Breasts and Regional Lymphatics

What are helpful reinforcers?

Pamphlets are helpful reinforcers; give woman two pamphlets to take home and encourage her to give one to a relative or friend; this may promote discussion, which is reinforcing

What should you do if the woman reports spontaneous nipple discharge?

Press to areola inward with your index finger - repeat from a few directions. Note color and consistency if present

Racial differences in mortality may relate to what?

Racial difference in mortality may relate to insufficient use of early detection procedures, including mammograms and breast self-examinations

Eczema or other dermatitis

Rarely starts at the nipple unless it is due to breastfeeding. It usually starts on the areola or surrounding skin and then spreads to the nipple.

Past breast cancer increases risk for what?

Recurring breast cancer

What is the best way to assess her technique and understanding of the procedure?

Return demonstration! Encourage woman to palpate her own breasts while you monitor her technique

The breasts, or mammary glands, are present in both males and females, but in males they are what?

Rudimentary throughout life.

Keep your teaching what?

SIMPLE - more likely to comply

Mammograms can reveal what?

Cancers too small to be detected by the woman or by most experienced examiners.

The areola also has smooth muscle fibers that do what?

Cause nipple erection when stimulated

What is within each lobule?

Clusters of aveoli that produce milk. Each lobe empties into a lactiferous duct.

Which exams do you combine with males?

Combine breast exam with that of anterior thorax

The glandular tissue

Contains 15-20 lobes radiating from the nipple, and these are composed of lobules.

On palpation of pregnant woman's breast, how do they feel?

On palpation, breasts feel more nodular, and thick yellow colostrum can be expressed after first trimester

African American girls and breast development

Onset of breast development occurred at an average (mean) age of 8.87 years for African American girls and 10 years for white girls

Menses began at what age for African American and white girls?

Menses began at an average age of 12.16 years for African American girls and 13 for white girls

Nodularity increases from when?

Midcycle up to menstruation

Subjective data - breast

Pain Lump Discharge Rash Swelling Trauma History of breast disease Surgery Self-care behaviors Perform breast self-examination Last mammogram

In terms of environmental factors, what may contribute to early onset of puberty?

- Obesity (higher BMI) - higher incidence of early breast budding and early menarch THUS, ongoing epidemic or childhood obesity in the US is a major determinant of early-age pubertal milestones

What can cause breast cancer?

- Poor diet - Alcohol - Overweight/weight gain

4 directions to move in axilla

1. down the chest wall in a line from the middle of the axilla 2. along the anterior border of the axilla 3. Along the posterior border 4. Along the inner aspect of the upper arm

3 ways to palpate the breasts

1. Vertical strip pattern 2. Spokes on a wheel pattern 3. Concentric circles pattern

Skin

- Normally is 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

Menarch occurs in breast development stages ___?

3 or 4, usually just after the peak of the adolescent growth spurt around age 12.

The nurse is teaching a woman how to perform breast self-examination (BSE). Which statement by the patient would indicate a need for further teaching? "The best time to check my breasts is a week before my cycle." "I will check my breasts in the shower one week after my cycle." "I will exam my breast in a clock-like sequence so that I don't miss any surface area." "I will be sure to check my arm pits."

"The best time to check my breasts is a week before my cycle."

A pregnant woman who has breast implants asks the nurse if she can still breastfeed. What is the nurse's best response? "You should not have any problems breast feeding because your implants do not affect milk production." "When the breast implants are inserted they usually affect the milk glands, and breastfeeding is not possible." "This would depend on which type of implants were placed and which procedure was used by the surgeon. Check with your surgeon to see if your milk production will be affected."

"This would depend on which type of implants were placed and which procedure was used by the surgeon. Check with your surgeon to see if your milk production will be affected."

What might be palpable now?

- 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

After palpating over the 4 breast quadrants, what do you palpate?

- 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

Supernumerary nipple is normal variation

- An extra nipple along embryonic "milk line" on thorax or abdomen is congenital finding - Usually, below breast near midline and has no associated glandular tissue; looks like a mole, although a close look reveals a tiny nipple and areola

Fixation

- Asymmetry, distortion, or decreased mobility with the elevated arm maneuver. - As cancer becomes invasive, the fibrosis fixes the breast to the underlying pectoral muscles.

