CHAPTER

16  

Breasts and Axillae

T he breast examination is typically performed when a patient

presents with a specific breast concern, as a follow-up to an
abnormal examination or increased risk for breast cancer, or as
  http://evolve.elsevier.com/Seidel
• Physical Exam Key • NCLEX Review Questions • Videos
Points • Interactive Activities • Student Checklist
part of an overall health visit for both women and men. Examina-
tion of the breasts includes examination of the axillae and rele-
vant lymph node chains. A major focus of the examination in
ANATOMY AND PHYSIOLOGY
adults is identification of breast masses, skin, or vascular changes
that could indicate malignancy. Breast examination is important The breasts are paired mammary glands located on the anterior
in children for Tanner staging and as part of an evaluation chest wall, superficial to the pectoralis major and serratus ante-
regarding premature or delayed puberty. rior muscles (Fig. 16-1). In women, the breast extends from the

Physical Examination Preview

Here is a preview of the steps involved in conducting a physical • Seated and leaning over
examination of the breasts and axillae. These procedures are • In recumbent position
explained in detail in this chapter and are available on Evolve in 4. Perform a chest wall sweep (p. 360).
printable formats. 5. Perform bimanual digital palpation (p. 360).
6. Palpate for lymph nodes in the axilla, down the arm to the
Breasts and Axillae
elbow, and in the axillary, supraclavicular, and infraclavicular
Females
areas (p. 360).
1. Inspect with patient seated. Compare breasts for (p. 355):
7. Palpate breast tissue with patient supine, using light, medium,
• Size
and deep pressure (p. 361).
• Symmetry
8. Depress the nipple into the well behind the areola (p. 361).
• Contour
• Retractions or dimpling Males
• Skin color and texture 1. Inspect breasts for the following (p. 355):
• Venous patterns • Symmetry
• Lesions • Enlargement
• Supernumerary nipples • Surface characteristics
2. Inspect both areolae and nipples and compare for (p. 356): 2. Inspect both areolae and nipples and compare for (p. 356):
• Shape • Shape
• Symmetry • Symmetry
• Color • Color
• Smoothness • Smoothness
• Size • Size
• Nipple inversion, eversion, or retraction • Nipple inversion, eversion, or retraction
3. Reinspect breasts with the patient in the following positions 3. Palpate breasts and over areolae for lumps or nodules (p. 363).
(p. 357): 4. Palpate for lymph nodes in the axilla, down the arm to the
• Arms extended over head or flexed behind the neck elbow, and in the axillary, supraclavicular, and infraclavicular
• Hands pressed on hips with shoulder rolled forward areas (p. 360).

350
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 CHAPTER 16  Breasts and Axillae 351

Anatomy and Physiology

Clavicle
Intercostal
muscle
Pectoralis
major muscle
Alveolus
Ductule
Duct
Lactiferous
duct

Lactiferous
sinus

Nipple
pore

Suspensory
ligaments
of Cooper

FIGURE 16-1  Anatomy of the breast showing position and major structures.

