Chapter Nineteen Breasts and regional lymphatics

ANATOMY

The breasts lie anterior to the pectoralis major and serratus anterior muscles, between the second and sixth ribs. The upper outer corner of breast tissue, called the axillary tail of Spence, projects up and laterally into the axilla.

Externally, the nipple is just below the centre of the breast. It is rough, round and usually protuberant; its surface looks wrinkled and indented with tiny milk duct openings. The areola surrounds the nipple for a 1 to 2 cm radius. In the areola are small elevated sebaceous glands, called Montgomery’s glands. These secrete a protective lipid material during lactation. The areola also has smooth muscle fibres that cause nipple erection when stimulated (Fig 19.1).

Figure 19.1 Breast anatomy (A).

The male breast is a rudimentary structure consisting of a thin disk of undeveloped tissue underlying the nipple. The female breast is composed of (1) glandular tissue, containing 15 to 20 lobes radiating from the nipple, which are composed of lobules (clusters of alveoli that produce milk), which empty into a lactiferous ducts converging toward the nipple; (2) the suspensory ligaments, or Cooper’s ligaments, are fibrous bands extending vertically from the surface to the chest wall muscles supporting the breast and (3) the adipose, or fatty tissue which provides most of the bulk of the breast (Fig 19.2). The relative proportion of glandular, fibrous and fatty tissue varies depending on age, menstrual cycle, pregnancy, lactation and general nutritional state.

Figure 19.2 Breast anatomy (B).

The breast may be divided into four quadrants by imaginary horizontal and vertical lines intersecting at the nipple. This makes a convenient map to describe clinical findings: upper outer, lower outer, lower inner and upper inner quadrants (Fig 19.3).

Figure 19.3 Breast quadrants.

LYMPHATICS

The breast has an extensive lymphatic drainage system comprised of: (1) central axillary nodes high up in the middle of the axillae that receive lymph from the three other groups of axillary nodes; (2) pectoral nodes along the lateral edge of the pectoralis major muscle; (3) subscapular nodes along the lateral edge of the scapula and (4) lateral nodes along the humerus, inside the upper arm. From the central axillary nodes, drainage flows up to the infraclavicular and supraclavicular nodes (Fig 19.4).

Figure 19.4 Breast lymphatics.

DEVELOPMENTAL CONSIDERATIONS

The adolescent

During adolescence, it is common for the male’s breast tissue to temporarily enlarge, producing gynaecomastia. This condition is usually unilateral and temporary. Reassurance is necessary for the adolescent male, whose attention is riveted on his body image.

At puberty the oestrogen hormones stimulate breast changes in the female. The breasts enlarge, mostly as a result of extensive fat deposition. The duct system also grows and branches and masses of small, solid cells develop at the duct endings. These are potential alveoli.

Ethnicity and genetic correlates of race appear to be important factors affecting the onset of puberty (Butts and Seifer, 2010). Occasionally, one breast may grow faster than the other, producing a temporary asymmetry. This may cause some distress; reassurance is necessary. Tenderness is also common due the influence of reproductive hormones, particularly oestrogen.

The pregnant female

During pregnancy, breast changes start during the second month. Pregnancy stimulates the expansion of the ductal system and supporting fatty tissue as well as development of the true secretory alveoli. Thus the breasts enlarge and feel more nodular. The nipples are larger, darker and more erectile. The areolae become larger and grow a darker brown as pregnancy progresses. After the fourth month, colostrum may be expressed. This thick yellow fluid is the precursor for milk. The breasts produce colostrum for the first few days after delivery. It is rich with antibodies that protect the newborn against infection. Milk production (lactation) begins 1 to 3 days postpartum.

Late adulthood (65+ years)

Gynaecomastia may reappear in the male over 65 years and may be due to testosterone deficiency.

After menopause, the female’s ovarian secretion of oestrogen and progesterone decreases, which causes the breast glandular tissue to atrophy. This is replaced with fibrous connective tissue. These changes decrease breast size and elasticity so the breasts droop and sag. The decreased breast size makes inner structures more prominent. A breast lump may have been present for years but is suddenly palpable.