Gynecomastia

- Benign enlargement of male breast that occurs when peripheral tissues convert androgen hormones to estrogens. - Mobile disc of tissue - occurs with obesity, cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, drugs, ACE inhibitors, estrogen, digoxin, psyoactive drugs

Fibroadenoma

- Benign tumors, most commonly present as self-detected in late adolescence - Solitary nontender mass that is solid, firm, rubbery and elastic. - Round, oval or lobulated. - 1- 5 cm - Freely movable, slippery, fingers slide easily through tissue. - Diagnose by triple test (palpation, ultrasound, needle biopsy).

Adolescent girl - when does breast development occur?

- Breast development usually begins on an average between 8 and 10 years - Expect some asymmetry during growth; record stage of development using Tanner's staging

What are complementary screening measures?

- Breast self examination (BSE) - Clinical breast examination (CBE) - Mammogram

What breast changes occur at puberty?

- Breasts enlarge, mostly as a result of extensive fat de-position; duct system also grows and branches, and masses of small, solid cells develop at duct endings; these are potential alveoli - Puberty is occurring earlier - Tenderness - Onset of breast development occurred at an average (mean) age between 8 and 9 years for black girls and by 10 years for white girls; earlier studies cited breast development beginning at an average age of 10 to 11

The pregnant woman

- Breasts increase in size, as do nipples - Delicate blue vascular pattern is visible over the breasts - Jagged linear stretch marks, or striae, may develop if breasts have large increase - Nipples become darker and more erectile - Areolae widen; grow darker; and contain small, scattered, elevated Montgomery's glands

Aging woman

- Breasts look pendulous, flat, and sagging - Nipples may be retracted but can be pulled outward - On palpation, breasts feel more granular; terminal ducts around nipple feel more prominent and stringy - Thickening of inframammary ridge at lower breast is normal, and feels more prominent with age - Reinforce value of BSE - Women over 50 years old have increased risk of breast cancer - Older women may have problems with arthritis, limited range of motion, or decreased vision that may inhibit self-care - Suggest aids to self-examination; for example, talcum powder helps fingers glide over skin

Lactation

- Colostrum changes to milk production around the 3rd postpartum day - Breasts may become engorged, appearing enlarged, reddened, and shiny and feeling warm and hard - Frequent nursing helps drain ducts and sinuses and stimulate milk production - Nipple soreness normal, appearing around 20th nursing, lasting 24 to 48 hours, then disappearing - Nipples may look red and irritated; may even crack but will heal rapidly if kept dry and exposed to air; frequent nursings best treatment for nipple soreness

After the 4th month of pregnancy, what may appear?

- Colostrum may be expressed after fourth month - This 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

Gynecomastia

- Condition is usually unilateral and temporary - Reassurance is necessary for adolescent male, whose attention is riveted on his body image - Gynecomastia may reappear in aging male and may be due to testosterone deficiency

A decreased breast size in the older women makes what more prominent?

- Decreased breast size makes inner structures more prominent

Skin retraction

- Dimpling or a pucker when hands on hip

Maneuvers to screen for retraction

- Direct woman to change position to check breasts for skin retraction signs; first ask her to lift arms slowly over head; both breasts should move up symmetrically - Next ask her to push her hands onto her hips and then to push her two palms together; these maneuvers contract pectoralis major muscle; slight lifting of both breasts will occur - Ask woman with large pendulous breasts to lean forward while you support her forearms; note symmetric free-forward movement of both breasts

Inspect and palpate 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 4 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

Nipple retraction

- Flat and broader nipple look, like an underlying crater - recent retraction suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. - May also occur with benign lesions such as ectasia of the ducts. - do not confuse with inversion, which has no broadening and isnt fixed

Inspect the breast

- General appearance - Skin - Lymphatic drainage areas - Nipple

Teaching Breast Self- Exam (BSE)

- Help each woman establish regular schedule of self-care - Advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month - Stress that self-examination will familiarize woman with her own breasts and their normal variation; emphasize absence of lumps (not the presence of them) - Encourage her to report any unusual finding promptly

Palpate the breasts

- Help woman to a supine position - Tuck a small pad under side to be palpated and raise her arm over her head to flatten breast tissue and displace it medially; any significant lumps will then feel more distinct - Use pads of your first three fingers and make a gentle rotary motion on breast; vary pressure palpating light, medium, and deep tissue in each location - Vertical strip pattern currently recommended to detect a breast mass, but 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

Central axillary nodes

- High up in the middle of the axilla, over the ribs and serratus anterior muscle. - These recieve lymph from the other 3 groups of nodes.