second or third rib to the sixth or seventh rib and from the
sternal margin to the midaxillary line. The nipple is located cen-
trally, surrounded by the areola. The male breast consists of a
small nipple and areola overlying a thin layer of breast tissue.
The female breast is composed of glandular and fibrous tissue
and subcutaneous and retromammary fat. The glandular tissue
is arranged into 15 to 20 lobes per breast that radiate about the
Tail of
nipple. Each lobe is composed of 20 to 40 lobules; each lobule Spence
consists of milk-producing acini cells that empty into lactiferous Upper Upper
ducts. These cells are small and inconspicuous in nonpregnant, inner outer
nonlactating women. A lactiferous duct drains milk from each
lobe onto the surface of the nipple. Lower
Lower
The layer of subcutaneous fibrous tissue provides support for inner outer
the breast. Suspensory ligaments (Cooper ligaments) extend
from the connective tissue layer through the breast and attach to
the underlying muscle fascia, providing further support. The
muscles forming the floor of the breast are the pectoralis major, FIGURE 16-2  Quadrants of the left breast and axillary tail of Spence.
pectoralis minor, serratus anterior, latissimus dorsi, subscapu-
laris, external oblique, and rectus abdominis.
Vascular supply to the breast is primarily through branches
of the internal mammary artery and the lateral thoracic artery. Breast tissue extends from this quadrant into the axilla, forming
This network provides most of the blood supply to the deeper the tail of Spence. In the axillae the mammary tissue is in direct
tissues of the breast and to the nipple. The subcutaneous and contact with the axillary lymph nodes.
retromammary fat that surrounds the glandular tissue consti- The nipple is located centrally on the breast and is surrounded
tutes most of the bulk of the breast and gives the breast its soft by the pigmented areola. The nipple is composed of epithelium
consistency. The proportions of each of the component tissues that is infiltrated with circular and longitudinal smooth muscle
vary with age, nutritional status, pregnancy, lactation, and genetic fibers. Contraction of the smooth muscle, induced by tactile,
predisposition. sensory, or autonomic stimuli, produces erection of the nipple
For the purposes of examination the breast is divided into five and causes the lactiferous ducts to empty. Tiny sebaceous glands
segments, four quadrants and a tail (Fig. 16-2). The greatest may be apparent on the areola surface (Montgomery tubercles or
amount of glandular tissue lies in the upper outer quadrant. follicles). Hair follicles may be found about the circumference of

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 352 CHAPTER 16  Breasts and Axillae

the areola. Supernumerary nipples or breast tissue is sometimes The posterior axillary (subscapular) nodes lie along the lateral
present along the mammary ridge that extends from the axilla to border of the scapula and deep in the posterior axillary fold,
Anatomy and Physiology

the groin (see Fig. 16-10).
Each breast contains a lymphatic network that drains the
breast radially and deeply to underlying lymphatics. Superficial
lymphatics drain the skin, and deep lymphatics drain the
mammary lobules. Table 16-1 summarizes the patterns of
lymph drainage.
The complex of lymph nodes, their locations, and direction of
drainage are illustrated in Figure 16-3. The axillary nodes are
more superficial and accessible to palpation when enlarged. The
anterior axillary (pectoral) nodes are located along the lower
border of the pectoralis major, inside the lateral axillary fold. The
midaxillary (central) nodes are high in the axilla close to the ribs.
whereas the lateral axillary (brachial) nodes can be felt along the
upper humerus.
  Children and Adolescents
The breast evolves in structure and function throughout life.
Childhood and preadolescence represent a latent phase of breast
development (see Physical Variations, “Breast Development”).
Thelarche (breast development) represents the first sign of
puberty in girls. The developmental process can be classified
using the five Tanner stages of breast development and sexual
maturation rating, as discussed in Chapter 6.

Physical Variations
Table 16-1  Patterns of Lymph Drainage Breast Development
As girls approach puberty they often worry about when their breasts
Area of Breast Drainage
will begin to develop. Thelarche occurs earlier in black girls than in
Superficial white girls. For Hispanic girls the age is between that of the other two
Upper outer quadrant Scapular, brachial, intermediate nodes groups. Racial and ethnic differences reflect a combination of genetic,
toward axillary nodes social, and environmental factors.
Medial portion Internal mammary chain toward
opposite breast and abdomen Euling et al, 2008.

Deep
Posterior chest wall and
portion
Anterior chest wall
Upper arm
Retroareolar area
Areola and Nipple
Posterior axillary nodes (subscapular)
of the arm
Anterior axillary nodes (pectoral)
Lateral axillary nodes (brachial)
Interpectoral (Rotter) nodes into the
axillary chain
Midaxillary, infraclavicular, and
supraclavicular nodes
In using the Tanner system to stage breast development, it
is important to note temporal relationships. It is unusual for
the onset of menses to occur before stage 3. About 25% of
females begin menstruation at stage 3. Approximately 75% are
menstruating at stage 4 and are beginning a regular menstrual
cycle. Some 10% of young women do not begin to menstruate
until stage 5. The average interval from the appearance of the
breast bud (stage 2) to menarche is 2 years. Breasts develop at

