PRELIM NCM 106 (SL)

ASSESSMENT AND MANAGEMENT OF PATIENTS WITH BREAST DISORDER

 IN MALES and females, the breast is the same until puberty, when estrogen and other hormones initiate breast development in females.
 This development usually occurs at about the age of 10 years and continues until about 16 years of age, although the range is wide and
can vary from 9-18 years.

Stages of Breast development by Tanners

1. Stage 1 = describes a prepubertal breast

2. Stage 2 = the breast budding. First sign of puberty in female
3. Stage 3 = further enlargement of the breast tissue and the areola (the darker tissue ring around the nipple)
4. Stage 4 = when the nipple and areola form a secondary mound on the top of breast tissue
5. Stage 5 = the continued development of a larger breast with a single contour.

Breast

 Contains glandular (parenchyma) and ductal tissue, along with fibrous tissue that binds the lobes together and fatty tissue in and
between the lobes.
 The paired mammary glands are located between the second and sixth ribs over the pectoralis major muscle from the sternum to the
midaxillary line.
 Each breast consists of 12-20 cone-shaped lobes that are made up of lobules containing cluster of acini, small structure ending in a duct
 About 85% of the breast is fat.

TAIL OF SPENCE

 Area of breast tissue extend to the axilla

COOPERS LIGAMENTS

 Fascial bands, support the breast on the chest wall.

ASSESSMENT

HEALTH HISTORY AND CLINICAL MANIFESTATIONS

 In assessing a patient who describes a breast problem, the nurse should ask the woman when she noted the problem and how long it has
been present. And also, if there is a pain associated with the symptoms and can feel any areas in your breast which are concern. The
nurse will ask what is her BSE practice? If she had mammogram or any other screening or diagnostic test?
 The woman will have asked about her reproductive history because of its relationship to risk for breast disorder
 It includes also the menarche, last menstrual period, cycle regularity, and use of oral contraceptives or other hormone products.
 Also, the history of pregnancies, livebirth, miscarriages, abortion, and breastfeeding
 If the patient is postmenopausal, her age at menopause and any symptoms she experienced and current or previous use of tobacco and
alcohol.
 The assessment also includes the medical and surgical history of disease particularly cancer.
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  Social information such as marital status, occupation, and the availability of resources and support persons.

PHYSICAL ASSESSMENT: FEMALE BREAST

 Examination of female breast can be conducted during any general physical or gynecologic examination or whenever the [patients
suspect, reports, or fears breast disease.
 A clinical breast examination is recommended at least every 3 years for women between the ages of 20 and 40 years and then annually.
 A thorough breast examination, including instruction in BSE, takes at least 10 minutes or more

1. INSPECTION
 The patient disrobes to the waist and sits in comfortable position facing the examiner
 The breast will inspect for size and symmetry
 A slight variation in the size of each breast is common and generally a normal finding.
 The skin is inspected for color, venous pattern, thickening or edema.

ERYTHEMA

 (REDNESS) indicate benign local inflammation or superficial lymphatic invasion by a neoplasm.

Prominent venous return= can signal increased blood supply required by a tumor.

EDEMA AND PITTING OF THE SKIN =result from neoplasm blocking lymphatic drainage and giving the skin an orange-peel appearance (peau d’
orange) , a classic sign of advanced breast cancer.

Abnormal breast findings

RETRACTION SIGNS

 Sign includes skin dimpling, creasing or changes in the contour of the breast or nipple
 Secondary to fibrosis or scar issue formation in the breast
 Retraction signs may appear only which position changes or with breast palpation

BREAST CANCER MASS (MALIGNANT TUMOR)

 USUALLY OCCUR AS ASINGLE MASS (lump) in one breast

 Usually nontender
 Irregular shape

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  Firm hard, embedded in surrounding tissue
 Referral and biopsy indicated for definitive diagnosis

Breast cysts (benign mass of fibrocystic disease)

 Occur as single or multiple lumps in one or both breasts

 Usually tender (omitting caffeine reduces tenderness), tenderness increases during premenstrual period
 Round shape
 Soft, firm, mobile
 Referral and biopsy indicated for definitive diagnosis, especially for first mass: later masses may be evaluated over time by specialist

Fibroadenoma (benign breast lump)

 Usually occur as a single mass in woman aged 15-35 years

 Usually nontender
 Maybe lobular or round
 Firm, mobile and not fixed to breast tissue or chest wall
 No premenstrual changes
 Referral and biopsy indicated for definitive diagnosis.

