Breasts and Regional Lymphatics

1. Breasts and Regional Lymphatics

2. Structure and Function Surface anatomy • Location of breasts on chest wall • Axillary tail of Spence • Nipple and areola

3. Developmental care Adolescent Puberty Pregnant female Aging female Menopause Male breast Structure and Function Preadolescent Breast Bud Stage Breast/Areola Enlarge Areola/Nipple form 2ndary Mound Mature Breasts

4. Breast Cancer • 2nd leading cause of cancer death in women • Second to lung cancer • NCI-Lifetime risk for a women to develop breast cancer 12% • The 10-year risk for breast cancer: • at age 40: 1 and 69 • at age 50: 1 and 42 • at age 60: 1 and 29

5. Breast Cancer Risk Factors • Increased age (>40) • Personal or family history of breast cancer or disease • Early onset menarche (before age 13) • Late-age menopause (after age 50) • Nulliparous (never having borne a child) • Late first pregnancy (after age 30) • Recent use of oral contraceptives

6. Inherited Risk Factors-BRCA 1 or BRCA 2 Mutation • Diagnosed with breast cancer before age 50 and/or ovarian cancer at any age • Have close family member (on mother’s or father’s side) diagnosed with breast cancer before age 50, ovarian cancer at any age, or male breast cancer at any age. • Half of all women with hereditary risk inherited it from father’s side. Myriad Genetic Laboratories

7. BRCA 1 and BRCA 2 Mutation • Women with BRCA mutation have: • 33%-50% risk of developing breast cancer by age 50 • 56%-87% risk by age 70 • 27%-44% chance of developing ovarian cancer by age 70 • Men with BRCA mutation have: -6% risk of developing breast cancer Myriad Genetic Laboratories

8. Screening-Average Risk • American Cancer Society (2003) • Film Mammogram • Annually after 40 years old • Clinical Breast Examination (CBE) • Every 3 years for age 20-40 • Annually after 40 years old • Breast Self-Examination (BSE) • Option for women starting at age 20 • Women 20 years of age or older need to report any breast changes to a health care provider immediately • “It is acceptable for women to choose not to do BSE or to do BSE irregularly.”

9. Screening- Average Risk • US Preventive Services Task Force (USPSTF) (2009) • Film Mammogram • Not recommended in women 40-49 years old • Biennial for women 50-74 years old • Insufficient evidence for recommendation in women ≥75 • Clinical Breast Examination (CBE) • Insufficient evidence for recommendation • Breast Self-Examination (BSE) • Not recommended

10. Health History • Assess patient’s risk factors • Assess socioeconomic status • Fixed or low-income may be less likely to pursue CBE and mammography • Consider importance of teaching SBE • Provide with resources for free/low cost screening • If already performs self breast exam: • Assess methods and times performs in relations to menstrual cycle

11. Health History • Presence of: • Pain or tenderness • Discharge • Distortion or retraction • Rash or scaling of nipple • Change in size of breast or swelling • Lump • Onset- When first noticed? • Duration- Always present or come and go? • Characteristics- Changed in size, shape, or with menstrual cycle? • Associated Symptoms?

12. Health History • Medication Use: • Oral contraceptives • Diuretics • Steroids • Estrogen • Caffeine Intake • Level of activity • Alcohol intake • Weight

13. Breast/Axilla Inspection • General appearance • Symmetry • Skin • Smooth and even in color. • Reddness • Bulging or dimpling • Edema (peau d’orange) • Skin or vascular lesions • Axillary rash or infection 2 1 3

14. Breast/Axilla Inspection • Nipple • Position • Protrude, flat, or inverted • Skin lesions • Dry scaling, fissures, ulcerations, bleeding, or dc • Supernumerary nipples

15. Maneuvers to screen for retraction

16. Breast/Axilla Palpation • Palpate Lymph nodes in Axilla • Down chest wall, middle of axilla (central) • Anterior border (pectoral) • Posterior border (subscapular) • Inner aspect of upper arm (lateral) • One or more soft, small (<1cm), nontender nodes are often felt • Nodes that are large (>1cm), firm or hard, matted together, or fixed to the skin suggest malignancy

17. Breast/Axilla Palpation • Position • Supine with pillow under side to be palpated • Arm above head • Palpation technique • Use pads of first three fingers and make gentle rotary motion • Vertical stripping pattern recommended • Apply light, medium and deep palpation • Cover entire breast, including the periphery, tail, and axilla Vertical Stripe Spokes Concentric Circle

18. Breast/Axilla Palpation • Nipple • No mass, induration, or dc • Expected findings • Nulliparous- firm, smooth, elastic • Post pregnancy-softer and looser • Premenstrual engorgement-enlargement, tenderness, nodularity, prominent lobes, inframammary ridge • Bimanual palpation • For large pendulous breasts

19. Location Size Shape/Distinctness Consistency Mobility Nipple retraction Overlying skin Tenderness Lymphadenopathy Detection of a Breast Lump

20. Breast Masses • Fibroadenoma- Benign fibrous tumor • Age 15-25 up to 55 • Round, disc like or lobular, well delineated, mobile, usually non-tender, usually firm but may be soft. • Cysts • Age 30-50 • Round, soft to firm, well delineated, mobile, tender • Cancer • Age 30-90 • Irregular, firm to hard, not clearly delineated, may be fixed, usually non-tender, retraction may be present

21. Male Breast Exam • Inspect chest wall for enlargement, lumps or swelling • Gynecomastia • Palpate nipple area for lumps or enlargement • Palpate axillary lymph nodes Breast tissue without enlargement, masses, or swelling. Axillary lymph nodes nonpalpable.

22. Breast Self-Examination • Step 1: • Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. • Here's what you should look for: • breasts that are their usual size, shape, and color • breasts that are evenly shaped without visible distortion or swelling • If you see any of the following changes, bring them to your doctor's attention: • dimpling, puckering, or bulging of the skin • a nipple that has changed position or an inverted nipple (pushed inward instead of sticking out) • redness, soreness, rash, or swelling • Step 2: Now, raise your arms and look for the same changes. • Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

23. Breast Self-Examination • Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. • Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. • Follow a pattern to be sure that you cover the whole breast. You can begin at the nipple, moving in larger and larger circles until you reach the outer edge of the breast. You can also move your fingers up and down vertically, in rows, as if you were mowing a lawn. Be sure to feel all the breast tissue: just beneath your skin with a soft touch and down deeper with a firmer touch. Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage. • Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.

24. Sample Charting