1. BREAST AND AXILLA
EXAMINATION

2. Breast Anatomy
Primarily adipose tissue, glandular tissue, and suspensory ligaments
Composed of radially arranged lobes of parenchyma, each associated with a major lactiferous duct
Each major duct extends from the nipple to terminate in a “terminal duct-lobular unit” via branching ducts of diminishing caliber

3. A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

4. Breast Anatomy
Ruan, W, Kleinberg, DL. Endocrinology 1999; 140:5075. Copyright © 1999 The Endocrine Society.

5. Microscopic
Glands,
Dense stroma
Interlobular stroma

6. Evaluation: History History:
Change in general appearance of breast (size, symmetry)
New or persistent skin changes
New nipple inversion
Breast pain (cyclic vs. noncyclic, duration, location in breast)
Breast mass (how it was discovered, duration, change in size, location)
Relationship of mass to menstrual cycles
Nipple discharge (unilateral vs. bilateral, color)
Medications (e.g. hormones)
Risk factors for breast cancer

7. Risk factors
BRCA1 and BRCA2
1˚ relative with breast or ovarian cancer
Personal history of breast disease
Age > 70 yrs
Age at menarche < 12 yrs
Nulliparous or age at first birth > 30 yrs
Never breastfed
Age at menopause > 55 yrs
Protective factors
Breastfeeding
Parity
Recreational exercise
Postmenopause BMI < 23
Oophorectomy at < 35 yrs
Aspirin

8. Evaluation: Physical Exam
Clinical Breast Exam:
Inspect (relaxed, arms raised, hands on hips)
Breast symmetry
Skin changes (dimpling, retraction, edema, ulceration)
Nipples (symmetry, inversion/retraction, discharge)
Palapation (breasts, axillae, entire chest wall)
Pain
Masses
Regional lymph nodes (Axillary and Supraclavicular)
Documentation
“Clock” system
Location of concern and abnormality
Distance from areola
Size of mass

9. Benign Characteristics Malignant Characteristics
Benign vs. Malignant
Chief Complaint
Benign Characteristics
Malignant Characteristics
Breast mass
Multiple lesions
Single lesion
“Rubbery”
Hard
Mobile
Immovable
Well circumscribed border
Irregular borders
Nipple discharge
Bilateral
Unilateral
Multiductal
Uniductal
Milky
Bloody, Clear, or Colored
Spontaneous
Persistent
Skin changes
Retraction
Dimpling
Thickening

10. Breast Disease Benign Malignant Nonproliferative
Fibrocystic changes
Simple cysts
Lactational adenoma
Fibroadenoma
Hyperplasia without atypia
Epithelial hyperplasia
Sclerosing adenosis
Intraductal papillomas
Malignant
Ductal carcinoma
Lobular carcinoma
Tubular carcinoma
Mucinous carcinoma
Micropapillary carcinoma
Metaplastic carcinoma
Inflammatory carcinoma

11. Irregular thickening in the breast-fibrocystic disease,
Areola changes-Paget’s disease of the breast,
Pus- duct ectasia

12. Mastalgia: Incidence
Approximately 45% of women have mild breast pain, and 21% have severe breast pain in their lifetime
Breast cancer is found in 1.2 – 6.7% of women presenting with breast pain

13. Mastalgia: Etiology Differential Diagnosis: Cyclic Non-cyclic
Cyclic mastalgia
Fibrocystic disease
Non-cyclic
Large pendulous breasts
Diet, lifestyle
Mastitis
Hormone replacement therapy
Ductal ectasia
Inflammatory breast cancer
Extramammary (non-breast) pain

14. Mastalgia: Fibrocystic Disease
Premenopausal women
Premenstrual breast swelling/tenderness
Nodules/masses/lumps related to dense breast tissue or cysts
Fibrous tissue
Cystically dilated ducts
+ Calcifications
+ Ductal hyperplasia

15. Mastalgia: Inflammatory Breast Cancer
Peau d’orange-dimpling of involved skin due to retraction caused by lymphatic involvement and obstruction
Associated erythema
Cellulitis may mimic inflammatory carcinoma

16. Breast Mass: Etiology
More than 90% of palpable breast masses in women in their 20’s to early 50’s are benign
Differential Diagnosis:
Fibrocystic changes
Fibroadenoma
Fat necrosis
Phyllodes tumor
Intraductal papilloma
Breast cancer

17. Breast Mass: Fibroadenoma
Solitary, firm, rubbery, mobile mass
Women < 30 yrs
Slow growing (? hormonally mediated)
Fibroadenoma gross specimen
Firm, tan, lobulated
Well circumscribed mass
Variable size

18. Breast Mass: Fat Necrosis
Caused by trauma
Tender, firm mass with indistinct borders
May appear suspicious on physical exam
Benign breast calcification seen on mammography
Fat necrosis manifesting as a spiculated mass
Densely calcified 3-cm area of fat necrosis 2 years after blunt trauma to the breast.

