BREAST AND AXILLAE

• Breasts

  • also called mammary glands in women, lie on the anterior

  also called mammary glands in women, lie on the anterior chest wall. They’re located vertically between the second or third and the sixth or seventh ribs over the pectoralis major muscle and the serratus anterior muscle, and horizontally between the sternal border and the midaxillary line. or third and the sixth or seventh ribs over the pectoralis major muscle and the serratus anterior muscle, and horizontally between the sternal border and the midaxillary line.
• Breast structures 


  Each breast has a 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.
• Tail of Spence: A small triangle of tissue projects into the axilla.
• Cooper’s ligaments: Attached to the chest wall musculature are fibrous bands that support each breast.
• Support structures of the breast

  A) axillary tail of spence

  B) areola

  C) Montgomery's tuburcles

  
• Lobes and Ducts


  In women, 12 to 25 glandular lobes containing alveoli that produce milk surround each breast. The lactiferous ducts from each lobe transport milk to the nipple
• Lobes and Ducts

  A) Cooper's ligament

  B) Lobe

  C) Lactiferous duct

  D) Lactiferous sinus

  E) Lobule

  
• 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.
• Changes during puberty

  • Breast development is an early sign of puberty in girls and usually starts with the breast and nipple protruding as a single mound of flesh between ages 8 and 13. Development of breast tissue in girls younger than age 8 is abnormal.
• Changes during the reproductive years

  • During the reproductive years, a woman’s breasts may become full or tender in response to hormonal fluctuations during the menstrual cycle.
  • During pregnancy, breast changes occur in response to hormones from the corpus luteum and the placenta
• Changes after menopause

  • After menopause, estrogen levels decrease, causing glandular tissue to atrophy and be replaced with fatty deposits
• During Pregnancy

  • The breasts enlarge because of the proliferation and hypertrophy of the alveolar cells and lactiferous ducts.
• During Pregnancy

  • Striae may appear as a result of stretching, and Montgomery’s tubercles may become prominent
• Assessment


  Inspect the skin of the breast. Check for edema. Note breast size and symmetry. Then, inspect the nipples.
• Assessment 


  Examining the breasts: Inspection

  • Inspect the skin of the breast. It should be smooth, undimpled, and the same color as the rest of the skin.
  • Check for edema, which can accompany lymphatic obstruction and may signal cancer. Note breast size and symmetry.
  • Asymmetry may occur normally in some adult women, with the left breast usually larger than the right.
  • Inspect the nipples, noting their size and shape. If a nipple is inverted, dimpled, or creased, ask the patient when she first noticed the abnormality.
• Examining the breast: Inspection 2

  Next, inspect the patient’s breasts while she holds her arms over her head, and then again while she has her hands on her hips. These positions may help you detect skin or nipple dimpling that wasn’t obvious before.

  • If the patient has large or pendulous breasts, have her stand with her hands on the back of a chair and lean forward. This position helps reveal subtle breast or nipple asymmetry.
• Palpation

  • Ask the patient to lie in a supine position, and place a small pillow under her shoulder on the side you’re examining.
  • Have the patient put her hand behind her head on the side you’re examining. This spreads the breast evenly across the chest and makes finding nodules easier.
  • If her breasts are small, she can leave her arm at her side.
• Performing breast palpation

  • Use your three middle fingers to palpate the patient’s breasts systematically.
  • Rotate your fingers gently against the chest wall.
  • Make sure you include the tail of Spence in your examination.

  
• Examining the areola and nipple

  • After palpating the breasts, palpate the areola and nipple.
  • Gently squeeze the nipple between your thumb and index finger to check for discharge.

  
• Breast palpation methods

  According to the American Cancer Society, the vertical strip method is the most effective method to ensure that the entire breast is palpated. Whatever method you use, be consistent and palpate the entire breast, including the periphery, tail of Spence, and the areola.

  A) Circular

  B) Wedged

  C) Vertical strip

  
• Identifying locations of breast lesions

  A) Upper Inner Quadrant

  B) Upper Outer Quadrant

  C) Lower Inner Quadrant

  D) Lower Outer Quadrant

  
• Documenting a breast lump If you palpate a lump, record these characteristics: SSCMDL

  • size in centimeters
  • shape — round, discoid, regular, or irregular
  • consistency — soft, firm, or hard
  • mobility
  • degree of tenderness
  • location, using the quadrant or clock method
• Evaluating breast lumps

  A) Round and Lobular

  B) Irregular or Star-shaped

  C) demarcation

  D) soft

  E) hard

  F) mobility and number

  G) Nontender

  H) Commonly tender

  I) usually non tender

  J) Fibroadenoma

  K) Fibrocystic disease

  L) Cancer

  
• Examining the axillae


  Inspection

  • With the patient sitting or standing, inspect the skin of the axillae for rashes, infections, or unusual pigmentation.
• Examining the axillae


  Palpation

  • Ask the patient to relax her arm on the side you’re examining. Support her elbow with one of your hands.
  • Cup the fingers of your other hand, and reach high into the apex of the axilla.
  • Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle.
• Palpating the axilla 1

  • Palpate the central nodes by pressing your fingers downward and in toward the chest wall, as shown.
  • Palpate the pectoral and anterior nodes by grasping the anterior axillary fold between your thumb and fingers and palpating inside the borders of the pectoral muscles.
• Palpating the axilla 2

  • Palpate the lateral nodes by pressing your fingers along the upper inner arm. Try to compress these nodes against the humerus.
  • To palpate the subscapular or posterior nodes, stand behind the patient and press your fingers to feel the inside of the muscle of the posterior axillary fold.
• Ductal carcinoma in situ

  • It is a breast cancer in the earliest stage developing in the ducts
• Infiltrating (invasive) ductal carcinoma

  • Cancer begins within the duct and spreads to the breast’s parenchymal tissue.
• Breast dimpling

  • the puckering or retraction of skin on the breast, results from abnormal attachment of the skin to underlying tissue.
  • It suggests an inflammatory or malignant mass beneath the skin surface and usually represents a late sign of breast cancer.

  
• Fibrocystic changes (benign cysts)

  • are round, elastic, mobile masses that are commonly tender on palpation, especially around menstruation.
  • Multiple cysts may be present. Typically, there’s no evidence of skin retraction.

  
• Fibroadenoma

  • is a benign, round, lobular, and well demarcated mobile mass that feels slippery and firm to soft on palpation. It’s usually nontender and causes no visible skin retraction.

  
• Peau d'orange (orange peel skin)

  • Usually a late sign of breast cancer
  • is the edematous thickening and pitting of breast skin. This sign can also occur with breast or axillary lymph node infection or Graves’ disease.
  • Its striking orange peel appearance stems from lymphatic edema around deepened hair follicles

  
• Nipple retraction

  • the inward displacement of the nipple below the level of surrounding breast tissue, may indicate an inflammatory breast lesion or cancer.
  • It results from scar tissue formation within a lesion or large mammary duct. As the scar tissue shortens, it pulls adjacent tissue inward, causing nipple deviation, flattening, and finally retraction.

  
• Paget’s disease

  • is a rare form of breast cancer that usually starts as a red, granular or crusted, scaly lesion on the nipple or areola.
  • The lesion may ulcerate and cause erosion of the nipple.