Breast and Axillae

• AREOLA- tip of the breast

• NIPPLE- center
o lactiferous ducts empty into a
depression at the top of the nipple
• LOBULES- where milk is secreted
o Each duct leads from the alveoli
within the breast
• GLANDULAR TISSUE- form from the
ducts and lobules
• ADIPOSE TISSUE- surround the breast

MALE BREAST
• Small nipple and areola
• Lacking estrogen and progesterone stimulation, ductal branching
and development of lobules are minimal.

LYPHATICS
• Most common breast drains toward the axilla.
o AXILLARY LYMPH NODES

NODES DRAINAGE LOCATION

Most/frequent palpable
CENTRAL NODES- palpable Drains Chest wall, high in
most frequently channels the axilla; midway
from other between the
groups of anterior
lymph nodes and posterior
axillary folds
Seldom palpable
PECTORAL NODES- Anterior lower border of
ANTERIOR- chest wall the pectoralis
Much of the major
breast inside the
anterior axillary
fold
SUBCAPULAR NODES- Posterior Along the lateral
POSTERIOR chest wall border of the
Portion of the scapula
arm
LATERAL NODES Most of the along the upper
arm humerus
 Health History
Use OLD CART on the ff:
• Lump or mass Lumps may be physiologic
• Pain or discomfort or pathologic, ranging
• Change in shape from cysts and
fibroadenomas to breast
• Discharge cancer.
• Edema
• Rashes or scaling
• Dimpling
• Retraction Galactorrhea
the inappropriate discharge
of milk-containing fluid, is
abnormal if it occurs 6 or
more months after
childbirth or cessation of
breast-feeding

History
• Medications?
• Pregnancies?
• Menstruation?
• Previous history of breast cancer?
• Previous breast biopsy?
• BSE- breast self-examination?
• CBE- Clinical breast examination?
• MRI- Mammogram?

Family History
• History of breast cancer?
• History of reproductive cancer (eg ovarian)?
• BRCA testing?
 Lifestyle Habits
• Alcohol intake?
• Physical activity?

Physical Examination
• Let the patient know that you are about to examine her breasts.
o This may be a good time to ask if she has noticed any lumps,
other problems or if she performs BSE
• Cover the breast while you are palpating the other
• The best time for examination is 5 to 7 days after the onset of
menstruation
o If nodules appear prior menstruation, reevaluate 5-7 days
after onset of menses

✓ INSPECTION
o Inspect the breasts and nipples with the patient in the
sitting position and disrobed to the waist
▪ skin changes
▪ symmetry
▪ contours
▪ and retraction
4 views

Note the clinical

features:
INSPECT POSSIBLE FINDINGS
Color
Appearance of the skin Edema (peau d’orange)
in breast cancer
Size and symmetry
Contour Flattening, dimpling
Characteristics of nipples:
(Size, shape, direction) Inversion, retraction,
deviation
(Rashes, ulceration and Paget’s disease of the
discharge.) nipple, galactorrhea
Consistency Physiologic nodularity
Tenderness Infection, premenstrual
tenderness
Nodules Cyst, fibroadenoma,
cancer

✓ PALPATION
o Palpation is best performed when the breast tissue is
flattened. The patient should be supine.
o Use the finger pads of the 2nd, 3rd, and 4th fingers,
keeping the fingers slightly flexed
o Vertical strip pattern is the best validated technique for
detecting masses.
▪ Circular or wedge pattern may also be used
o Palpate in small, concentric circles
▪ Applying light, medium, and deep pressure
 Male Breast
• May be on supine or sitting position
• Inspect and palpate nipple and areola
o Possible findings: Gynecomastia, mass suspicious for
caner, fat
 Axillae
Examination POSSIBLE FINDINGS
Inspect rashes, infection, and Hidradenitis suppurativa,
pigmentation acanthosis nigricans
Palpate axillary nodes lymphadenopathy
SPECIAL TECHNIQUE
BREAST DISCHARGE
Compress the areola in a Type and source of discharge
spokelike pattern around the may be identified.
nipple. Watch for discharge.

