breast and axilla examination. primarily adipose tissue, glandular tissue, and suspensory ligaments...
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• BREAST AND AXILLA• EXAMINATION
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
Breast Anatomy
• 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
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
Evaluation: History
• 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
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
Evaluation: Physical Exam
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
Benign Nonproliferative
Fibrocystic changes Simple cysts Lactational adenoma Fibroadenoma
Hyperplasia without atypia Epithelial hyperplasia Sclerosing adenosis Intraductal papillomas
Breast Disease
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
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: Incidence
Differential Diagnosis: 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: Etiology
Fibrocystic disease Premenopausal women Premenstrual breast swelling/tenderness Nodules/masses/lumps related to dense breast tissue or cysts
Mastalgia: Fibrocystic Disease
Fibrous tissue Cystically dilated ducts + Calcifications + Ductal hyperplasia
Inflammatory breast cancer
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
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: Etiology
Fibroadenoma Solitary, firm, rubbery, mobile mass Women < 30 yrs Slow growing (? hormonally mediated)
Breast Mass: Fibroadenoma
Fibroadenoma gross specimen Firm, tan, lobulated Well circumscribed mass Variable size
Fat Necrosis Caused by trauma Tender, firm mass with indistinct borders May appear suspicious on physical exam Benign breast calcification seen on mammography
Breast Mass: Fat Necrosis
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
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
Breast Mass: 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
Nipple Discharge: Evaluation
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., 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 axillaeDeviation from
normalNormal 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
Assessing Breasts and axillaeDeviation from
normalNormal 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 axillaeDeviation from
normalNormal 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 axillaeDeviation from
normalNormal 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 axillaeDeviation 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 axillaeAssessment
*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 axillaeDeviation from normal Normal
findingsAssessment
-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
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
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.
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.
Assessing Breasts and axillaeDeviation from normal Normal
findingsAssessment
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 axillaeDeviation from normal Normal
findingsAssessment
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.