CULTURAL AND SOCIAL CONSIDERATIONS

Breast cancer is the most common cancer that occurs in Australian and New Zealand women. The risk of developing breast cancer to age 85 years is 1 in 9 for Australian women and 1 in 767 Australian men (Australian Institute of Health and Welfare (AIHW), 2008). There are similar rates of breast cancer in New Zealand (New Zealand Ministry of Health, 2009).

The incidence of breast cancer varies with different cultural groups. Although the incidence of breast cancer is significantly lower in Indigenous Australian women than in non-Indigenous Australian women; Indigenous Australian women have significantly lower 5-year crude survival rates (65% and 82% crude survival, respectively) (AIHW and National Breast and Ovarian Cancer Centre (NBOCC*), 2009). In New Zealand, although breast cancer occurs with equal frequency in Māori and non-Māori women, Māori women are nearly twice as likely to die from the disease as non-Māori women, mainly because they tend to present with late stage breast cancer at the time of diagnosis (Cancer Control Council of NZ, 2008).

Breast checks

Breast checks are about women taking the time to get to know the normal look and feel of their breasts. Technique of checking is not important. Knowing what is normal will help detect any changes for investigation. Women can be educated to undertake breast checks during routine daily activities such as showering, dressing, putting on body lotion or simply looking in the mirror. Nine out of 10 breast changes are not due to cancer, but should be investigated. (See http://www.nbocc.org.au/breast-cancer/awareness/).

Cancer Australia’s guide about risk factors for breast cancer provides a review of epidemiological studies about risk factors for breast cancer. The risk factors are graded according to their relative risk (RR). Modest RR factors are graded between 1.25 and 1.99. Moderate RR are graded as 2.00–3.99. Strong RR is graded as 4+ and factors which are potentially protective as RR<0.8 (NBOCC*, 2009).

TABLE 19.1 Breast cancer risk factors

SUBJECTIVE DATA

Because of the physiological relationship between the breasts and lymph glands, any assessment of a woman’s breast must include an assessment of the axillary lymph glands.

Assessment components

Breast

1. Pain

2. Lump

3. Nipple discharge

4. Rash

5. Swelling

6. Trauma

7. History of breast disease (including familial history)

8. Surgical history (breast, chest, axilla, thorax)

9. Self-care behaviours (breast check practices and date of last mammogram)

Axilla

1. Tenderness, lump or swelling of the axilla or arm

2. Rash

OBJECTIVE DATA

Preparation	Equipment needed
The woman is sitting up, facing you. Maintain privacy by only exposing the breasts, axilla and arm upper. During palpation, the woman is supine with her arm positioned above her head; cover one breast with the gown while examining the other. Your examination of the male breast can be much more abbreviated, but do not omit.	Small pillow Ruler marked in centimetres