How do you inspect and palpate the male breast?

- Inspect chest wall, noting skin surface and any lumps or swelling - Palpate nipple area for any lump or tissue enlargement; it should feel even, with no nodules - Palpate axillary lymph nodes

What is colostrum rich in?

- It is rich with antibodies that protect newborn against infection, so breastfeeding is important

The nipple

- Just below the center of the breast - Round, rough and usually protuberant - Surface looks wrinkled and indented with tiny milk duct openings

Where are the breasts located

- Lie anteriorly to the pectoralis major and serratus anterior muscles. - Located between the 2nd and 6th ribs, extending from the side of the sternum to the midaxillary line.

If you feel a lump or mass, note characteristics

- 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? - 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?

Edema (peau d'orange)

- Lympatic obstruction produces edema - Thickens the skin and exaggerates the hair follicles, giving pigskin or orangle peel look - This condition suggests cancer. - Edema usually begins in skin around and beneath the areola, the most dependent area of the breast. - Nipple infiltration

Be selective in your choice of factual material, use:

- Majority of women will never get breast cancer - Great majority of breast lumps are benign - Early detection of breast cancer is important; if cancer is not invasive, survival rate close to 98%

What might the breasts of a neonate secrete?

- May secrete a clear or white fluid, called "witch's milk" - This is not significant and are resolved within a few days to a few weeks

Benign breast disease (formerly fibrocysticbreast disease)

- Multiple tender masses - 6 diagnostic categories exist based on symptoms and findings: 1. swelling and tenderness 2. Mastlagia (pain) 3. Nodularity (lumps) 4. Dominant lumps 5. Nipple discharge 6. Infections and inflammations

What happens to the breasts during pregnancy?

- Pregnancy stimulates expansion of ductal system and supporting fatty tissue as well as development of true secretory alveoli - Thus breasts enlarge and feel more nodular; nipples are larger, darker, and more erectile - Areolae become larger and grow darker brown as pregnancy progresses, and tubercles become more prominent - Venous pattern prominent over skin surface

Premenstrual engorgement is normal from what?

- Premenstrual engorgement is normal from increasing progesterone - Consists of slight enlargement, tenderness to palpation, and generalized nodularity; lobes feel prominent and their margins more distinct

Breast abscess

- Rare complication of generalized infection - Pocket of puss accumulates in one local area - must temporarily discontinue nursing on affected breast - treatment; antibiotics, surgical incision, drainage

When is the best time to examine breasts?

- Right after the menstrual period or the 4th-7th day of the menstrual cycle when hormone levels are lower and edema is not present - when breasts are smallest and least congested

The male breast

- Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple - Areola well developed, although nipple is small

Note position of nipples on prepubertal child

- Should be symmetric, just lateral to midclavicular line, between fourth and fifth ribs - Nipple is flat, and areola is darker pigmented

Nipple

- Should be symmetrical 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

Dimpling

- Sign of skin retraction - Cancer causes fibrosis, which contracts the suspensory ligaments - may be apparent at rest, with compression, or with lifting of the arms. - Distortion of areola as fibrosis pulls the nipple toward it.

Cancer

- Solitary, unilateral, nontender mass. - Single focus in one area, but can be interspersed with other nodules. - Solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invascive. - irregular borders and poorly delineated. - Grows constantly - Often painless - most common in upper outer quadrant - As cancer advances, signs include firm or hard irregular axillary nodes, skin dimpling, nipple retraction, elevation, and discharge

The areola

- Surrounds the nipple for a 1-2 cm radius - Contain small elevated sebaceous glands, called Montgomery's glands

How should palpation be performed during BSE?

- Teach woman to do this in front of a mirror while she is disrobed to waist - Supine position and in the shower where soap and water assist palpation.

The 15-20 lactiferous ducts form what?

- The 15-20 lactiferous ducts form a collecting duct system converging toward the nipple - There, the ducts form ampullae, or lactiferous sinuses, behind the nipple, which are reservoirs for storing milk.

Who has a higher incidence of breast cancer, whites or African American's?

- White women have a higher incidence of breast cancer than AA women starting at age 45. - BUT African American have a higher incidence before age 45 and are more likely to die of the disease at every age.

