Breastsand Axillae

Breasts and Axillae
. an imprint of Elsevier Inc.

Copyright © 2015 by Mosby,
Breasts and Axillae
 The breast examination is typically
performed:
 When the patient has a specific breast complaint
 As part of an overall annual well person
examination
 Examination of the breasts includes:
 Examination of the axillae
 Relevant lymph node chains
Copyright © 2015 by Mosby, an imprint of Elsevier Inc. 2

Breasts and Axillae (Cont.)
 Major focus of the examination in adults is
identification of breast masses, skin, or
vascular changes that could indicate
malignancy.
 In children, it is important for Tanner staging
and as part of the evaluation with hormonal
concerns.

Physical Examination Preview

Females
 Inspect with patient seated. Compare breasts
for:
 Size
 Symmetry
 Contour
 Retractions or dimpling
 Skin color and texture
 Venous patterns
 Lesions
 Supernumerary nipples

Females (Cont.)
 Inspect both areolae and nipples and
compare for:
 Shape
 Symmetry
 Color
 Smoothness
 Size
 Nipple inversion, eversion, or retraction

Females (Cont.)
 Reinspect breasts with the patient in the
following positions:
 Arms extended over head or flexed behind the
neck
 Hands pressed on hips with shoulder rolled
forward
 Seated and leaning over
 Recumbent position

Females (Cont.)
 Perform a chest wall sweep.
 Perform bimanual digital palpation.
 Palpate for lymph nodes in the axilla, down
the arm to the elbow, and in the
supraclavicular and infraclavicular areas.
 Palpate breast tissue with patient supine,
using light, medium, and deep pressure.
 Depress the nipple into the well behind the
areola.

Males
 Inspect breasts for the following:
 Symmetry
 Enlargement
 Surface characteristics

Males (Cont.)
 Inspect both areolae and nipples and
compare for:
 Shape
 Symmetry
 Color
 Smoothness
 Size

Males (Cont.)
 Palpate breasts and over areolae for lumps or
nodules.
 Palpate for lymph nodes in the axilla, down
the arm to the elbow, and in the
supraclavicular and infraclavicular areas.

Anatomy and Physiology

Copyright © 2015 by Mosby, 12
Breasts
 Paired mammary glands on anterior chest
wall, superficial to the pectoralis major and
serratus anterior muscles
 Male breast consists of:
 Small nipple and areola
 Thin layer of breast tissue

Breasts (Cont.)
 Female components
 Nipple and areola
 Glandular tissue
 Fibrous tissue
 Subcutaneous fat
 Retromammary fat

Figure 16-03. Lymphatic drainage of the breast. Nodes in bold notation are accessible to palpation.

Breasts (Cont.)
 Glandular tissue
 Fifteen to 20 lobes per breast radiate about nipple.
• Lobes are composed of 20 to 40 lobules.
 Lobules consist of milk-producing acini cells.
 Lactiferous ducts drain milk from each lobe onto
nipple surface.

Breasts (Cont.)
 Fibrous tissue
 Subcutaneous
 Provides breast support
 Suspensory ligaments (Cooper ligaments)
• Extend from the connective tissue layer through the
breast and attach to the underlying muscle fascia
providing further support

Breasts (Cont.)
 Muscles forming floor of breast
 Pectoralis major and minor
 Serratus anterior
 Latissimus dorsi
 Subscapularis
 External oblique
 Rectus abdominis

Breasts (Cont.)
 Vascular supply
 Internal mammary artery
 Lateral thoracic artery
 Subcutaneous and retromammary fat
 Supplies bulk of breast
 Varies with age, pregnancy, lactation, and genetics

Breasts (Cont.)
 Five segments (for examination purposes):
four quadrants and tail
 Upper outer quadrant: greatest amount of
glandular tissue
 Upper inner quadrant
 Lower inner quadrant
 Lower outer quadrant
 Tail of Spence

Figure 16-02. Quadrants of the left breast and axillary tail of Spence.

