Definitions, Structure and FunctionChapters 14,20,21,&22

Key DefinitionsGynecomastia: abnormal enlargement of one

or two breasts in men.Supernumerary breast: extra breast tissue,

sometimes with a nipple.Dysmenorrhea: painful menstrationDyspareunia: painful intercourseGravida: # of pregnancies regardless of

outcome.Parity: # of deliveries, regardless of outcome.Menarche: age at which menstruation begins.

Key DefinitionsMenopause: age at which menstruation

ends.Puberty: secondary sexual characteristics

appear, reproductive ability develops.Androgens: male sex hormones.Circumcision: surgical removal of the

prepuce (foreskin)Phimosis: abnormal tightness of the

prepuce.Hypospadias: opening of the urethral

meatus on ventral surface of the penis.

Structure and Function

Surface AnatomyLie anterior to the pectoralis major & serratus ant. mus.Between the second and sixth ribsFrom lateral side of sternum to the midaxillary line.Tail of Spence: projects up and laterally into the axilla.Nipple is located below the center of the breast (milk

duct openings)Areola: surrounds the nipple, contains small elevated

sebaceous glands called “Montgomery’s glands/tubercles ” (secrete protective lipid material during lactation). 2.5-10 cm in diameter

One breast may be slightly larger than the other, this is One breast may be slightly larger than the other, this is normal.normal.

Quadrants of Left BreastBreast may be

divided into 4 quadrantsUIQLIQLOQUOQ extends into

axilla note Tail of Spence

Internal AnatomyThe breast is composed of:1. Glandular tissue2. Fibrous tissue including suspensory ligaments (Cooper’s

Ligament) provide support for breast tissue. In Cancer these become contracted and cause dimpling.

3. Adipose tissue (fat)4. Breasts are supported by a bed of muscles:

1. Pectoralis major & minor2. Latissimus dorsi3. Serratus anterior4. Rectus abdominus5. External oblique

15-20 lobes15-20 lobesEach with 20-40Each with 20-40Lobules (contain alveoli)Lobules (contain alveoli)Each empties intoEach empties intoLactiferous dusts to Lactiferous dusts to Lactiferous sinuses.Lactiferous sinuses.(reservoir behind nipple)(reservoir behind nipple)

Milk LineEctodermal Galactic BandDevelops during 5th week

of fetal devmtMost of the band

atrophies except in the thoracic area

Incomplete atrophy results in the development of extra nipples known as supernumerary nipples

Lymphatic DrainageThe breast has extensive lymphatic drainage.More than 75% drain into the ipsilateral axillary nodes.Central axillary nodes, pectoral, subscapular and lateral

nodes.Internal mammary nodes

****

**

**

Sm group flow up into infraclavicular, chest, abdomen or across to breastSm group flow up into infraclavicular, chest, abdomen or across to breast

Developmental ConsiderationsDiagram of breast development-note changes p 416

at puberty - breast development begins between ages 8 & 10 – stimulated by estrogen release during puberty- with the appearance of breast buds - onset of menses usually follows in 2-3 years – asymmetry in breast development is not abnormal.

during pregnancy and lactation - enlarge several times normal size, colostrum after the fourth month

maturity - after menopause - as estrogen secretion declines the tissue atrophies and is replaced with fatty deposits - reduction in breast size results - breasts become flabbier and hang more loosely from the chest wall as the ligaments relax

Male BreastDuring adolescence, temporary enlargement is common

(gynecomastia)UnilateralProvide reassuranceGynecomastia reappears in the aging male and may be

due to testosterone deficiency.

Health HistoryPatient profile

AgeGenderRace

Common chief complaintsBreast mass, tenderness, dischargeAssess characteristics

Location Quality Quantity Associated manifestations Aggravating factors Alleviating factors Timing

Health HistoryPast health history

MedicalBreast specific vs. nonbreast specificSurgicalMedicationsAllergiesInjuries and accidents

Family historyBreast cancerBenign breast disease

Health History

Social historyAlcohol useTobacco useWork environmentHome environmentEconomic statusEthnic background

Health maintenance activitiesDietExerciseUse of safety devicesHealth check-upsMonthly breast self-

examMammogram

EquipmentTowel, drape, centimeter ruler, teaching aid for breast self-exam

General approachInspectionPatient positions

Subjective DataBreast Pain Lump Discharge Rash Swelling Trauma Hx of breast disease Surgery

Breast self-exam, mammogram

Axilla Tenderness Lump or swelling rash

AssessmentInspect specific areas

BreastsAxillaeAreolar areasNipplesContour (see pg 422 for illustrations)Lesions or massesExudates

AssessmentNormal Findings for Inspection:

Breast and axillae are flesh coloredAreolar areas and nipples are darker in pigmentationMoles and nevi are normal variantsNo thickening or edemaMinor size variation in the breasts and areolar areasBreast on dominant side usually is largerNipples should point upward and laterally, may point outward