Breast cancer risk factors that CANNOT be changed:

- female gender, age >50 years - Personal history of breast cancer - Mutation of BRCA 1 and BRCA 2 genes - First degree relative with breast cancer - High breast tissue density - Biopsy-confirmed atypicaly hyperplasia - High-dose radiation to chest - Early menarch (<12 years) or late menopause (>55 years)

How can you tell that a woman is embarrassed talking about her breasts?

- lack of eye contact - minimal responses - nervous gestures - inappropriate humor - talking wryly and disparingly about her breasts

Cyclic pain is common with what?

- normal breasts, oral contraceptives, and benign breast (firbrocystic) disease

Breast cancer risk factors that CAN be changed:

- nulliparity or first child after age 30 - recent oral contraceptive use - never breast fed child - recent and long term use of estrogen/progestin - alcohol intake of 1 or more daily - Obesity (esp after menopause) and high fat diet - Physical inactivity

Mammary duct ectasia

- pastelike matter in subareolar ducts produces sticky, purulent discharge that may be white, gray, brown, green or bloody - Caused by stagnation of cellular debris and secretions in the ducts, leading to obstruction, inflammation, and infection. - Occurs in women who have lactated; usually occurs perimenopause - Itching, burning, or drawing pain around nipple - Redness and swelling - Ducts are palpable as rubbery, twisted tubules under areola. - not malignant, but need biopsy

The bimanual technique

- woman is in sitting position, leaning forward - support the inferior part of breast with one hand, use other hand to palpate breast tissue against supporting hand

Objective data - preparation

- woman sitting up facing examiner. - Use short gown, open at back, lift up to woman's shoulders during inspection - During palpation when woman is supine, cover one breast with gown. - use sensitive but matter of fact approach - after teach them BSE

When does milk production (lactation) begin?

1-3 days postpartum.

4 groups of axillary nodes are present:

1. Central axillary nodes 2. Pectoral (anterior) 3. Subscapular (posterior) 4. Lateral

What is the breast composed of internally?

1. Glandular tissue 2. Fibrous tissue including the suspensory ligaments 3. Adipose tissue

Tanners stages:

1. Preadolescent: only small elevated nipple 2. Breast bud stage: small mound of breast and nipple develops; the areola widens 3. The breast and areola enlarge; the nipple is flush with the breast surface 4. The areola and nipple form a secondary mound over the breast. 5. Mature breast: only the nipple protrudes; the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women)

Gynecomastia

A benign growth of this breast tissue, making it distinguishable from the other tissues in the chest wall

The normal male breast has what beneath the nipple?

A flat disk of undeveloped breast tissue

Both and nipple and areola are what pigment?

More darkly pigmented than the rest of the breast surface; the color varies from pink to brown depending on the person's skin color and parity (condition of giving birth).

General appearance

Note symmetry of size and shape; common to have a slight asymmetry in size; often left breast is slightly larger than right

Lymphatic drainage areas

Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema

The examination of the male breast can be what?

Abbreviated, but do not omit it

The female breasts are what and for what function?

Accessory reproductive organs whose function is to produce milk for nourishing the newborn.

The lobes are embedded in what?

Adipose tissue

The aging woman - menopause, what happens?

After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy

After pregnancy, how does the breast tissue feel?

After pregnancy, tissue feels softer and looser

The relative proportion of glandular, fibrous, and fatty tissue varies depending on what?

Age, cycle, pregnancy, lactation, and general nutritional state.

Lateral

Along the humerus, inside the upper arm.

Pectoral (anterior)

Along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold.

Subscapular (posterior)

Along the lateral edge of the scapula, deep in the posterior axillary fold

What is a good program to mention?

American Cancer Society Tell A Friend program: trained volunteers contact 5 women and remind them to get a mammogram.

African American girls and puberty

American girls African American girls begin puberty about 1 to 1.5 years earlier than white girls and start menstruating about 8.5 months earlier

Deviation in nipple pointing

An underlying cancer causes fibrosis in the mammary ducts which pulls the nipple angle toward it. Swelling that tilts the nipple laterally

Breast cancer is what in terms of leading causes of death?

Breast cancer is the 2nd major cause of death from cancer in women.

The pregnant woman- what is the early sign of pregnancy for most women?

Breast changes start during the second month of pregnancy and are an early sign for most women

The best way to detect a person's risk for breast cancer is by doing what?

Asking the right history questions.