Breasts (Cont.)
 Nipple
 Located centrally on the breast and surrounded by
the pigmented areola
 Epithelium infiltrated with smooth muscle fibers
 Lactiferous ducts empty onto nipple
 Contraction of the smooth muscle, induced by
tactile, sensory, or autonomic stimuli, produces
erection of the nipple and causes the lactiferous
ducts to empty
 Sebaceous glands (Montgomery tubercles) on
areola

Breasts (Cont.)
 Lymphatic network
 Drains breast radially and deeply to underlying
lymphatics
 Superficial lymphatics drain skin
 Deep lymphatics drain mammary lobules
 Complex of axillary lymph nodes

Axillae
 Axillary lymph nodes
 Anterior axillary (pectoral) nodes
 Midaxillary (central) nodes
 Posterior axillary (subscapular) nodes
 Lateral axillary (brachial) nodes

Children and Adolescents
 Breast development
 Latent phase in children and preadolescence
 Thelarche (breast development) early sign of
puberty in adolescent girls
 Tanner’s five stages of developing sexual maturity
 Breasts develop at different rates in
individuals; may result in asymmetry

Tanner’s Five Stages of Breast
Development
 Tanner 1 (preadolescent)
 Only the nipple is raised above the level of the
breast, as in the child.
 Tanner 2
 Budding stage, bud-shaped elevation of the areola
 Tanner 3
 Breast and areola enlarged
 No contour separation

Tanner’s Five Stages of Breast
Development (Cont.)
 Tanner 4
 Increasing fat deposits
 Areola forms a secondary elevation above that of
the breast.
• Occurs in approximately half of all girls and in some
cases persists in adulthood
 Tanner 5 (adult stage)
 Areola is (usually) part of general breast contour
and is strongly pigmented.
 Nipple projects

Pregnant Women
 Lactiferous ducts proliferate.
 Alveoli increase in size and number.
 Breasts enlarge 2- to 3-fold.
 Colostrum is produced.
 Areolar pigment increases.
 Areolae become more erect.
 Vascularization increases.

Lactating Women
 Colostrum secreted in the first few days after
delivery
 More protein and minerals than does mature milk
 Contains antibodies and other host resistance
factors
 Milk produced 2 to 4 days after delivery
 Breasts full and tense
 Involution period over a period of
3 months after termination of lactation

Older Adults
 Decrease in glandular tissue is replaced by
fat.
 Inframammary ridge thickens.
 Breasts hang loosely.
 Result of the tissue changes and relaxation of the
suspensory ligaments
 Nipples are smaller and flatter.
 Skin may take on a relatively dry, thin texture.
 Hair decreases in axilla.

Review of Related History

History of Present Illness
 Breast discomfort
 Temporal sequence
 Relationship to menses
 Character
 Associated symptoms
 Contributory factors
 Medications: nonprescription or hormones

History of Present Illness (Cont.)
 Breast mass or lump
 Temporal sequence
 Symptoms
 Changes in lump
 Medications: nonprescription or hormones

 Nipple discharge
 Character
 Associated factors
 Medications: contraceptives, hormones,
phenothiazines, digitalis, diuretics, steroids

 Breast enlargement in men
 History of hyperthyroidism, testicular tumor,
Klinefelter syndrome
 Medications: cimetidine, omeprazole,
spironolactone, finasteride, some
antihypertensives, some antipsychotics
 Treatment for prostate cancer: androgens or
GnRH analogues
 Illicit and/or recreational drugs: anabolic steroids,
marijuana

Past Medical History
 Previous breast disease: cancer,
fibroadenomas, fibrocystic changes
 Known BRCA1 or BRCA2 mutation; other
known hereditary cancer syndromes
 Previous other related cancers: ovarian,
colorectal, endometrial
 Surgeries: breast biopsies, aspirations,
implants, reduction, plasties; oophorectomy

