Chapter 18: Breasts, Axillae, and Regional Lymphatics
Breasts: made up of glandular tissue, fibrous tissue (including suspensory ligaments) and
adipose tissue
● Glandular tissue: contains 15-20 lobes radiating from the nipple and these are
composed of lobules that empty into a lactiferous duct (for milk)
● Fibrous tissue: includes suspensory ligaments or Cooper ligaments that extend
vertically from skin surface to attach on chest wall muscles
● Adipose tissue: subcutaneous and retromammary fat that provide most of the bulk of the
breast
● Four quadrants
○ Upper, outer quadrant is the site of most breast tumors
○ Axillary tail of spence: cone shaped breast tissue that projects up into the
axilla, close to the pectoral group of axillary nodes
○ Upper outer quadrant most likely to get tumors
○
Nipple: surrounded by areola for a 1-
2m radius
● Montgomery glass: small, elevated, sebaceous glands in the areola that secrete a
protective lipid material during lactation
Lymphatics: the breast has extensive lymphatic drainage, 75% drains into the ipsilateral (same
side) nodes so if there is an infection the same side nodes would enlarge
● Four groups of axillary nodes
○ Pectoral: lower middle of outer breast, anterior axillary
○ Subscapular: posterior axillary
○ Central: central axillary, where armpit creases, over ribs
○ Lateral: upper axillary, along humerus inside
the upper arm Developmental competence
● Birth: the only breast structure present are the lactiferous ducts within the nipple;
nipple is inverted, flat, and rises above the skin during childhood
○ Supernumerary nipple: extra niple along mammery ridge, insignificant finding
● Adolescence: breast development usually begins around 8-10 years of age
○ Overweight girls have higher occurrence of early onset breast development
(before 8 for AA, 10 for white), and early menarche
○ Breast development precedes menarche by approx 2 years, full development
, takes an average of 3 years but can be 1.5-6 years
○ One breast may grow faster, producing temporary asymmetry; reassure them that
this is normal
○ Tenderness is common
○ Development: 5 stages
■ Preadolescent: small, elevated nipple
■ Breast bud: small mount of breast and nipple develops, areola widens
● Mean onset 8.8 yrs for AA, Hispanic 9.2 yrs, Caucasian 9.6 yrs, Asians
9.9 yrs
● Higher BMI = earlier budding
■ 3: breast and areola enlarge, nipple flush with breast
■ 4: secondary mounds of areola and nipple
■ 5: mature, only nipple protrudes, areola is flush
● Non-pregnant women: different breast sizes by as much as 1 cup is normal unless the
change is sudden growth
○ Larger breast is usually left. Nurse should verify asymmetry is new
○ Breast size changes with flow of hormones
■ 3-4 days before menstruation breasts feel full, tight, heavy, sore
, ■ Day 4-7 of menstrual cycle is when breasts are smallest
● Pregnant women: ductal expansion and supporting fatty tissue expands; breasts
enlarge and feel more nodular; development of true secretory alveoli
○ Areola becomes larger and grows darker brown as pregnancy progresses,
tubercle becomes more prominent; brown color fades after lactation but
they never return to the original color
○ Venous pattern is prominent over the skin surface
○ Colostrum: thick yellow fluid that is the precursor for milk, can appear after 4th
month of pregnancy; same amount of protein and lactose but practically no fat
■ Rich with antibodies that protect the newborn against infection,
breastfeeding important
■ Produced 1st few days after delivery
● Aging women: hormonal changes of menopause cause glandular tissue to
atrophy making breasts more pendulous, flattened, flabby, and saggy making
inner structures more prominent
○ After menopause glandular tissue is replaced with fibrous connective tissue
○ Fat envelope also atrophies beginning in middle years and becoming significant in
the 70s and 80s
○ Axillary hair decreases
● Men
○ During adolescence the tissue may enlarge temporarily producing gynecomastia;
may reappear in aging men and may be the result of testosterone deficiency
○ Gynecomastia can also appear from the use of anabolic steroids, alcohol,
marijuana use, estrogen treatment for prostate cancer, antibiotics
(metronidazole and isoniazid), digoxin, ACE inhibitors, diazepam, TCAs,
cushing’s, liver cirrhosis, adrenal disease, and hypothyroidism
Culture and genetics
● Breast cancer
○ Incidence and survival varies by group, stage at diagnosis
■ Asian and pacific islanders have highest survival rates
■ Hispanic women have the lowest rate
■ Black and hispanic women have lower screening and utilization compared to
white women
○ BRCA1 and 2
■ BRCA1: 72% chance of breast cancer, 44% ovarian
■ BRCA2: 69% chance of breast cancer, 17% ovarian
■ Ashkenazi jewish women have a higher BRCA1 and 2 prevalence
○ 5 year survival
■ 83% black women: tend to be diagnosed at later stages, higher rates
of aggressive, triple negative breast cancer
■ 92% white women
○ Other important factors: low income, low education levels, unemployment,
pain, embarrassment, lack of insurance, residence area, weight (1.5x
overweight, 2x obese), smoking, etc
○ Reduce risk: regular activity lowers risk by 10-20%, high levels of fruit and
veggies can lower risk Subjective data
● Pain: mastalgia occurs with trauma, infection, and benign breast disease
○ Cyclic pain is common with normal breasts, oral contraceptives, and
benign breast disease (fibrocystic)
● Lump: examine unaffected breast first to learn a baseline of normal consistency for
this individual
○ Lumps that have been present for years and have not changed may not be
serious but should still be explored
, ○ Any new lump should be evaluated with suspicion
● Discharge:
○ if any, ask
■ When they first noticed it
■ Color of discharge, consistency, odor
○ Galactorrhea: discharge from breast or nipple
■ oral contraceptives, phenothiazines, diuretics, digitalis, steroids,
methyldopa, calcium channel blockers may cause clear nipple
discharge
○ Bloody or blood tinged is significant especially with presence of lumps
● Rash: location where it first appeared is determined
○ Ask where it started (nipple, areola, skin)
○ Paget disease: starts with small crust on nipple apex and spreads to areola
○ Eczema or other dermatitis rarely starts at nipple unless it is caused by
breastfeeding, usually start on areola or surrounding skin and spread to
nipple
● History of breast cancer
○ Presence of benign disease makes it hard to examine breasts, lumpiness can
conceal new lumps
○ Past breast cancer can increase risk; ask what type, how it was diagnosed,
when it occurred, how
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