& downwardBreasts, areolar areas, nipples should be symmetricalBreasts are convex, without flattening, retractions, or dimplingFree from masses, tumors, primary or secondary lesionsNo discharge from nipples in nonpregnant, nonlactating

female

PalpationSequential mannerSupraclavicular and infraclavicular nodesBreasts with arms at side, arms raised over

headAxillary lymph node regionBreasts with pt in supine position

Palpationwhile sittingPalpate Supraclavicular & Infraclavcicular lymph nodes

Bimanual palpation while sitting

Palpation of Axillary Nodes while sitting

Palpation while supine

Palpation Methods-Wedge-Concentric lines-Parallel lines

Palpation of Glandular tissue

Palpation of Areola

Palpation of Nipple

Normal Findings for PalpationPalpable lymph nodes less than 1 cm in diameter

usually are clinically insignificantPalpation should not elicit painConsistency of breast tissue is highly variable

depending on age, time in menstrual cycle, and proportion of adipose tissue

Breasts are usually nodular or granular before menses

Variation with breast augmentation—breasts feel firm throughout

Evaluation of Breast Mass Characteristics

LocationSizeShapeNumberConsistency

DefinitionMobilityTendernessErythemaDimpling or retractionLymphadenopathy

P. 429

Risk Factors for Breast CancerAge > 50 Personal history of breast cancerMother, grandmother, or sister with breast

cancerMenarche at an early ageMenopause at advanced ageObesityAlcohol intake > 3 servings per dayAmerican or European descentUrban dweller

(continues)

Risk Factors for Breast CancerEstrogen replacement therapy (ERT),

Hormone (HRT)NulliparousFirst birth after age 30Higher education and socioeconomic statusAtypical hyperplasiaSignificant mammographic breast density

(indicates a grter amt of glandular tissue)BRCA 1 or BRCA 2 gene mutation

Jarvis p.416Jarvis p.416

•Mutation of BRCA1 Mutation of BRCA1 and BRCA2 genesand BRCA2 genes

•Previous positive Previous positive breast biopsy or breast biopsy or irrradiationirrradiation

•Menopause after Menopause after 50s50s

•White raceWhite race

•Long term use of Long term use of HRTHRT

•No breast feedingNo breast feeding

•Physical inactivity Physical inactivity

Breast CancerSecond major cause of death from cancer in womenidentify risk factors70% of breast cancers occur with only age and gender as

identifiable risk.5 year survival rate for localized breast cancer is 98%.If cancer has spread regionally, the rate is 76 to 88%.

Breast Self-ExamVideo in labSee handout last pagesTeach during palpation stage of assessmentCheck for dimpling, retraction, breast flattening,

dischargeAlso report redness, inflammation, masses, puckering,

sunken areas, asymmetrical nipples direction, bleeding, lesions

Benign Breast Disease

•Cyclic Swelling•Pain, cyclic: non-cyclic•Nodularity, cyclic: non-cyclic bilaterallymobile, feel rubbery like water balloons•Dominant lumps•Nipple discharge•Infections/inflammations

50% have some form of benign breastDisease.Rule out cancer with biopsySometimes difficult to detect cancer lumps

Cancer

•Solitary, unilateral non-tender mass•Single focus (one area)•Solid, hard, dense and fixed to tissues or skin as cancer becomesinvasive•Borders irregular and poorly delineated•Grows constantly•May have pain or be painless•Most common in upper outer quadrant

30-80 yrsAdvanced cancer=firm or hard irregularaxillary nodesskin dimpling, nipple retraction, elevationand dischargeDiagnosed by biopsy

Fibroadenoma

•Solitary non-tender mass•Category of benign breast disease•Solid, firm, rubbery, and elastic•Round, oval, or lobulated•1 to 5 cm•Freely movable, slippery

Most common between 15 to 30Up to age 55Grows quickly and constantlyDiagnosed by biopsy

Diagnostic TechniquesMammographyX rayUltrasonographyMagnetic resonance imaging

Gerontological VariationsBreast tissue atrophiesDecreased glandular tissue,

resulting in granular feelBreasts become smaller,

pendulous, and wrinkledDuctal tissue becomes more

palpable; feels stringy

Breast Self-Examination (BSE)Performed once a monthPerformed on a fixed date each month, or 8

days after mensesAvoid completing during menstruation or

ovulationUse calendar for monthly reminderInclude significant other in examination

process

Breast Self-Examination (BSE)Bed (B): Supine position

Use palmar surface of fingersPlace right arm over head and palpate

right breastMove in concentric circles from the periphery

inwardSqueeze the nipple to examine for dischargeUse same procedure to check left breast

Breast Self-Examination (BSE)Standing (S)

Repeat previous process in standing positionStand before mirror, arms at sideAssess for symmetry, retractions, dimpling,

inverted nipples, or nipple deviationRepeat with arms above headRepeat with hands pressed into hips

Lying Down & Standing BSE