At age 8, what occurred with african american + white girls?

At age 8, about half of African American girls and 14.7% of white girls began breast and pubic hair development

At birth, what are the only breast structures present?

At birth, the only breast structures present are lactiferous ducts within nipple; no alveoli have developed; little change occurs until puberty

While teaching, Focus on positive aspects of BSE and avoid what?

Avoid citing frightening mortality statistics about breast cancer and generating excessive fear and denial that actually obstructs a woman's self-care action

What hair decreases in the aging adult?

Axillary hair decreases

How does the breast develop?

Breast develops along ridge over thorax, and rest of the ridge usually atrophies

The genetic contribution of breast cancer involves specific mutations at what locations?

BRCA1 and BRCA2

Carcinoma

Bloody nipple discharge that is unilateral and from a single duct.

How can you be sure of the color of discharge?

Blot against white gauze. test for blood

Women with these mutations are at increased risk for what?

Breast and ovarian cancer

Asian, Hispanic, and American Indian women have a lower risk for development of what?

Breast cancer

Tenderness in the axilla is important, why?

Breast tissue extends up into the axilla, and the axilla contains many lymph nodes

What happens with the breasts 3 or 4 days before menstruation?

Breasts feel full, heavy, and occasionally sore.

When is the breast volume the smallest?

Days 4-7 of the menstrual cycle

Changes in breast contour, size and firmness are important because why?

Decreased estrogen level causes decreased firmness. Rapid decreases in estrogen cause shrinkage

A smaller amount of lymphatic drainage does not take these channels, but instead, flows where?

Directly up to the infraclavicular group, deep into the chest, or into the abdomen, or directly across to the opposite breast.

Discharge is ONLY normal when?

During pregnancy and lactation

What else occurs during puberty?

During this time, pubic hair develops, and axillary hair appears 2 years after onset of pubic hair

What has improved survival rates?

Early detection and improved treatment

Paget's disease (intraductal carcinoma)

Early lesion has unilateral, clear, yellow, discharge and dry scaling crusts, friable at nipple apex. - Spreads outward with erythematous halo on areola and crusted eczematous retracted nipple. - Later reddend nipple that is ulcerated with bloody discharge when surface is eroded. - Tingling, itching, burning

Occasionally what can persist?

Occasionally a supernumerary nipple (i.e., an extra nipple) persists and is visible along track of mammary ridge

What might sometimes happen with the breast size during puberty

Occasionally, one breast may grow faster than other, producing a temporary asymmetry

Edema on breast

Exaggerates the hair follicles, giving "pigskin" or "orange-peel" look --> peau d'orange

Plugged duct

Fairly common, not serious - one milk duct is clogged - one section of breast is tender - may be redenned - want them as empty as possible and mild flowing - nurse baby frequently on affected side first. - usually resolves in less than a day

Retraction signs are due to what?

Fibrosis in the breast tissue, usually caused by growing neoplasms

When doing pendulous breasts, what should you look for?

Fixation to chest wall or skin retraction

Breastfeeding alone for 6 months provides the perfect what?

Food and antibodies for the baby - Decreases risk of ear infections, promotes bonding, provides relaxation

The timing of puberty is influenced by what?

Genetic and environmental factors, with genetics determining 50-80% of the variation.

During male adolescence, it is common for the breast tissue to temporarily enlarge, producing what?

Gynecomastia

In the neonate, how do the breasts appear?

In neonate, breasts may be enlarged and visible due to maternal estrogen crossing placenta

In nulliparous women, how does normal breast tissue feel?

In nulliparous women, normal breast tissue feels firm, smooth, and elastic

Breast cancer ocurring before menopause in certain family members does what?

Increases risk for this woman

A sudden increase in size of one breast signifies what?

Inflammation or new growth

Is gynecomastic unilateral?

It can be unilateral, bilateral and is temporary

Breast drooping is accentuated by what in some older women?

Kyphosis

The breast has extensive what?

Lymphatic drainage

The breasts are also known as what?

Mammary glands

Many examiners use what to teach?

Many examiners use a simulated breast model so that woman can palpate a "lump"

What might temporary asymmetry in the breasts cause?

May cause some distress; reassurance is necessary

The beginning of breast development preceeds what?

Menarch (beginning of menstruation) by about 2 years.