Past Medical History (Cont.)
 Changes in breast characteristics: pain,
tenderness, lumps, discharge, skin changes,
size or shape changes
 Changes in breast occurring with menstrual
cycle: tenderness, swelling, pain, enlarged
nodes
 Risk factors for breast cancer
 Mammogram and other breast imaging
history: frequency, date of last imaging,
results

 Menstrual history: first date of last menstrual
period, age at menarche or menopause,
cycle length, duration and amount of flow,
regularity, associated breast symptoms
(nipple discharge; pain or discomfort)

 Pregnancy: age at each pregnancy, length of
each pregnancy, date of delivery or
termination
 Lactation: number of children breast-fed;
duration of breast-feeding; date of last breast-
feeding; medications to suppress lactation

 Menopause: onset, course, associated
problems, residual problems
 Use of hormonal medications: name and
dosage, reason for use, length of time on
hormones, date of termination
 Other nonprescription or prescription
medications: tamoxifen, raloxifene

Family History
 Breast cancer: primary relatives, secondary
relatives; type of cancer; age at time of
occurrence; treatment and results; known
BRCA1, BRCA2, or other mutation
 Other cancers: ovarian, colorectal known
hereditary cancer syndromes
 Other breast disease in female and male
relatives: type of disease; age at time of
occurrence; treatment and results

Personal and Social History
 Age
 Breast support used with strenuous exercise
or sports activities
 Amount of caffeine intake; impact on breast
tissue
 Breast self-awareness/self-examination:
frequency; at what time in the menstrual cycle
 Use of alcohol; daily amounts
 Use of anabolic steroids or marijuana

Pregnant Women
 Sensations: fullness, tingling, tenderness
 Presence of colostrum and knowledge about
how to care for breasts and nipples during
pregnancy
 Use of supportive brassiere
 Knowledge and information about breast-
feeding
 Plans to breastfeed, experience, expectations

Lactating Women
 Breast cleaning procedures
 Nursing bra
 Nipples: tenderness, pain, or related
problems
 Associated problems
 Nursing routine

Lactating Women (Cont.)
 Breast milk–pumping device and frequency of
use
 Cultural beliefs about nursing
 Food and environmental agents that affect
milk
 Medications that cross milk–blood barrier
 All medications, prescription and nonprescription,
should be evaluated for potential side effects in
the newborn.

Older Adults
 Skin irritation under pendulous breasts from
tissue-to-tissue contact or from rubbing of
brassiere; treatment
 Hormone therapy during or since menopause:
name and dosage of medication; duration of
therapy

Examination and Findings

Breast Self-Examination (BSE)
 BSE remains an important tool in the
detection of breast cancer.
 Women should be told about the benefits and
limitations of BSE.
 Every woman should be familiar with her own
breasts and report any breast change to her
health care provider.

Breast Self-Examination (BSE)
(Cont.)
 The American Cancer Society recommends
BSE as an option for women beginning in
their 20s.
 As you discuss BSE, it would be an
appropriate time to review the accepted
recommendations for early breast cancer
detection and to discuss the issues related to
breast cancer screening.

Inspection
 Breasts: with patient seated and arms
hanging loosely at the sides―inspect both
breasts and compare the following:
 Size, symmetry, and contour
 Retractions or dimpling
 Skin color and texture
 Venous patterns
 Lesions
 Supernumerary nipples

Peau d’orange Appearance
 Peau d’orange appearance indicates edema
of the breast caused by blocked lymph
drainage.

Figure 16-05. Peau d'orange appearance from edema. (From Gallager, 1978.)

Inspection (Cont.)
 Inspect both areolae and nipples, compare
for the following:
 Shape
 Symmetry
 Color
 Smoothness
 Size

Variations in Breast Size and
Contour
Figure 16-04. Variations in breast size and contour. A, Conical. B, Convex. C, Pendulous. D, Large
pendulous. E, Right larger than left.