Supraclavicular nodes
Interpectoral
(Rotter) nodes
Midaxillary
nodes

Lateral
axillary
(brachial)
nodes

Subclavicular
(Infraclavicular) nodes
Subscapular nodes Internal mammary
nodes
Anterior axillary
(pectoral) nodes Cross-mammary pathways
to opposite breast
Pathways to
subdiaphragmatic
nodes and liver

FIGURE 16-3  Lymphatic drainage of the breast. Nodes in bold notation are accessible to palpation.

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different rates in the individual, which can result in temporary
asymmetry.
  Pregnant Women
Striking changes occur in the breasts during pregnancy. In
response to luteal and placental hormones, the lactiferous
ducts proliferate and the alveoli increase extensively in size and
number, which may cause the breasts to enlarge two to three
times their prepregnancy size. The increase in glandular tissue
displaces connective tissue and the breasts become softer and
looser. Toward the end of pregnancy, as epithelial secretory activ-
ity increases, colostrum is produced and accumulates in the
acinus cells (alveoli).
The areolae become more deeply pigmented and their diam-
eter increases. The nipples become more prominent, darker, and
more erectile. Montgomery tubercles often develop as sebaceous
glands hypertrophy.
Mammary vascularization increases, causing veins to engorge
and become visible as a blue network beneath the surface of
the skin.
  Lactating Women
In the first few days after delivery, small amounts of colostrum
are secreted from the breasts. Colostrum contains more protein
and minerals than does mature milk. Colostrum also contains
antibodies and other host resistance factors. Milk production
replaces colostrum 2 to 4 days after delivery in response to
surging prolactin levels, declining estrogen levels, and the stimu-
lation of sucking. As the alveoli and lactiferous ducts fill, the
breasts may become full and tense. This, combined with tissue
edema and a delay in effective ejection reflexes, produces breast
engorgement.
At the termination of lactation, involution occurs over a
period of about 3 months. Breast size decreases without loss of
lobular and alveolar components; the breasts rarely return to
their prelactation size.
  Older Adults
After menopause, glandular tissue atrophies gradually and is
replaced by fat. The inframammary ridge at the lower edge of
the breast thickens. The breasts tend to hang more loosely from
the chest wall as a result of the tissue changes and relaxation
of the suspensory ligaments. The nipples become smaller and
flatter and lose some erectile ability.
The skin may take on a relatively dry, thin texture. Loss of
axillary hair may also occur.
REVIEW OF RELATED HISTORY
For each of the symptoms or conditions discussed in this section,
targeted topics to include in the history of the present illness are
listed. Responses to questions about these topics help fully assess
the patient’s condition and provide clues for focusing the physical
examination and the development of an appropriate diagnostic
evaluation. Questions regarding medication use (prescription
and over the counter preparations) as well as complementary and
alternative therapies are relevant for each.
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CHAPTER 16  Breasts and Axillae 353
History of Present Illness
Review of Related History
• Breast discomfort/pain
• Temporal sequence: onset gradual or sudden; length
of time symptom has been present; does symptom come
and go or is it always present
• Relationship to menses: timing, severity
• Character: stinging, pulling, burning, drawing, stabbing,
aching, throbbing; unilateral or bilateral; localization;
radiation
• Associated symptoms: lump or mass, discharge from
nipple
• Contributory factors: skin irritation under breasts from
tissue-to-tissue contact or from rubbing of undergar-
ments; strenuous activity; recent injury to breast
• Medications: hormones or bioidentical hormones; oral
contraceptives
• Breast mass or lump
• Temporal sequence: length of time since lump first noted;
does lump come and go or is it always present; relationship
to menses
• Symptoms: tenderness or pain (characterize as described
previously), dimpling or change in contour
