HA: Breast and Axillae

• Assessing the axillae can be the pits. Get it? "The pits"?
• Although we tend to focus on assessing the female breast, don't ignore this part of an assessment in male patients. In men, breast structures include a nipple, an areola, and flat tissue bordering the chest wall.
• Breast structures


  • Centrally located nipple of pigmented erectile tissue ringed by an areola that's darker than the adjacent tissue
  • Sebaceous glands, also called Montgomery's tubercles, are scattered on the areola surface, along with hair follicles

  
• Normal breast anatomy


  • The breasts, also called mammary glands in women, lie on the anterior chest wall
  • Located vertically between the second or third and the sixth or seventh ribs over the pectoralis major muscle and the serratus anterior muscle
  • Located horizontally between the sternal border and the midaxillary line

  
• Differences in areola pigmentation


  • Whites have light-colored nipples and areolae, usually pink or light beige
  • People with darker complexions, such as Blacks and Asians, have medium brown to almost black nipples and areolae
• Support structures of the breast

  • Fibrous bands, called Cooper's ligaments, that support each breast
  • Fatty tissue
  • Glandular tissue
• Lobes and ducts


  1. 12 to 25 glandular lobes containing alveoli that produce milk surround each breast

  2. The lactiferous ducts from each lobe transport milk to the nipple
• Lymph nodes of the breast and axillary region


  • The pectoral lymph nodes drain lymph fluid from most of the breast and anterior chest
  • The brachial nodes drain most of the arm
  • The subscapular nodes drain the posterior chest wall and part of the arm
  • The midaxillary nodes located near the ribs and the serratus anterior muscle high in the axilla are the central draining nodes for the pectoral, brachial, and subscapular nodes
  • In women, the internal mammary nodes drain the mammary lobes
  • The superficial lymphatic vessels drain the skin
• In men and women, the lymphatic system is the most common route for the spread of breast cancer cells.
• Breast changes through the life span

  1. Before age 8: The breast and nipple protrude as a single mound of flesh

  2. Between ages 8 and 13: The breast and nipple protrude as a single mound of flesh

  3. During adulthood (having never given birth): Breasts may become full or tender in response to hormonal fluctuations during the menstrual cycle

  4. During pregnancy: The areola becomes deeply pigmented and increases in diameter, the nipple becomes darker, more prominent, and erect, the breasts enlarge because of the proliferation and hypertrophy of the alveolar cells and lactiferous ducts, as veins engorge, a venous pattern may become visible, striae may appear as a result of stretching, and Montgomery's tubercles may become prominent

  5. After pregnancy: During breast-feeding, a woman's breasts become full and tense and may feel firm and warm, after breast-feeding ceases, breast size decreases, but usually doesn't return to the prepregnancy state

  6. After menopause: The breasts become flabbier and smaller, as the ligaments relax, the breasts hang loosely from the chest, the nipples flatten, losing some of their erectile quality, the ducts around the nipples may feel like firm strings
• Examining the breasts


  • Inspect the skin of the breast, check for edema, note breast size and symmetry, inspect the nipples
  • Palpate the breasts systematically, rotate fingers gently against the chest wall, include the tail of Spence in the examination
  • Palpate the areola and nipple, gently squeeze the nipple between thumb and index finger to check for discharge
• Stress with your patients the importance of having regular clinical breast examinations, and make sure they know how to perform breast self-examination.
• Documenting a breast lump


  • Record size in centimeters, shape, consistency, mobility, degree of tenderness, location using quadrant or clock method
• Breast palpation methods


  Circular, wedged, vertical strip
• Identifying locations of breast lesions


  • Mentally divide the breast into four quadrants and a fifth segment, the tail of Spence, or think of the breast as a clock with the nipple in the center
• Evaluating breast lumps outside the norm


  Assess mobility and number, assess for demarcation and consistency, determine if lump is tender and if there is skin retraction
• Identifying locations of breast lesions

  Locate lesions or other findings by the distance in centimeters from the nipple
• Breast quadrants


  • Upper inner
  • Upper outer
  • Lower inner
  • Lower outer
• Clock positions


  • 12:00
  • 9:00
  • 3:00
  • 6:00
• Evaluating breast lumps


  1. Assess mobility and number

  2. Assess for demarcation and consistency

  3. Determine if lump is tender

  4. Determine if skin retraction is present
• Fibroadenoma (benign mass)


  • Very mobile; single; feels slippery
  • Well demarcated; feels firm to soft
  • Nontender; no skin retraction
• Fibrocystic disease (benign cysts)


  • Mobile; usually multiple
  • Commonly tender, especially just before menstruation; no skin retraction
• Cancer (malignant mass)


  • Fixed and single
  • Poorly defined edges; feels firm to hard
  • Usually nontender with skin retraction
• Palpation


  Pressing fingers downward and in toward the chest wall to assess axillary nodes
• Abnormal axillary nodes


  • Hard, large, or tender lesion
• Assessing the clavicular nodes


  1. Relax neck muscles by flexing head slightly forward

  2. Hook fingers over clavicle beside sternocleidomastoid muscle

  3. Rotate fingers deeply into this area to feel the supraclavicular nodes
• To minimize patient discomfort, warm hands before palpation
• Infiltrating (invasive) ductal carcinoma


  • Irregularly shaped mass with poorly defined edges
  • Fixed, feels firm to hard, usually nontender
  • Evidence of skin retraction may be present
• Ductal carcinoma in situ


  • Cancer begins within the duct and spreads to the breast's parenchymal tissue
• Fibrocystic changes (benign cysts)


  • Round, elastic, mobile masses
  • Commonly tender on palpation, especially around menstruation
  • Multiple cysts may be present
  • No evidence of skin retraction
• Breast dimpling


  • Puckering or retraction of skin on the breast
  • Suggests an inflammatory or malignant mass beneath the skin surface
  • Usually a late sign of breast cancer
• Peau d'orange (orange peel skin)


  • Edematous thickening and pitting of breast skin
  • Can occur with breast or axillary lymph node infection or Graves' disease
  • Striking orange peel appearance stems from lymphatic edema around deepened hair follicles
• Fibroadenoma


  • Benign, round, lobular, and well-demarcated mobile mass
  • Feels slippery and firm to soft on palpation
  • Usually nontender and causes no visible skin retraction
• Nipple retraction


  • Inward displacement of the nipple below the level of surrounding breast tissue
  • May indicate an inflammatory breast lesion or cancer
  • Results from scar tissue formation within a lesion or large mammary duct
• Paget's disease


  • Rare form of breast cancer
  • Usually starts as a red, granular or crusted, scaly lesion on the nipple or areola
  • Lesion may ulcerate and cause erosion of the nipple
• Mastitis


  • Breast becomes tender, hard, swollen, and warm
  • Develops when a pathogen in the breastfeeding infant's nose or pharynx invades breast tissue through a fissured or cracked nipple and disrupts normal lactation
• Breast engorgement


  • Painful breasts that feel heavy and may feel warm
  • Results from venous and lymphatic stasis and alveolar milk accumulation
• Men also need clinical breast examinations and the incidence of breast cancer in males is rising
• Gynecomastia (abnormal enlargement of the male breast)


  • Usually bilateral
  • Can be caused by cirrhosis, leukemia, thyrotoxicosis, hormones, illicit drug use, or alcohol consumption
• Nipple discharge


  • Can occur spontaneously or be elicited by nipple stimulation
  • Can be a normal finding or signal serious underlying disease, particularly when accompanied by other breast changes