Axilla  Tenderness, lump, or swelling Appearance: Any tenderness or lump in the underarm area? Location: Where? When did you first notice this?  Rash Appearance: Any axillary rash? Please describe it. Precipitating factor: Does it seem to be a reaction to deodorant? Copyright © 2020 by Elsevier Inc. All rights reserved.  Additional History Questions  Preadolescent girl  Appearance: Have you noticed your breasts changing?  Onset: How long has this been happening?  Description: What have you noticed?  Feelings: What do you think about all this?  Pregnant woman  Appearance: Have you noticed any enlargement or fullness in the breasts?  Presentation: Is there any tenderness or tingling?  Medical history: Do you have inverted nipples?  Anticipatory planning: Are you planning to breastfeed your baby?  Menopausal woman  Have you noticed any change in breast contour, size, or firmness? Copyright © 2020 by Elsevier Inc. All rights reserved.  Risk Profile for Breast Cancer  Breast cancer is second major cause of death from cancer in women.  However, early detection and improved treatment have increased survival rates.  Review factors associated with “relative risk”  RR above 1 indicates a higher likelihood of occurrence among exposed than unexposed persons. Copyright © 2020 by Elsevier Inc. All rights reserved.  Objective Data  Preparation  Woman sitting up facing examiner An alternative draping method is to use a short gown, open at back, and lift it up to woman’s shoulders during inspection.  During palpation when woman is supine, cover one breast with gown while examining other. Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach.  After examination, be prepared to teach woman breast self-examination.  Equipment  Small pillow  Ruler marked in centimeters  Pamphlet or teaching aid for breast self-examination (BSE) Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection of the Breast (1 of 2)  General appearance  Note symmetry of size and shape.  Common to have a slight asymmetry in size  Skin  Normally smooth and of even color  Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern.  Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy.  Normally no edema is present. Copyright © 2020 by Elsevier Inc. All rights reserved. General Appearance of Breasts Copyright © 2020 by Elsevier Inc. All rights reserved.  Inspection of the Breast (2 of 2)  Lymphatic drainage areas  Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema.  Nipple  Should be symmetric on same plane on both breasts  Nipples usually protrude, although some are flat and some are inverted.  Normal nipple inversion may be unilateral or bilateral and usually can be pulled out.  Note any dry scaling, any fissure or ulceration, and bleeding or other discharge.  Supernumerary nipple is normal variation.  Check the breast for skin retraction  Perform sequence of maneuvers to assess for this abnormality. Copyright © 2020 by Elsevier Inc. All rights reserved. Inspection and Palpation of the Axillae  Examine axillae while woman is sitting.  Inspect skin, noting any rash or infection; lift woman’s arm and support it so that her muscles are loose and relaxed; use right hand to palpate left axilla.  Reach fingers high into axilla; move them firmly down in four directions.  Move woman’s arm through range-of-motion to increase surface area you can reach.  Usually nodes are not palpable, although you may feel a small, soft, nontender node in central group.  Note any enlarged and tender lymph nodes. Copyright © 2020 by Elsevier Inc. All rights reserved.  Palpation of the Breasts (1 of 2)  Vertical strip pattern is recommended to detect for breast masses.  Two other patterns are in common use: From the nipple palpating out to periphery as if following spokes on a wheel Palpating in concentric circles out to periphery  In nulliparous women, normal breast tissue feels firm, smooth, and elastic.  After pregnancy, tissue feels softer and looser.  Premenstrual engorgement is normal from increasing progesterone. Copyright © 2020 by Elsevier Inc. All rights reserved.  Palpation of the Breasts (2 of 2)  After palpating over four breast quadrants, palpate nipple; note any induration or subareolar mass.  With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily.  If woman reports spontaneous nipple discharge  press areola inward with your index finger.  repeat from a few different directions; note color and consistency of any discharge.  