Procedures and normal findings	Abnormal findings and clinical alerts
Inspect the breasts
Note symmetry of size and shape (common to have a slight asymmetry in size).	A sudden increase in size of one breast may signify trauma, inflammation, infection or neoplasm.
The skin is normally smooth and of even colour with no redness, bulging, dimpling, skin lesions or focal vascular pattern. A fine blue vascular network is normally visible in lightly pigmented females during pregnancy. Pale linear striae, or stretch marks, often follow pregnancy.	Oedema exaggerates the hair follicles, giving a ‘pigskin’ or ‘orange peel’ look (also called peau d’orange). Hyperpigmentation. Redness and heat with inflammation. Unilateral dilated superficial veins in a non-pregnant woman.
The nipples should be symmetrically located and usually protrude, although some are flat and some inverted. Distinguish a recently retracted nipple from one that has been inverted for many years or since puberty.	Deviation in pointing. Recent nipple retraction signifies acquired disease. (See Table 27.3, JF&W.)
Note any dry scaling, any fissure or ulceration and bleeding or other discharge from the nipple. Normally, there are none.	Any discharge must be explored.
A normal variation in about 1 per cent of men and women is supernumerary nipple, a congenital finding. Usually, it is 5 to 6 cm below the breast near the midline and looks like a mole, although a close look reveals a tiny nipple and areola. It is not significant.	Rarely, additional glandular tissue called a supernumerary breast is present.
Manoeuvres to screen for skin retraction
First ask the woman to lift arms slowly over her head. Both breasts should move up symmetrically.	Note a lag in movement of one breast. Retraction signs are due to fibrosis in the breast tissue, usually caused by growing neoplasms.
Next ask her to put her hands onto her hips and push, and then to push her two palms together. There will be a slight lifting of both breasts.	Note a dimpling or a pucker that indicates skin retraction. (See Table 27.3, JF&W.)
Ask the woman with large pendulous breasts to lean forwards while you support her forearms. Note the symmetrical free forwards movements of both breasts.	Note fixation to the chest wall or skin retraction.
Inspect and palpate the axilla
The axillary and supraclavicular regions have no bulging, discolouration or oedema. Inspect the skin, noting any rash or infection.
Lift the woman’s arm and support it yourself so that her muscles are loose and relaxed. Reach your fingers high into the axilla and move them firmly down in four directions; (1) mid axilla, (2) anterior axilla, (3) posterior axilla, (4) inner aspect of the upper arm. Usually nodes are not palpable, although you may feel a small, soft, nontender node in the central group. Expect some tenderness when palpating high in the axilla.	Nodes may enlarge with any local infection of the breast, arm, or hand and with breast cancer metastases.
Palpate the breasts
Help the woman into a supine position. Tuck a small pillow under the side to be palpated and raise her arm over her head to flatten the breast tissue and displace it medially. Use the pads of your first three fingers and make a gentle rotary motion on the breast. Vary your pressure so you are palpating light, medium and deep tissue in each location. Start high in the axilla and palpate down just lateral to the breast. Proceed in overlapping vertical lines ending at the sterna edge. After palpating the four breast quadrants and the tail of Spence high in the axilla, palpate the nipple.
In nulliparous women, normal breast tissue feels firm, smooth and elastic. After pregnancy, the tissue feels softer and looser. Premenstrual engorgement is normal due to increasing progesterone and consists of a slight enlargement, tenderness on palpation and a generalised nodularity; the lobes feel prominent and their margins are more distinct.	Heat, redness and swelling in non-lactating and non-postpartum breasts may indicate inflammation. If you feel a lump or mass, note these characteristics:
A firm transverse ridge of compressed tissue in the lower quadrants, the inframammary ridge, is especially noticeable in large breasts. Do not confuse it with an abnormal lump. For a woman with large pendulous breasts, you may palpate by using a bimanual technique. Support the inferior part of the breast with one hand, using your other hand to palpate the breast tissue against your supporting hand.	• Location—Diagram the breast in the woman’s record, divided into 4 quadrants, and mark the location of the lump • Size—In centimetres: width × length × thickness • Shape—Oval, round, lobulated or indistinct • Consistency—Soft, firm or hard • Moveable—Freely moveable or fixed • Distinctness—Solitary or multiple • Nipple—Displaced or retracted • Skin over the lump—Erythematous, dimpled or retracted • Tenderness—To palpation Lymphadenopathy Abnormal findings may indicate breast cancer (biopsy would be required to diagnose malignancy) or benign breast disease which is divided into 6 categories:
	1 Swelling and tenderness 2 Mastalgia (severe pain) 3 Nodularity (significant lumpiness) 4 Dominant lumps (including cysts and fibroadenomas) 5 Nipple discharge 6 Infection/inflammation (See Tables 27.4 and 27.5, JF&W.)

Summary checklist

1. Inspect the breasts

2. Inspect and palpate the axilla

3. Palpate the breasts

4. Discuss breast awareness