The Breast and Regional Lymphatics

Breast Anatomy

The breast is a complex structure composed of glandular, adipose, and connective tissues, and is supported by muscles and lymphatic drainage. Understanding its anatomy is essential for clinical assessment and health promotion.

• Key Structures:

  • Axillary tail of Spence: Extension of breast tissue into the axilla, important for assessment.

  • Adipose tissue: Provides shape and protection.

  • Areola and nipple: Central features, contain Montgomery's glands.

  • Muscles: Pectoralis major and serratus anterior support the breast.

• Quadrants: The breast is divided into four quadrants (upper/lower, inner/outer) for clinical localization of findings.

Health History and Risk Factors

Collecting a thorough health history is crucial for identifying potential breast issues and risk factors for disease.

• Symptoms:

  • Pain (mastalgia)

  • Lump

  • Discharge

  • Rash

  • Swelling

  • Trauma

• History:

  • Previous breast disease or surgery

  • Self-care behaviors (e.g., breast self-exam)

  • Axilla (armpit) symptoms

• Developmental Considerations:

  • Preadolescent: Breast changes

  • Pregnant: Changes, breastfeeding

  • Menopausal: Changes

• Risk Factors: Family history, age, hormonal factors, lifestyle

Physical Assessment of the Breast

Physical assessment includes inspection and palpation to detect abnormalities and ensure breast health.

• Inspection:

  • Skin changes (orange-peel, prominent venous pattern)

  • Lymphatic drainage areas

  • Nipple and areola (discharge, color, retraction)

  • Axillae

• Palpation:

  • Support arm and move through range of motion

  • Use 3 finger pads with rotary motion

  • Palpate every inch of breast and tail of Spence

  • Apply light, medium, and firm pressure

  • Bimanual technique for large breasts

• Palpation Patterns:

  • Grid pattern

  • Spokes of wheel

  • Circular pattern

• Masses:

  • Note location, size, shape, distinctness, consistency, mobility, tenderness, lymphadenopathy

• Nipples:

  • Induration, mass under areola, discharge, color

  • Retraction or deviation

Common Breast Findings

Several findings may be observed during breast assessment, some of which require further investigation.

• Supernumerary Nipple: Extra nipple along the embryonic milk line.

• Edema (Peau d’Orange): Skin appears like an orange peel, often due to lymphatic obstruction.

• Retraction: Nipple or skin pulled inward, may indicate underlying mass.

• Induration: Hardening of tissue under the areola.

• Discharge: Color and consistency should be noted.

• Mastectomy Site: Assess scar and remaining tissue for recurrence or complications.

Male Breast Assessment

Male breast assessment is similar to female, with attention to gynecomastia (enlargement) and other abnormalities.

• Gynecomastia: Benign enlargement of male breast tissue, often due to hormonal changes.

• Inspection and Palpation: As with female breast, check for masses, tenderness, and skin changes.

Developmental Considerations

Breast development and changes occur throughout life, influenced by hormonal and physiological factors.

• Infants & Children:

  • Enlargement due to maternal estrogen

  • Witch’s milk: Temporary milk secretion

• Adolescents:

  • Asymmetry common during growth

  • Tanner’s Staging: Five stages of breast development

• Pregnant:

  • Increased size, vascularity, striae, darker areola/nipples, colostrum production

• Lactating:

  • Milk production begins 3rd day postpartum

  • Engorgement, redness, warmth, hard tissue

  • Nipples may be cracked or sore

• Older Adult:

  • Pendulous, sagging, retracted nipples

  • Breast awareness important due to increased risk after age 50

Tanner’s Staging of Breast Development

Tanner’s Staging is used to classify breast development in adolescents:

• Stage 1 (Preadolescent): Only a small elevated nipple is present.

• Stage 2 (Breast bud stage): Small mound of breast and nipple develops; areola widens.

• Stage 3: Breast and areola enlarge; nipple flush with breast surface.

• Stage 4: Areola and nipple form a secondary mound over the breast.

• Stage 5 (Mature breast): Only the nipple protrudes; areola flush with breast contour.

Health Promotion and Screening Recommendations

Health promotion focuses on education, risk reduction, and appropriate screening for breast cancer.

• Canadian Task Force on Preventive Health Care (CTFPHC) Recommendations:

  • Do not use MRI, tomosynthesis, or ultrasound for screening in women not at increased risk.

  • Do not perform clinical breast examinations to screen for breast cancer.

  • Do not advise women to practice breast self-examination for screening.

• Mammography: Remains the primary screening tool for breast cancer.

Summary Table: Breast Assessment Patterns

The following table summarizes the main breast palpation patterns used in clinical assessment:

Additional info:

• Breast self-examination is no longer recommended for routine screening, but breast awareness is encouraged for recognizing changes.

• Clinical judgment, client education, and communication are essential concepts in breast health promotion.