19. Breast Ultrasound

20. Breast Mass: Evaluation
Initial evaluation
< 30 yr – Diagnostic ultrasound + Diagnostic mammogram
> 30 yr – Diagnostic mammogram
Further evaluation
Simple cyst
Symptomatic – Aspirate
Asymptomatic – Observe for 2-4 months
Complicated cyst – Ultrasound-guided aspiration
Solid mass – Core needle biopsy (CNB) or Excision
No specific findings – Re-examine after two cycles

21. Nipple Discharge: Evaluation
History
Unilateral vs. bilateral
Spontaneous vs. provoked discharge
Appearance of discharge
Medications (e.g. antipsychotics, antidepressants)
History of trauma
History of amenorrhea
History of hypogonadism (e.g. hot flashes, vaginal dryness)
Clinical breast exam
Attempt to elicit discharge, identify involved duct(s)
Evaluate discharge for gross blood or guaiac positivity

22. Mamogram
Fibroadenoma
Breast cancer

23. A 42 year old lady see her physician due to
Odd changes in the breast and felt small lump, while showering,
thickening in the breast,
No nipple discharge, no trauma and no pain.

24. Case studies A 22 year old lady noticed small mobile round
Lump in her breast,
39 year old lady, irregular small multiple lumps, firm ,tender more during mid cycle.

25. 41 year old lady 2 axillary lymph nodes, non tender, no barest mass ,mild weight loss.
39 year diffuse firm left breast and FNAC abnormal
26 year old lady with firm irregular 5mm lump

26. Medication history (e. g
Medication history (e.g., oral contraceptives, steroids, and diuretics) may cause nipple discharge.
Risk factors (e.g., mother, sister, aunt with breast cancer, alcohol consumption, high fat diet, obesity, use of oral contraceptives, menarche before age 12, menopause after age 55, age 30 or more at first pregnancy

27. Inquire if the client performs breast self examination, technique used, and when performed in relation to the menstrual cycle.
Estrogen replacement therapy may be associated with the development of cyst or cancer.

28. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
-Recent change in breast size, swelling, marked asymmetry.
Female: rounded shape, slightly
unequal in size, generally symmetric.
Male: breasts even with the chest wall, if obese may be similar in shape
to female breasts.
Inspect the breasts for:
Size.
Symmetry.
Shape.
While the client is in a sitting position

29. Inspect for: Skin changes Redness Visible bumps Nipple crusting
Symmetry
Look for any dimpling or unusual skin changes. There should be no visible bumps or bulges of the breast beyond the normal contour. The skin should be a uniform color and not have areas of redness suggesting increased blood flow. The nipples should have no visible secretions or crusting.

30. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
-Localized discolorations or hyperpigmentation.
-Retraction or dimpling.
-Unilateral localized hypervascular areas.
-Swelling or edema appearing as pig skin or orange peel due to exaggeration of the pores.
Skin : uniform in color and skin is smooth and intact.
Striae, moles and nevi.
*Inspect the skin for localized hyperpigmentation, retraction or dimpling, localized hypervascular areas, swelling or edema.

31. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
Breasts should rise evenly Watch for dimpling or retraction
*Emphasize any retraction by having the client:
-Raise the arms above the head.
-Push the hands together, with elbows flexed.
-Press the hands down on the hips.

32. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
Any a symmetry, mass, or lesion.
Rounded or oval bilaterally the same,
-Color varies from light pink to dark brown.
-Irregular
placement of sebaceous glands on the surface of areola.
Inspect the areola area for size, shape, symmetry, color, surface characteristics, and any masses or lesions.

33. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
-A symmetrical size and color.
-Presence of discharge, crusts, or cracks.
-Recent inversion of one or both nipples.
-Rounded, everted and equal in size.
-Similar in color, smooth, soft, both nipples point in same direction.
- No discharge, except from pregnant or breast feeding females.
-Inversion of one or both nipples that is present from puberty.
Inspect the nipples for size, shape, position, color, discharge, and lesions.