Inspection (Cont.)
 Nipple and areola—The 5 D’s
 Discharge
 Depression or inversion
 Discoloration
 Dermatologic changes
 Deviation

Figure 16-6. Montgomery tubercles. A, Light-skinned woman. B, Dark-skinned woman. (A, from Mansel and
Bundred, 1995.)

Figure 16-07. A, Left nipple inverted; right nipple everted. B, Close-up of nipple inversion. (From Lemmi and
Lemmi, 2000.)

Variations in Areola Color
Nipple retraction
Figure 16-09. Variations in color of areola. A, Pink. B, Brown. C, Black.

Figure 16-08. Nipple retraction laterally and swelling behind right nipple in Asian woman with breast cancer.
(From Mansel and Bundred, 1995.)

Inspection (Cont.)
 Reinspect breasts in varied positions.
 Arms extended over head or flexed behind neck
 Hands pressed on hips with shoulder rolled
forward
 Seated and leaning forward from waist

Figure 16-12. Inspect the breasts in the following positions. A, Arms extended overhead. B, Hands pressed
against hips. C, Pressing hands together (an alternative way to flex the pectoral muscles). D, Leaning forward
from the waist.

Palpation
 Patient in seated position
 Chest wall sweep
 Nodes should not be palpable

Figure 16-13. Chest wall Sweep. With the palm of your hand, sweep from the clavicle to the nipple, covering
the area from the sternum to the midaxillary line.

Figure 16-15. Palpation of the axilla for lymph nodes.

Palpation (Cont.)
 Palpation of the axillae and infraclavicular areas
 Nodes should not be palpable

Palpation (Cont.)
 Bimanual digital palpation
 Lymph node palpation

Figure 16-14. Bimanual digital palpation. Walk your fingers across the breast tissue, compressing it between
your fingers and the palmar surface of your other hand.

Palpation (Cont.)
 Patient in supine position
 All areas of breast tissue for lumps or nodules
 If a breast mass is felt, note characteristics and
palpate its dimensions, consistency, and mobility.

Figure 16-16. Supine position for palpation.

Palpation (Cont.)
 Document masses found.
 Location
 Size and shape
 Consistency
 Tenderness
 Mobility
 Borders
 Retraction

Palpation (Cont.)
 Tail of Spence
 Both axillae
 Masses
 Nipples
 Depression into well behind the areola
 Discharge (if present)
 Note if spontaneous, unilateral, from a single duct

Palpation (Cont.)
Various methods for palpation
Palpating for
consistency

Figure 16-18. A, Palpating for consistency of a breast lesion. B, Palpating for delineation of borders of breast
mass. C, Palpating for mobility of breast mass.

Supernumerary Nipples
Figure 16-10. Supernumerary nipples and tissue may arise along the “milk line,” an embryonic ridge. (From
Thompson et al, 1997.)

Figure 16-11. A, Supernumerary nipple without glandular tissue. B, Supernumerary breast and nipple on left
side and supernumerary nipple alone on right side. (B, From Mansel and Bundred, 1995.)

Palpation (Cont.)
 Males
 Expect to feel a thin layer of fatty tissue overlying
muscle.
 Obese men may have a somewhat thicker fatty
layer, giving the appearance of breast
enlargement.
 Firm disk of glandular tissue can be felt in some
men.

Infants
 Breasts of many well newborns, male and
female, are enlarged for a relatively brief
time.
 Result of passively transferred maternal estrogen
 Small amount of clear or milky white fluid,
commonly called “witch’s milk,” is sometimes
expressed.
 Breast enlargement usually disappears within
2 weeks, and rarely lasts beyond 3 months of
age.

