N202 Final

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N202 Final
2010-11-29 15:25:26
Breasts Regional Lymphatics

N202 Breast and Regional Lymphatics
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  1. What are the 4 quadrants of the breast & what % of breast cancer occurs in each?
    • 1. Upper outer quadrant (50% incidence of breast cancer) which contains Tail of Spence (part of breast tissue extending into axillae) – most common
    • site of malignancy
    • 2. Upper inner quadrant (15% incidence…)
    • 3. Lower inner quadrant (6% incidence….)
    • 4. Lower outer quadrant (11% incidence…)
  2. Landmarks of the Breast?
    • 1. Nipple
    • 2. Areola
    • 3. Montgomery's (sebaceous) gland
  3. What is breast tissue comprised of?
    • 1. Adipose tissue (most of breast tissue)
    • 2. Glandular tissue (secretes milk)
    • 3. Suspensory ligaments (Cooper's
    • Ligaments)
  4. What are the determining factors of breast tissue composition?
    • 1. Age
    • 2. Nutritional status
    • 3. Pregnancy
    • 4. Lactation
    • 5. Genetics
  5. What is the % incidence of breast cancer of the nipple?
  6. What does the Pectoral Lymph drain?
    Drains anterior chest wall & breast
  7. Where are the lymphatics (Lymph System) of the breast located?
    • 1. Pectoral (behind anterior axillary fold)
    • 2. Subscapular (located along lateral edge of the scapula just inside posterior axillary fold)
    • 3. Lateral (along the humerus inside the upper arm)
    • 4. Central axillary (high middle axillae)
  8. What is the Suspensory Ligaments (Cooper's Ligaments) made of?
    Fibrous bands that attach breast tissue to chest wall muscles. • Cancer may cause the ligaments to contract causing pits or dimples in theoverlying skin
  9. What does the Subscapular Lymph drain?
    Drains posterior chest wall & arm
  10. What does the Lateral Lymph drain?
    Drains the arm
  11. What does the Central Axillary lymph drain?
    • Receives drainage from all axillary nodes
    • 75% of drainage will go to infraclavicular & supraclavicular nodes on the same side
    • 25% of drainage will go to the opposite breast, abdomen, or deep into breast (a problem for metastatic disease) - increases spread to the other side
  12. What does Estrogen in Newborns of either sex cause?
    White nipple fluid which resolves in few days to few weeks
  13. What hormone stimulates breast development in female adolescents?
  14. At what age does breast development occur?
    Onset 8 - 13 years; average 10 - 11) - occurs over 3 yrs
  15. At what age does Precocious Development of the breasts occur in adolescents?
    Before 8 years of age
  16. At what age is breast development (puberty) considered Delayed?
    • After 13 1/2 (needs endocrine
    • evaluation)
  17. What noted changes occur in the female breast during pregnancy?
    • 1. Nipples enlarge, darken & become
    • more erect
    • 2. Increased venous pattern over skin (superficial vessels)
    • 3. Note elevated Montgomery glands
    • 4. Colostrum forms in the 4th month (precursor to milk) – thick yellow fluid
  18. When does Colostrom change to milk?
    3 days postpartum
  19. What will relieve the sensation of tenderness, engorgement in a nursing mother?
    Frequent nursing
  20. What can be a complication of the breast of a nursing mother?
    Mastitis (inflammation or infection of breast tissue after childbirth) - red, swollen, hot, painful breasts
  21. What happens to the breast tissue during Menopause?
    • 1. Glandular tissue atrophies - decreased breast size
    • 2. Decreased elasticity (r/t decreased adipose) - pendulous, flattened, sagging breasts
    • 3. Axillary hair decreases
  22. What is the Lifetime Risk of breast cancer in a Male?
    1 in 1,000
  23. Gynecomastia & when it can occur?
    • Nub of breast tissue under areola (of males) – feels like a large grape
    • May normally have enlargement in adolescence (usually unilateral & temporary) - excess testosterone is converted to estrogen
    • May occur in the aging male (unilateral or bilateral); Occurs when testosterone levels drop and estrogen becomes unopposed; May also be due to medication effects (e.g., Cimetadine) or a pituitary tumor
  24. What is an initial symptom of breast cancer?
    Pain that can be Localized or Generalized
  25. What are the characteristics of Breast Pain?
    Burning, pulling, vague discomfort
  26. What are the common causes of Cyclic Breast Pain?
    OCs (oral contraceptive) & fibrocystic changes
  27. What are associated factors to Breast Pain?
    underwire bras & exercise
  28. Fibrocystic (non cancerous) lumps
    • May enlarge and become more tender prior to the menstrural period
    • Caffeine intake may increase size and tenderness of cystic lumps
  29. Associated skin changes (Lumps)
    • Redness
    • Warmth
    • Dimpling
    • Swelling
  30. Nipple Discharge
    Needs evaluation, e.g., prolactin levels
  31. Clear discharge (Nipple)
    • May be due to meds:
    • OCs
    • Phenothiazides [thorazine]
    • Diuretics
    • Digitalis
    • Steroids
    • Tricyclic antidepressants [amitriptyline]
    • Reserpine
    • Aldomet)