If woman mentions a breast lump that she has discovered herself, examine unaffected breast first to learn a baseline of normal consistency for this woman. Copyright © 2020 by Elsevier Inc. All rights reserved. Characteristics of Lump or Mass (1 of 2)  Location  As with clock face, describe distance in centimeters from nipple; or diagram breast in woman’s record and mark in location of lump.  Size  Judge in centimeters in three dimensions: width, length, and thickness.  Shape  State whether lump is oval, round, lobulated, or indistinct.  Consistency  State whether lump is soft, firm, or hard.  Movable  Is lump freely movable or fixed when you try to slide it over chest wall? Copyright © 2020 by Elsevier Inc. All rights reserved. Characteristics of Lump or Mass (2 of 2)  Distinctness  Is lump solitary or multiple?  Nipple  Is it displaced or retracted?  Note skin over lump  Is it erythematous, dimpled, or retracted?  Tenderness  Is lump tender to palpation?  Lymphadenopathy  Are any regional lymph nodes palpable? Copyright © 2020 by Elsevier Inc. All rights reserved. Teach Breast Self-Examination (BSE) Copyright © 2020 by Elsevier Inc. All rights reserved.  BSE: Keep Teaching Simple  The simpler the plan, the more likely the person is to comply.  Describe correct technique and rationale and expected findings to note as woman inspects her own breasts.  Teach woman to do this in front of a mirror while she is disrobed to waist.  At home, she can start palpation in shower, where soap and water assist palpation.  Then palpation should be performed while lying supine.  Encourage woman to palpate her own breasts while you monitor her technique.  Use of model for return demonstration as well as pamphlets may be helpful. Copyright © 2020 by Elsevier Inc. All rights reserved.  Male Breast  Examination of male breast can be abbreviated, but do not omit it.  Normal male breast has flat disk of undeveloped breast tissue beneath nipple.  Gynecomastia Benign growth of this breast tissue, making it distinguishable from other tissues in chest wall. Feels like a smooth, firm, movable disk Occurs normally during puberty and is temporary  The adolescent is acutely aware of his body image.  Reassure him that this change is normal, common, and temporary. Copyright © 2020 by Elsevier Inc. All rights reserved. Developmental Competence (1 of 2)  Infants and children  In neonate, breasts may be enlarged and visible due to maternal estrogen crossing placenta. May secrete “witch’s milk”—not significant will resolve  Note position of nipples on prepubertal child. Symmetric, just lateral to midclavicular line, between fourth and fifth ribs Nipple is flat, and areola is darker pigmented.  Adolescent girl  Breast development usually begins on an average between 8 and 10 years.  Tanner staging  Teach BSE Copyright © 2020 by Elsevier Inc. All rights reserved. Developmental Competence (2 of 2)  Pregnant woman  Breasts increase in size, as do nipples. Vascular changes occur as a result of hormones of pregnancy. Nipples become darker, areola darken and widen.  Lactating woman  Colostrum changes to milk production around the third postpartum day. Breast engorgement occurs. Nipple soreness can occur.  Aging woman  On inspection, breasts look pendulous, flat, and sagging. Changes noted on breast tissue with aging Reinforce value of BSE. Women over 50 years old have increased risk for breast cancer. Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Signs of Retraction and Inflammation  Dimpling  Nipple retraction  Edema (peau d’orange)  Fixation  Deviation in nipple pointing Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Breast Lumps  Benign (Fibrocystic) breast disease  Cancer  Fibroadenoma  Differentiating breast lumps:  Age  Shape, consistency, and demarcation  Number, mobility, and tenderness  Skin retraction, pattern of growth, and risk to health Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings: Abnormal Nipple Discharge  Mammary duct ectasia  Intraductal papilloma  Carcinoma  Paget disease (intraductal carcinoma) Copyright © 2020 by Elsevier Inc. All rights reserved.  Abnormal Findings  Disorders occurring during lactation:  Mastitis  Breast abscess  Plugged duct  Male breast abnormalities  Gynecomastia  Male breast cancer Copyright © 2020 by Elsevier Inc. All rights reserved.  Summary Checklist: Breasts and Regional Lymphatics  Inspect breasts as 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. Copyright © 2020 by Elsevier Inc. All rights reserved.