35. Assessing Breasts and axillae
Assessment
*Palpate the axillary, subclavicular, and supraclavicular lymph nodes.
Client position: sits with arms abducted and supported on the nurse’s forearm.
Use the flat surfaces of all fingertips to palpate the four areas of axilla:
The edge of the greater pectoral muscle.
The thoracic wall in the midaxillary area.
The upper art of the humerus.
The anterior edge of the latissimus dorsi muscle along the posterior axillary line.

36. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
-Tenderness, masses, nodules, or nipple discharge.
If a mass was detected, record the following data:
A-Location and distance from the nipple in cm.
No tenderness, masses, nodules, or nipple discharge.
Palpate the breasts for masses, tenderness, and any discharge from the nipples.
Client position: supine
Rationale: The breasts flatten evenly against the chest wall, facilitating palpation

38. Use the Middle of Your Fingers
Fingertips are too sensitive (all breasts are somewhat lumpy)
Palm is too insensitive
Middle portion of fingers is just right
Don't use your fingertips...they are too sensitive and you will end up focusing on all the tiny irregularities and nodules that are present in everyone's breasts.
Don't use the palms of your hand...they are too insensitive and you can miss something important.
Use the middle portions of your fingers...they have just the right sensitivity for finding the lumps or masses you are seeking.

39. Move your hand in small circles
Stay in one place
Press in while circling with your hand
Feel for thickenings the size of a marble
Move your hand in small circles while feeling for lumps

40. Feel the Armpit Use the same circular motions.
Feel for breast lumps and lymph nodes.
Normal lymph nodes cannot be felt.
Enlarged lymph nodes are about the size of a pencil eraser, but longer and thinner.
Using the same circular motions, examine the armpit, feeling for any lumps in the "tail" of the breast or any lymph nodes. Lymph nodes are normally so small they cannot be felt. If enlarged due to infection or inflammation, they grow to about the size of a pencil eraser but are long and narrow rather than round.

41. Try to Express Nipple Discharge
Strip the ducts towards the nipple.
Normally, one or two drops of clear, milky or green-tinged secretions.
Should not be bloody or in large quantity, squirting out or staining the inside of a bra.
Using the thumb and fingers, squeeze the breast toward the nipple to try to express any discharge. This stripping of the milk ducts can be useful in identifying early problems with the ducts. You should squeeze not only from side to side, but also from top to bottom and at an angle.
In normal breasts, you can, with effort, usually produce a drop or two of clear, milky, or slightly green-tinged discharge. Abnormal findings would be a bloody discharge, or so much discharge that it squirts across the room or consistently stains the inside of your bra.

42. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
B-Size: the length, width, and thickness of the mass in cm.
C-Shape: round, oval, lobulated, indistinct, or irregular.
D-Consistency: hard or soft mass.
For patients who have a past history of breast masses, who are at high risk for breast cancer, examination in both a Supine and a Setting position is recommended.

43. Assessing Breasts and axillae
Deviation from normal
Normal findings
Assessment
E- Mobility: movable or fixed.
F-Skin over the lump: is reddened, dimpled, or retracted.
G-Nipple: whether it is displaced or retracted.
H-Tenderness: whether palpation is painful.
If the client reports a breast lamp, start with the “normal” breast to obtain baseline ass.
For palpation choose one of three patterns:
1- Concentric circles.

45. Assessment
2-Hands-of-the-clock or spokes-on-a-wheel

46. 3-Vertical strips pattern:
Start at one point for palpation, and move systematically to the end point to ensure that all breast surfaces are assessed.
Teach the client the technique of breast self examination.
Document findings.

47. Bottom Line Concepts
It is important to evaluate breast complaints thoroughly to ensure that breast cancers, as well as benign breast lesions, are diagnosed and treated promptly.
Evaluation of a woman presenting with a breast complaints requires careful assessment of symptoms and risk factors for developing breast cancer.
The clinical breast exam include inspection and palpation of the breast tissue, chest wall, and regional lymph nodes. Documentation should included both positive and negative findings.
Women with breast problems can present with any combination of symptoms including breast mass or thickening, breast pain, nipple discharge, or skin changes.
Typically, women presenting with a suspicious breast mass who are > 30 yrs should receive a diagnostic mammogram, whereas women younger than 30 should receive a diagnostic ultrasound.
Negative imaging should not stop further investigation is a suspicious lump is felt on clinical exam.
Masses that are solid on ultrasound imaging require biopsy to exclude cancer and provide a histological diagnosis.