Intraductal papailloma

Serous or serosanguineous discharge, which is spontaneous, unilateral, or from a single duct. - Lesion consists of tiny tumors, 2-3 mm. - Often palpable nodule in underlying duct - affect women 40-60; most benign.

How does the gynecomastia feel?

Smooth, firm, moveable disk Occurs normally during puberty

For the vertical strips pattern, where do you start and end?

Start high in the axilla and palpate down just lateral to the breast. Proceed in overlapping vertical lines ending at the sternal edge.

What do cooper's ligaments do?

Support the breast tissue.

Although the age of onset varies widely, the 5 stages of breast development follow what classic description of sexual maturity rating?

Tanner staging

What should you use to teach the adolescent normal developmental stages and assure her of normal progress?

Tanner's chart

When do you teach BSE?

Teach BSE as an adolescent, so that technique will become a natural, comfortable habit by time girl becomes an adult

Subjective data - axilla

Tenderness, lump, or swelling Rash

What is located in the upper outer quadrant?

The axillary tail of Spence, the cone-shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes.

For women with large pendulous breasts, what technique should you use to palpate?

The bimanual technique

Breasts of non-pregnant women change with what?

The ebb and flow of hormones during the monthly menstrual cycle.

The presence of a benign breast disease makes the breasts harder to examine, why?

The general lumpiness conceals a new lump

Tail of spence

The superior lateral corner of breast tissue projects up and laterally into the axilla.

Cooper's ligaments

The suspensory ligaments, are fibrous bands extending vertically from the surface to attach on chest wall muscles.

What should you make sure you palpate well?

The tail of spence high into the axilla

What is the most common site of breast tumors?

The upper outer quadrant

What is the white color of breast milk from?

The whitish color is from emulsified fat and calcium caseinate

These changes decrease what and cause what?

These changes decrease breast size and elasticity so breasts droop and sag, looking flattened and flabby

Adipose tissue

These layers of subcutaneous and retromammary fat actually provide most of the bulk of the breast.

What happens to Cooper's ligaments in cancer of the breast?

They become contracted in cancer of the breast, producing pits or dimples in the overlying skin

When breast glandular tissue atrophies, what replaces it?

This is replaced with fibrous connective tissue; fat envelope atrophies also, beginning in middle years and becoming marked in eighth and ninth decades

Normally, you may feel a firm transverse ridge of compressed tissue in lower quadrants, what is this?

This is the inframammary ridge, and it is especially noticeable in large breasts; do not confuse it with an abnormal lump (dont confuse this with abnormal lump)

The breast may be divided into 4 quadrants by imaginary horizontal and vertical lines intersecting at the nipple. What does this help with?

This makes a convenient map to describe clinical findings.

Premenopausal women at midcycle often have what?

Tissue edema and mastalgia (pain) that makes it hard to detect a lesion.

Mastalgia occurs with what?

Trauma, inflammation, infection and benign breast disease

From the central axillary nodes, drainage flows where?

Up to the infraclavicular and supraclavicular nodes

During embryonic life, what are present on the breast?

Ventral epidermal ridges, or "milk lines," are present and curve down from axilla to groin bilaterally

With maturing adolescents, how do you palpate the breast?

With maturing adolescents, palpate breasts as you would with adult; note any mass

Full development from stage 2-5 takes how long?

avg of 3 years, but range is 1.5-6 years

Premature thelarche

early breast development with no other hormone dependent signs (pubic hair, menses)

At puberty, what stimulates breast changes?

estrogen!

Most of the lymph, >75%, drains into what?

ipsilateral (same side) axillary nodes.

Factors that contribute to breast health care access include:

low income, lack of health insurance, geographic, cultural, and language barriers, and racial bias

Galactorrhea

medications may cause clear nipple discharge; oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers

Male breast cancer

no standard screening - painless palpable mass; hard, irregular, nontender, fixed to area, nipple retraction. - Nipple discharge - warning! - Early spread to axillary lymph nodes occurs due to minimal breast tissue - diagnosed 10 years later than women and at later stages: 60-70

Montgomery's glands

secrete a protective lipid material during lactation

Paget's disease

starts with a small crust on the nipple apex and then spreads to the areola.

Mastitis

uncommon - inflammatory mass before abscess formation - single quadrant - area is red, swollen, tender, hard, hot, right breast - headache, malaise, fever, chills and sweating, increased pulse, flu like symptoms. - Treat with antibiotics, rest, heat