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86 Cards in this Set
- Front
- Back
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In women what are the borders of the breast
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2nd/3rd to 7th rib bilaterally, sternal margin to midaxillary line
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Makeup of the glandular tissue in each breast
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15-20 lobes radiating around each nipple, which are composed of 20-40 lobules, each composed of milk producing acini, emptying into the lactiferous ducts
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What are Cooper ligaments?
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suspensory ligaments that extend from the connective tissue layer, through the breast, and attach to the underlying muscle fascia. support the breast.
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Vascular supply to the breasts
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internal mammary, and lateral thoracic artery (for deeper tissues and the nipple) intercostal arteries for superficial tissue
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What constitutes the bulk of the breast
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the subcutaneous and retromammary fat that surrounds the glandular tissue
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Where is the greatest amount of glandular tissue found/
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upper outer quadrant, extending into the axilla, forming the tail of spence
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Where do supernumerary nipples form?
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along the mammary ridge, also called the milk line
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To what lymph nodes does the upper, outer quadrant drain?
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the scapular, brachial, intermediate nodes, toward the axillary nodes
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To what lymph nodes does the medial portion drain?
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internal mammary chain, toward the opposite breast and abdomen
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To what lymph nodes does the posterior chest wall drain?
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posterior axillary nodes (subscapular) of the arm
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To what lymph nodes does the anterior chest wall drain?
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anterior axillary nodes (pectoral)
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To what lymph nodes does the upper arm drain?
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lateral axillary nodes (brachial)
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To what lymph nodes does the retroareolar area drain?
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interpectoral (rotter) nodes, into the axillary chain
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To what lymph nodes do the areola and nipple drain?
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midaxillary, subclavicular, and supraclavicular
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What does thalarche (breast development) indicate?
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early sign of puberty in adolescent girls
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What tanner stage is it unusual for Menarche to preceed?
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stage 3
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What % of females reach menarche at stage 3, 4, and 5
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25% reach during stage 3, and 75% by stage 4, 10 % during stage 5
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What is the average interval from breast bud stage to menarche?
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2 years
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What % of adolescents will have absent stage four, or minimal stage four?
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25% will not get stage four, another 25% will have minimal stage four
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what is produced by the nipples by the end of pregnancy, and what is it?
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colostrum, a protien/mineral rich milk precursor
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What tanner stage is it unusual for Menarche to preceed?
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stage 3
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What % of females reach menarche at stage 3, 4, and 5
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25% reach during stage 3, and 75% by stage 4, 10 % during stage 5
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What is the average interval from breast bud stage to menarche?
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2 years
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What % of adolescents will have absent stage four, or minimal stage four?
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25% will not get stage four, another 25% will have minimal stage four
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what is produced by the nipples by the end of pregnancy, and what is it?
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colostrum, a protien/mineral rich milk precursor
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After termination of lactation, how long does involution take to complete
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3 months
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Changes in a post menopausal breast
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thickening of inframammary ridge, fatter breasts, less alveolar and lobular tissue, more loosely hanging due to relaxing suspensory ligaments, nipples are smaller, flatter, and less erectile
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Increased risk of breast cancer due to genetics
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BRCA 1 and 2. confer a 35-85% chance of getting breast cancer. Genetics make up 10% of breast cancer causes
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Increased risk due to age of getting breast cancer
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over 40 is 18%, over 50 is 77%. only 5% is less than 40 years old
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Risks of breast cancer associated with elevated estrogen
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early menarche and late menopause, nulliparus or late childbirth (>30), birth control hormones (>26% increase in chances), obesity (60% greater risk),
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Other risks for breast cancer
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family history, higher with more member affected, personal history of breast cancer(not recurrence) previous biopsies, being white, previous radiation, DES exposure, alcohol use
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Age to start Breast Self Examinations (BSE), and reason for doing it
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20's increases their familiarity with their own breasts, so they know when something is wrong
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Characteristics of BSE
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monthly, 2-3 days after period, in front of mirror, hands at sides, hands behind head, hands on hips, in shower with soap: rub each breast in small circles. then do again supine
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In the two groups of women, 1 instructed on BSE and the other not instructed, what were the findings.