Adolescents
 The right and left breasts of the adolescent
female may not develop at the same rate.
 Reassurance
 Breast tissue of the adolescent female feels
homogeneous, dense, firm, and elastic.
 Start BSE early.
 Provides opportunity for reassurance and
education

Adolescents (Cont.)
 Transient unilateral or bilateral subareolar
masses in males
 Firm, sometimes tender, and often a source of
great concern to the patient and his parents
 Disappear, usually within a year
 Gynecomastia in males
 Unusual and unexpected enlargement that is
readily noticeable
 Usually temporary and benign and resolves
spontaneously

Pregnant Women
 Inspection
 Increase in size
 Tenderness and tingling
 Enlarged erect nipples
 Vascular spiders and striae
 Palpation
 Colostrum
 Coarse nodularity of breast tissue
 Dilated subcutaneous veins

Lactating Women
 Palpate breasts.
 Engorgement
 Clogged milk ducts
 Examine nipples.
 Irritation or blisters
 Petechiae
 Cracking

Older Adults
 Inspection
 Elongation or flattening
 Hanging tissue
 Smaller nipple size
 Palpation
 Fine granular glandular tissue
 Thickened inframammary ridge
 Fluid-filled cysts

Abnormalities

Breasts
 Galactorrhea
 Lactation not associated with childbearing

Figure 16-25. Galactorrhea produced by a prolactin-secreting pituitary tumor. (From Mansel and Bundred,
1995.)

Breasts (Cont.)
 Paget disease
 Surface manifestation of underlying ductal cancer

Figure 16-26. Paget disease. (Callen et al, 2000.)

Breasts (Cont.)
 Mastitis
 Inflammation and infection of the breast tissue

Figure 16-27. Mastitis. (From Lemmi and Lemmi, 2000.)

Breasts (Cont.)
 Gynecomastia
 Breast enlargement
in men
Prepubertal gynecomastia

Figure 16-28. Adult gynecomastia. (From Mansel and Bundred, 1995.)

Figure 16-29. Prepubertal gynecomastia, small and subareolar. (Courtesy Wellington Hung, MD; Children's
National Medical Center; Washington, DC.)

Breast Lumps
 Fibrocystic changes
 Benign fluid-filled cyst formation caused by ductal
enlargement
 Fibroadenoma
 Benign tumors composed of stromal and epithelial
elements that represent a hyperplastic or
proliferative process in a single terminal ductal unit

Breast Lumps (Cont.)
 Malignant breast tumors
 Ductal cancer arises from the epithelial lining of
ducts
 Lobular cancer originates in the glandular tissue of
the lobules

Figure 16-23. A, Patient with lump and nipple retraction in left breast. B, Patient with altered nipple height
resulting from breast cancer in left breast. (From Mansel and Bundred, 1995.)

Breast Lumps (Cont.)
 Fat necrosis
 Benign breast lump that occurs as an
inflammatory response to local injury

Figure 16-24. Fat necrosis presenting as a hard mass in the breast following an episode of trauma sufficient to
cause bruising. (From Mansel and Bundred, 1995.)

Nipples and Areolae
 Intraductal papillomas and papillomatosis
 Benign tumors of the subareolar ducts produce
nipple discharge
 Duct ectasia
 Benign condition of the subareolar ducts that
produces nipple discharge

Children
 Premature thelarche
 Breast enlargement in girls before onset of puberty
 Cause unknown
 Breasts continue to enlarge slowly throughout
childhood until full development reached during
adolescence

Question 1
The greatest amount of glandular tissue of the
breast lies in which of the following:
A. Tail of Spence
B. Upper outer quadrant
C. Lower outer quadrant
D. Lower inner quadrant

Question 2
Inspection of the breasts usually begins with the
patient in which position?
A. Lateral
B. Sitting
C. Standing
D. Supine

Question 3
The anterior axillary lymph nodes would best be
palpated at the:
A. Lateral axillary fold

B. Anterior axillary fold
C. Axilla close to the ribs
D. Posterior axillary fold

Question 4
A peppering of nontender, nonsuppurative
Montgomery tubercles is considered to be a:
A. Normal finding
B. Sign of cancer
C. Skin disease
D. Symptom of malnutrition

Breastsand Axillae

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Figure 16-09. Variations in color of areola. A, Pink. B, Brown. C, Black.

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