15 The breast

The two mammary glands are highly developed apocrine sweat glands. They develop embryologically along two lines extending from the axillae to the groin—the milk lines (see Fig. 15.1). In humans, only one gland develops on each side of the thorax although extra nipples with breast tissue may sometimes occur.

The breasts extend from the 2nd to the 6th ribs and transversely from the lateral border of the sternum to the midaxillary line.

For the purposes of examination, each breast may be divided into four quadrants by horizontal and vertical lines intersecting at the nipple. An additional lateral extension of breast tissue (the axillary tail of Spence) stretches from the upper outer quadrant towards the axilla (Fig. 15.2).

Each mammary gland consists of 15–20 lobes separated by loose adipose tissue and subdivided by collagenous septa. Strands of connective tissue called the suspensory ligaments of the breast (Cooper’s ligaments) run between the skin and deep fascia to support the breast. Each lobe is further divided into a variable number of lobules composed of grape-like clusters of milk-secreting glands termed alveoli and is drained by a lactiferous duct that opens onto the nipple. Myo-epithelial cells surround the alveoli which contract and help propel the milk toward the nipples.

The nipple is surrounded by a circular pigmented area called the areola and is abundantly supplied with sensory nerve endings. The surface of this area also contains the ‘sebaceous glands of Montgomery’ which act to lubricate the nipple during lactation.

Lymphatic drainage from the medial portion of the breast is to the internal mammary nodes. The central and lateral portions drain to the axillary lymph nodes which are arranged into five groups (see Fig. 15.7).

You should begin by establishing a menstrual history (see Chapter 13). You should also determine the date of the last period of menstruation. It is important to note that pre-existing disease in the breast is likely to become more noticeable during the 2nd half of the menstrual cycle—lumps often get bigger or become more easily palpable.

You should bear in mind that seeking medical attention for a breast lump or tenderness can produce extreme anxiety and embarrassment in patients. Men with gynaecomastia are also likely to feel anxious about their breast development. Ensure that you adopt an appropriately sensitive, sympathetic, and professional approach.

As for pain at any other site, you should establish the site, radiation, character, duration, severity, exacerbating factors, relieving factors, and associated symptoms. Also ask:

The commonest cause of mastalgia in premenopausal women is hormone-dependent change. Other benign causes include mastitis and abscesses. 1 in 100 breast cancers present with mastalgia as the sole symptom.

Important causes of nipple discharge include ductal pathology such as ductal ectasia, papilloma, and carcinoma.

Ask about:

A very important presenting complaint with a number of causes—the most important of which is cancer. Establish:

A good clue as to the likely diagnosis of a lump is the age of the patient:

This is enlargement of the male breast tissue which should not normally be palpable. There is an ? in the ductal and connective tissue.

A common occurrence in adolescents and the elderly. Gynaecomastia is seen in obese men due to increased adipose tissue.

In many patients, gynaecomastia is drug-related and the full causative list is long. Important drug causes include oestrogen receptor binders such as oestrogen, digoxin, and marijuana as well as anti-androgens such as spironolactone and cimetidine.

In the history, ask about drug and hormone treatment (e.g. for prostate cancer).

You should also make a full examination of the patient looking for signs of hypopituitarism, chronic liver disease, and thyrotoxicosis. Remember to make a careful examination of the genitalia.

Stand in front of the patient and observe both breasts, noting:

Note whether the nipples are:

Ask the patient to place her hands on her head and repeat the inspection process. Pay particular attention to any asymmetry or dimpling that is now evident. Examine the axillae for masses or colour change.

Finally, dimpling or fixation can be further accentuated by asking the patient to perform the following manoeuvres (see Fig. 15.3):

Palpation of the breast should be performed with the patient lying at about 45 degrees on the couch. Initially, the patient should have her hands by her sides. Examination of the upper-outer quadrant is best performed with the hand on the side to be examined placed behind her head (Fig. 15.4).

Ask the patient if there is any pain or tenderness—and examine that area last. Also ask her to tell you if you cause any pain during the examination.

You should begin the examination on the asymptomatic side, allowing you to determine the texture of the normal breast first.

Palpation should be performed by keeping the hand flat and gently rolling the substance of the breast against the underlying chest wall.

Most breasts will feel ‘lumpy’ if pinched.

You should proceed in a systematic way to ensure that the whole breast is examined. There are two regularly used methods (see Fig. 15.5) of which the authors favour the 1st:

Do not forget to examine the axillary tail of Spence stretching from the upper-outer quadrant to the axilla.

A lump may be described as tethered to the skin if it can be moved independently of the skin for a limited distance but pulls on the skin if moved further.

Tethering implies that an underlying lesion has infiltrated Cooper’s ligaments which pass from the skin through the subcutaneous fat.

On inspection at rest, there may be puckering of the skin surface (as if being pulled from within) or there may be no visible abnormality.

To demonstrate tethering:

This is caused by direct, continuous infiltration of the skin by the underlying disease. The lump and the skin overlying it cannot be moved independently. It is on a continuum with skin tethering. This may be associated with some changes of skin texture.

The lump may be tethered or fixed to the underlying muscle (e.g. pectoralis major).

Lumps that are attached to the underlying muscle can be moved to some degree if the muscle is relaxed but are less mobile if the muscle is tensed.

If a lump is immobile in all situations, it may have spread to involve the bony chest wall (e.g. in the upper half of the breast or axilla) or may be a lump arising from the chest wall.

If the patient complains of nipple discharge, ask her to gently squeeze and express any discharge, noting colour, presence of blood and smell.

The technique is described in detail in Chapter 3.

Support the patient’s arm. For example, when examining the right axilla, abduct the patient’s right arm gently and support it at the wrist with your right hand whilst examining the axilla with your left hand.

Examine the main sets of axillary nodes including:

If you feel any lymph nodes, consider site, size, number, consistency, tenderness, fixation, and overlying skin changes.

Remember to also palpate for lymph nodes in the lower deep cervical lymph chain at the same time as the supraclavicular nodes.

If cancer is suspected, it is worth performing a full general examination, keeping in mind the common sites of metastasis of breast cancer. Examine especially the lungs, liver, skin, skeleton, and central nervous system.

All suspected breast cancer cases should have ‘triple assessment’:

This can occur after trauma and the physical signs can mimic cancer (e.g. a firm hard lump with skin tethering).

Mainly occur during childbearing years and are often associated with trauma to the nipple during breastfeeding.

Present with a painful, spherical lump with surrounding oedema. They often show additional signs of inflammation (hot, red). The patient may have constitutional symptoms such as malaise, night sweats, hot flushes, and rigors.

Most recurrent or chronic breast abscesses occur in association with duct ectasia or periductal mastitis. The associated periductal fibrosis can often lead to nipple retraction.

Diseases of the nipple are important because they must be differentiated from malignancy and cause concern to patients.

Unilateral retraction or distortion of a nipple is a common sign of breast carcinoma; as is blood-stained nipple discharge. The latter suggests an intraductal carcinoma or benign papilloma.

A unilateral red, crusted, and scaling areola suggests an underlying carcinoma (Paget’s disease of the breast) or, more commonly, eczema. Ask the patient if she has eczema at other sites and examine appropriately.