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incidence and mortality were similar, but trained women found more benign lesions
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Clinical Breast exams, what is their sensitivity and specificity in finding breast cancer?
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sensitivity is 40-69%, specificity is 88-99%.
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What is the sensitivity and specificity of mammography, and does it change by age group?
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sensitivity is lower in women under 50 due to denser breasts or hormone therapy. Specificity is increased with shorter intervals and prior mammograms to reference. sensitivity for over 40 was 71-96%, specificity was 94-97%
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What age should a woman get a CBE and mammogram, and how often
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CBE older than 40 years annually, younger than 40 every 1 to 3 years. Mammograms start at 40, then yearly. if increased risk, younger and more frequent
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Age and regularity of BSE
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optional and starting in their 20s and monthly
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Different shapes of breasts
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convex, pendulous, conical
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What do retractions and dimpling of the breast signify?
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contraction of the fibrous tissue associated with carcinoma
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What would a peau de'orange appearance indicate? (first seen in areola)
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edema of the breast caused by blocked lymph drainage caused by inflammatory carcinoma
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Bilateral Large venous patterns and spider angiomas indicate what
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pregnancy, increased estrogen
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Unilateral large venous pattern indicate what
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increased blood flow to malignancy
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Finding of one or both inverted nipples indicates what?
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could be genetic, ask patient if there is a lifetime history. if unilateral inversion or retraction is recent, could indicate malignancy
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what is the cause of a recently inverted or retracted nipple?
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inward pulling by inflammatory or malignant tissue
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What do you suspect if nipples are pointing different directions?
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fibrotic tissue of carcinoma can change the axis of the nipple, causing it to point in a different direction
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What are the 5 D's related to nipples?
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Discharge, Deviation, Depression, Discoloration, Dermatologic changes
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What are supernumerary nipples, what are they associated with? and Which ethnic group has them more often?
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can be associated with renal or cardiac anomalies (mostly in whites) African American women have more, but arent associated with these conditions
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In the seated position with arms over head, or behind the neck, what are we looking for?
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(adds tension to suspensory ligaments) accentuates dimpling, and variations in contour and symmetry
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In the seated position with shoulders rolled forward and hands on hips, what are we looking for?
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flexes pec muscles, reveals deviation in contour and symmetry
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In the seated, leaning forward position, what are we looking for?
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also tenses suspensory ligaments, looking for equal hanging of breasts, especially helpful in assessing contour and symmetry in large breasts
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Know what to do in the chest wall sweep, bimanual digital palpation, and lymph node palpation
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All done in sitting position, palpating for lumps, and enlarged lymph nodes, also for tenderness.
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Should you be able to palpate lymph nodes in the average adult?
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no, a palpable node indicates inflammation. if tender, usually due to infection, if not tender, most likely malignant process
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What is Virchow nodes?
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the supraclavicular nodes. when they are enlarged it is highly significant, as the abdominal and thoracic carcinomas will go there
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How do you describe an abnormal finding
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location, size, shape, consistency, tenderness, fixation, and delineation of borders
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Breast examination in supine patient
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have them place one hand behind head, this spreads breast tissue evenly over chest wall. after exam, have patient switch arms and do the other side
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techniques to remember during any portion of breast exam
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use finger pads, not tips, slide hands, do not lift them, as you may miss something. use three depths of palpation at each location. light, medium, deep
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How do you document breast masses?
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lOCATION (clock direction from nipple, and distance from nipple in cm) SIZE in cm, thickness, length, width SHAPE: round, discoid, lobular, stellate, or irregular. CONSISTENCY, TENDERNESS, MOBILITY, BORDERS, RETRACTION
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Describe the 3 methods for palpation of breast
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vertical strip, circular, wedge
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Do we still do nipple compression to induce discharge?
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no, only done if patient reports spontaneous discharge
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What are the types of nipple dicharge?
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milky, multicolored sticky, purulent, watery, serosanguineous
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What drug can women take to reduce their risk of ER+ breast cancer by 50%
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Tamoxifen
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What is the reduction of risk by getting a prohpylactic mastectomy? in high risk patients
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90%
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Will the feel of a womans breast change based on when the exam is performed?