Increased venous prominence

 Associated with breast cancer if unilateral

 Unilateral localized increase in venous pattern associated with malignant tumor
 Normal with breast enlargement associated with pregnancy and lactation if bilateral and bilateral symmetry.

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PEAU D’ ORANGE (Edema)
 Associated with breast cancer
 Caused by interference with lymphatic drainage
 Breast skin has orange peel appearance
 Skin pores enlarge
 May be noted on the areola
 Skin become thick, hard, immobile
 Skin discoloration may occur

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Nipple Inversion
 Consider normal if long standing
 Associated with fibrosis and malignancy if recent development

Acute mastitis (inflammation of the breasts)

 Associated with lactation but may occur at any age
 Nipple cracks or abrasions noted
 Breast skin reddened and warm to touch

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  Tenderness
 Systemic signs include fever and increased pulse

Paget’s disease (malignancy of mammary ducts)

 Early signs: erythema of nipple and areola
 Late signs: thickening, scaling, and erosion of the nipple and areola

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PALPATION
 To examine the axillary lymph nodes, the examiner gently abducts the patients arm from thorax.
 The patients left forearm is grasped gently and supported with the examiners left hand.
 The right hand then free o palpates the axillae and note any lymph nodes that may be lying against the thoracic wall.
 The flat parts of the fingertips are used to gently palpate the areas of the central, lateral, subscapular, and pectoral nodes
 The breast is also palpated with the patient sitting in an upright position.
 The patient is then assisted to a supine position, before the breast is palpated, the patient shoulder is elevated by a small pillow to
balance the breast on the chest wall. Failure to do this allows the breast tissue to slip laterally and the breast mass may be missed in this
thickened tissue.
 If the mass detected, it is described by its location for example: left breast 2cm from the nipple at 2 o’clock position. Size, shape,
consistency, border delineation, and mobility are included in description.

PHYSICAL EXAMINATION: MALE BREAST

 Examination of the male breast and axillae is an important part of physical assessment.
 Most cancer in men are found at a later stage, possibly, because men are not aware of their risk for developing breast cancer.
GYNECOMASTIA
 Overdeveloped mammary glands in the male.
 Differentiated from the soft, atty enlargement of obesity by the firm enlargement of glandular tissue beneath AND IMMEDIATELY
Surrounding the areola.

DIAGNOSTIC EVALUATION

1. Breast-self Examination
 a technique which allows an individual to examine his/her breast tissue for any physical or visual changes. It is often used as an early
detection method for breast cancer. Both men and women should perform a BSE at least once each month beginning at age 18.
 BSE instruction can be performed during assessment.
 BSE is best performed after menses (5 days to 7 days ,counting the first day of menses as day 1.
 Do your BSE at the end of your monthly period.
 If you are pregnant, no longer have periods or your period is irregular, choose a specific day each month.
 This should not be performed in the shower or with lotion on your skin or fingers.
 If you find a lump or notice other unusual changes, Don’t panic. About 80% of lumps found are not cancerous. See your doctor
promptly for further evaluation.

How To Do A Breast Self-Exam Part 1: TOUCH

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Check the OUTER HALF of your right breast. Lie down and roll on to your left side to examine your right breast. Place
your right hand, palm up on your forehead. Your breast should lie as flat on your chest as possible. It may be easier and
more comfortable if you put a pillow behind your shoulder or back.

Using the flat pads of your three middle fingers—not the tips—move the pads of your fingers in little circles, about the size of a dime. For each
little circle, change the amount of pressure so you can feel ALL levels of your breast tissue. Make each circle three times—once light, once medium,
and once deep—before you move on to the next area.

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Start the circles in your armpit and move down to just below the bra line. Then slide your fingers over—just the width of one finger and move up
again. Don’t lift your fingers from your breast as you move them to make sure you feel the entire area. Continue this up-and-down vertical strip
pattern—from your collarbone to just below your bra line—until you reach the nipple.

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Check the INNER HALF of your right breast. When you reach the nipple, remove pillow and roll on to your back, remove your hand from your
forehead and place this arm at a right angle (see drawing). Carefully check the nipple area using the same circular pressures as before, without
squeezing. Then examine the remaining breast tissue using the up-and-down vertical strip pattern, until you reach the middle of your chest. Place
your non-palpating hand down at your side, make a row of circles above and below your collarbone, working from your shoulder to your mid-line.
Roll on to your right side and repeat these steps on your left breast, using your right hand.