(BSE) BREAST SELF- EXAMINATION

• Inexpensive and
may promote
stronger health
awareness and
more active self-
care
Common Breast Masses
 Visible Signs of Breast Cancer
• Retraction signs

o Fibrosis from breast cancer produces

retraction signs: dimpling, changes in
contour, and retraction or deviation of
the nipple. Other causes of retraction
include fat necrosis and mammary duct
ectasia.

Skin Dumpling
▪ Look for this sign with the pt
patient’s arm at rest, during
special positioning, and on
moving or compressing the
breast

o Abnormal contours
▪ Look for any variation in the
normal convexity of each breast,
and compare one side with the
other. Special positioning may
again be useful
 o Nipple Retraction and Deviation
▪ A retracted nipple is flattened or
pulled inward. It may also be
broadened and feel thickened.
▪ The nipple may deviate, or point in a
different direction, typically toward
the underlying cancer.

• EDEMA of the skin

o From lymphatic blockade, appearing as
thickened skin with enlarged pores—the
so-called peau d’orange (orange peel)
sign.

• PAGET’S DISEASES of the nipple

o An uncommon form of
breast cancer that
usually starts as a
o scaly, eczemalike lesion.
o The skin may also weep,
crust, or erode.
o A breast mass may be
present.
o Suspect Paget’s disease
in any persisting dermatitis of the nipple and areola.
 Health Promotion
o Breast cancer is the second leading cause of cancer death
in women, with highest mortality rates in women 35 years
or younger and older than 75 years.
o Breast cancer is the most commonly diagnosed cancer
among African American women.

• ASSESSING RISK FACTORS FOR BREAST CANCER

o MODIFIABLE
▪ although these tend to confer lower relative risk:
• postmenopausal obesity
• use of estrogen-progesterone combination HRT
• alcohol use
• physical inactivity
o NON-MODIFIABLE
▪ Many risk factors cannot be readily altered, such as
gender,
• Age
• family history
• race, genetics
• personal history of breast cancer
• age at first full-term pregnancy
• early menarche
• late menopause
• breast density

Breast Cancer in Women: Factors That Increase Relative Risk

RELATIVE RISK FACTOR
>4.0 • female
• age 65+
• inherited genetic mutation
(BRCA1/BRCA2)
• 2 or more, first-degree of
relatives diagnosed w/
breast cancer
• History of breast cancer
• High breast tissue density
 • Biopsy-confirmed atypical
hyperplasia
2.0-4.0 • One fist degree relative
w/ breast cancer
• High-dose radiation to
chest
• High bone density
(postmenopausal)
1.1-2.0 • Late age at first full term
Factors that affect circulating pregnancy (30 yrs above)
hormones • Early menarche (<12
years)
• Late menopause (>55
years)
• No full-term pregnancies
• Never breast-fed a child
• Recent oral contraceptive
use
• Recent and long-term use
of hormone replacement
therapy
• Obesity
(postmenopausal)
Other factors • Personal history of
endometrium, ovary, or
colon cancer
• Alcohol consumption
• Height (tall)
• High socioeconomic status
• Jewish heritage

TERMS:

BRCA- Breast Cancer genes

Menarche- first menstruation

 Breast Cancer Screening
• MAMMOGRAPHY
o For women 40 years of age and older (40-50 years)
o Done yearly
o Women 50 Years or Older. Screening mammography
reduces breast cancer mortality in women 50 to 74 years
• CLINICAL BREAST EXAMINATION (CBE)
o By a health care professional
o Every 3 years for women 20 and 40 years of age
o Annually after 40 years of age
• BREAST SELF-EXAMINATION (BSE)
o In conjunction with mammography, and CBE
• MAGENTIC RESONANCE IMAGING (MRI)
o MRI has helped improve detection of multicentric or
contralateral breast cancer in women at high risk for breast
cancer, younger women, women with dense breasts, and
the contralateral breast of women with newly diagnosed
breast cancer.