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yes, changes in hormones during the cycle will cause the breast to change in size, nodularity, and tenderness. also older women will have more granular feel
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Do you inspect a woman who has had a mastectomy?
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yes, inspect the normal breast and the site of mastectomy as carefully as you normally would.
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What if the baby girls breasts are enlarged? What if there is milk that can be expressed?
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it is normal, from hormones passed on from mom, the milk is witches milk, and will go away in 2 weeks to 3 months
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What if a pubescent male has unilateral or bilateral subareolar masses?
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it is normal and should resolve on its own.
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What does it mean if an adolescent girls breasts are different sizes?
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it is normal, breasts do not always develop symmetrically
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What trimester will spider angiomas appear on the chest?
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2nd trimester, these are a result of elevated estrogen
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If a clogged duct is left unattended, what could it lead to?
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mastitis
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What is benign cyst formation caused by ductal enlargement, associated with a long luteal phase of the menstral cycle? and what are the clinical presentations?
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fibrocystic change, seen in 20-40 yr range, usually bilateral, could be single or multiple, round, soft to firm feel, mobile, and tender, well delineated border, and changes with menses
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What are benine tumors composed of stromal and epithelial elements? represent a hyperplastic process in 1 terminal ductal unit?
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fibroadenoma, usually 15-55 years, usually bilateral, single or multiple, round or discoid, firm, rubbery, mobile, nontender, well deliniated, not associated with menses
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What are the clinical presentations and age presentation of malignant breast tumors?
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30-80 years,usually unilateral, single, irregular or stellate, hard, stonelike, fixed, nontender, retraction signs, poorly delineated, irregular border, not associated with menses.
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What is the presenting symptom in 80% of women with breast cancer?
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painless lump
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What is the peak incidence od breast cancer in women?
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40-75 years, with the majority occurring older than 50.
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Clinical findings of breast cancer
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mass or breast thickening, marked asymmetry, prominent unilateral veins, discolorations (erythema echymosis), peau de'orange, dimpling, ulcerations, inversion, deviation, erosion, crusting, change in surface
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What is a firm irregular mass, appearing as an area of discoloration?
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fat necrosis, follows a trauma or local injury
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What are benign 2-3 cm tumors of the subareolar ducts, may be single or multiple, that cause serous or bloody nipple discharge
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intraductal papillomas or papillomatosis. need to be biopsied to rule out cancer
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What is a red, crusty, scaling patch of skin on the nipple, areola, and surrounding skin?
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Pagets disease of the breast. is the surface manifestation of underlying ductal carcinoma. does not respond to steroids
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Adult gynocomastia (bitch tits)
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smooth, firm, mobile, tender disk of breast tissue behind the areola in males. may be unilateral or bilateral. can be caused by testicular, pituitary, or hormone secreting tumors. also liver failure, antihypertensive meds, ketoconazole, or steroids
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What are retention cysts?
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inflammation of the sebaceous glands in the areola, may become tender and supporative. not the same as montgomery tubercles in pregnancy.
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What is lactation, not associated with pregnancy?
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galactorrhea. could be due to drugs, also intrinsic causes is a prolactinoma, or hypothyroidism, cushing syndrome, hypoglycemia. can also be in a dude
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Gynocomastia (bitch tits in an adolescent/young man)
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enlargement of breast tissue in boys caused by hormones, testicular or pituitary tumor, meds with estrogens or steroids
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Formation of breast tissue in a girl in the absence of other signs of sexual maturation
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thelarche
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Inflammation and infection of the breast characterized by sudden onset of swelling, tenderness, erythema, and heat
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Mastitis, seen with fever, chills, increased pulse. mostly staphylococcus aureus, common in lactating women
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What is mammary duct ectasia?
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subareolar ducts become clogged with desquamating secretory epithelium, necrotic debris, and chronic inflammatory cells. bilateral, pain, tenderness, inflammation, and nipple discharge. sticky, multicolored, and multiple ducts
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