    Or a pituitary tumor
  32. Galactorrhea
    Milk discharge associated with a pituitary tumor
  33. Bloody discharge or thick yellow with blood (Nipple)
    (always significant, especially when associated with a lump) – may indicate ductal cancer
  34. Paget’s disease
    (advanced ductal CA) - starts as a small crust on the nipple with surrounding erythema
  35. Screening Recommendations
    • Mammograms
    • Clinical Breast Exam
    • Breast Self Exam (BSE)
  36. Mammograms
    • Yearly starting at age 40 (ASC)
    • Biennial (every 2-years) between ages 50 – 74 (USPSTF)
  37. Clinical Breast Exam
    • 20 – 30 years old - Q 3 years
    • ≥ 40 years old - Yearly
  38. Breast Cancer (Stats)
    • 2nd major cause of cancer death in women; lung CA #1
    • 1 in 8 women will develop breast CA before age 45 (incidence increases with age)
    • Incidence increases with age (80% of breast CA after age 40)
    • Need to identify early & treat early for good results
  39. How many more times will a female get breast cancer compared to a male?
    100 X
  40. Age as a Risk Factor (breast cancer)
    1 in 8 before age 45 & progressively increases with age
  41. If cancer in one breast, how many times is chance in other breast?
    increases risk 3-4 x
  42. 1st degree relative
    Family Hx of breast cancer before age 50
  43. What % of breast cancer pts have a Family Hx?
    20 - 30%
  44. How many % of females do not have Family Hx of breast cancer?
  45. Gene mutations for breast cancer (men & women)?
    BRACA 1 or BRACA 2
  46. Are breast symmetric or asymmetric?
    Asymmetric - left breast larger than rt
  47. Peau d' orange (orange peel skin)
    • Caused by blocked lymph ducts
    • Common with CA
    • Edema may exaggerate hair follicles causing bumpy texture & large pores appearing like an orange peel
  48. Palpate?
    • High into axilla
    • Anterior axilla
    • Posterior axilla
    • Down chest wall
    • Supraclavicular and infraclavicular areas (metastatic nodes)
  49. Inverted nipples
    Suspect malignancy if a recent change & unilateral
  50. Supernumerary nipple
    • 2 nipples along the mammary ridge at MCL
    • Occurs in 1% of men and women
    • Appear like a nevus
  51. Retraction Maneuvers
    • Observe breasts with hands at sides
    • Lift arms overhead
    • Push hands on hips
    • Push palms together
    • Lean forward (to see underside of large
    • breasts)
  52. What are you looking for when performing the Retraction Maneuvers?
    Observe changes in contour, symmetry, retraction, & dimpling associated with CA
  53. CA characteristics
    painless lump, ulceration, retraction, nipple discharge
  54. Mobility of Breast Lump
    • Mobile = fibrocystic
    • Fixed = CA
  55. Educate re Self Breast Exam
    • Educate during or after completing the exam
    • Examine 5 to 7 days after 1st day of menses
    • Postmenopausal (examine at same time each month)
    • Emphasize the importance of early detection
    • Watch her demonstrate