How To Do A Breast Self-Exam Part 2: LOOK

Stand in front of a mirror and look closely at your breasts in the following three positions, viewing from the right and left as well as facing forward.
Check for changes in the following:

 Shape: Compare one to the other. One breast may normally be larger than the other, but sudden changes in size should not occur.
 Skin: Check for rash, redness, puckering, dimpling, or orange-peel-textured appearance.
 Nipples: Check for any physical changes such as a sudden inversion, scaliness, redness, itching, swelling, or discharge.
 Vein patterns: Look for a noticeable increase in size or number of veins compared to the other breast.

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 Arms at your sides
1. Stand before a mirror
2. Check both breast for anything unusual
3. Look for discharge from the nipple, wrinkling dimpling or scaling of the skin.

Arms raised above your head bending forward, and

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1.Place hands on your hips and hunch over.
2.Note any change

MAMMOGRAHY
 Abreast imaging technique that can detect nonpalpable lesions and assist in diagnosing palpable masses.
 It takes about 20 mins.ca n perform in hospital
 Two views can be taken of each breast
1. Craniocaudal view
2. Mediolateral oblique view
 Theses views; the breast is mechanically compressed from top to bottom and side to side
 The woman can experience a fleeting discomfort because maximum compression is necessary for proper visualization.

GALACTOGRAPHY
 Mammographic diagnostic procedure that involves injection of less than 1 ml of radiopaque material through a cannula inserted into a
ductal opening on the areola, followed by a mammogram
 It is performed when the patient has a bloody nipple discharge on expression, spontaneous nipple, discharge, or solitary dilated duct
noted on mammography.

ULTRASONOGRAPHY
 Used in conjunction with mammography to distinguish fluid-filled cysts from other lesions.
 A transducer is used to transmit high frequency sound waves through the skin and into the breast an echo signal is measured.
 The echo waves are interpreted electronically and then displayed on a screen.
 This technique is 95% to 99% accurate in diagnosing cysts but does not definitively rule out a malignant lesion.

MAGNETIC RESONANCE IMAGING (MRI)

 A promising tool for use in diagnosing breast condition.
 It is a highly sensitive, although not specific, test and serve as an adjunct to mammography.
 A coil is placed around the breast and the patient is placed inside the MRI machine for 2 mins.
 An injection of gadolinium, a contrasts dye, is given intravenously.

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  Helpful in determining the exact size or presence of multiple foci of a lesion more precisely than mammography.
 Detect breast cancer, determining tumor response to chemotherapy and determining integrity of saline or silicone breast implants

PROCEDURE FOR TISSUE ANALYSIS

1. Fine Needle Aspiration
 Outpatient procedure usually initiated when mammography, ultrasonography or palpation detects lesion.
 Surgeon perform the procedure
 Perform under x ray guide for nonpalpable lesion
 The surgeon inserted 21-22-gauge needle attached to the syringe into the site to be sampled
 Result are available quickly

2. Stereotactic Biopsy
 Outpatient procedure, performed for nonpalpable lesions found on mammography.
 The patient lies prone on a special table and breast is positioned through an opening in the table and compressed for a mammogram

3. Surgical Biopsy
 The most common outpatient surgical procedure
 It is important to note that 8 out of 10 lesions on biopsy are benign
 The procedure is usually done using local anesthesia. Conscious or monitored (or sedation or both
 The biopsy involves excising the lesion and sending it to the laboratory for pathologic examination.
A. EXCISIONAL BIOPSY
 The usual procedure for any palpable breast mass.
 The entire lesion with a margin of surrounding tissue is removed.
 A frozen section (a small piece of the mass or lesion is given a provisional diagnosis by pathologist) may be done at the time of
biopsy.
B. INCISIONAL BIOPSY
 Performed when tissue sapling alone is required and this is done both to confirm a diagnosis and to determine hormonal receptor
status.
 This procedure is often performed in women with locally advanced breast cancer or in cancer patients with a suspicion of recurrent
diseases whose treatment may depend on the tumors estrogen and progesterone receptor status.
C. TRU-CUT CORE BIOPSY
 THE SURGEON USES a special large-lumen needle to remove a core of tissue
 Tis procedure is used when a tumor is relatively large and close to the skin surface and the surgeon strongly suspects that the lesion is
carcinoma.

D. WIRE NEEDLE LOCALIZATION

 A technique used when mammography detects minute, pinpoint calcification (indicating a potential malignancy) or nonpalpable lesions
and biopsy is necessary.
 A long thin wire is inserted, usually painlessly through a needle before the excisional biopsy under mammographic guidance to ensure
that the wire tip designates the area to undergo biopsy.

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