• Changes in lump: size, character, relationship to menses
(timing or severity)
• Associated symptoms: nipple discharge or retraction,
tender lymph nodes
• Medications: hormones or bioidentical hormones
• Nipple discharge
• Character: spontaneous or provoked; unilateral or bilat-
eral, onset gradual or sudden, duration, color, consistency,
odor, amount
• Associated symptoms: nipple retraction; breast lump or
discomfort
• Associated factors: relationship to menses or other activ-
ity; recent injury to breast
• Medications: contraceptives; hormones, phenothiazines,
digitalis, diuretics, steroids
• Breast enlargement in men
• History of hyperthyroidism, testicular cancer, Klinefelter
syndrome
• Medications: cimetidine, omeprazole, spironolactone,
antiandrogens (finasteride), human immunodeficiency
virus (HIV) medications (efavirenz), some chemotherapy
agents, some antihypertensives, some antipsychotics
• Treatment for prostate cancer with antiandrogens or
gonadotropin-releasing hormone analogs
• Illicit drugs: anabolic steroids, marijuana
Past Medical History
• Previous breast disease: cancer, fibroadenomas, fibrocystic
changes
• Known BRCA1, BRCA2, or other genetic mutation; known
hereditary cancer syndrome (hereditary nonpolyposis colorec-
tal cancer [HNPCC], Li-Fraumeni syndrome, or Cowden
syndrome)
 354 CHAPTER 16  Breasts and Axillae
Box 16-1  Screening Recommendations
for Breast Cancer
Review of Related History
Breast cancer is the most common cancer among women in the
United States and is the second leading cause of cancer death in
women. Early detection through screening is important for timely
treatment and prevention of death. Authorities do not completely
agree on the need for, frequency of, and timing of screening (see the
Evidence-Based Practice box). CBE, mammography, MRI, and breast
self-awareness are the currently available modalities for screening
asymptomatic women.
Summary of Recommendations
CBE
• Younger than 40 years of age: every 3 years (ACS, 2012)
• Older than 40 years of age: annually (ACS, 2012)
• Insufficient evidence to assess the additional benefits and harms
of CBE beyond screening mammography in women 40 years or
older (USPSTF, 2009)
Mammogram
• Yearly starting at 40 years of age and continuing for as long as
a woman is in good health (ACS 2012)
• Biennial screening mammography for women between the ages
of 50 and 74 years (USPSTF, 2009)
• Insufficient evidence to assess the additional benefits and harms
in women 75 years or older (USPSTF, 2009)
MRI
• Women at high risk:
• Known BRCA mutation or untested but have a first-degree
relative with a BRCA mutation
• Greater than 20% lifetime risk based primarily on family
history
• Prior mantle radiation
• MRI in addition to mammogram every year (ACS, 2012)
Breast Self-Awareness
• Women should be familiar with their breasts and report any
changes to their health care provider (ACS, 2012)
• Not addressed by USPSTF (USPSTF, 2009)
ACS, American Cancer Society; USPSTF, United States Preventive Services Task Force.
• Previous other related cancers: ovarian, colorectal,
endometrial
• Surgeries: breast biopsies, aspirations, implants, reductions,
reconstructions, oophorectomy
• Risk factors for breast cancer (see the Risk Factors box)
• Mammogram and other breast imaging history: frequency,
date of last imaging, results (Box 16-1)
• Menstrual history: first day of last menstrual period; age at
menarche and menopause; cycle length, duration, amount of
flow, and regularity; associated breast symptoms (nipple dis-
charge; pain or discomfort)
• Pregnancy: age at each pregnancy, length of each pregnancy,
date of delivery or termination
• Lactation: number of children breast-fed; duration of time for
breast-feeding; date of termination of last breast-feeding;
medications used to suppress lactation
• Menopause: onset, course, associated problems, residual
problems
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• Use of hormonal medications: name and dosage, reason for
use (contraception, menstrual control, menopausal symptom
relief ), length of time on hormones, date of termination
• Other medications: nonprescription or prescription; hor-
mones (estrogen, progesterone), selective estrogen receptor
modulators (SERMS) (tamoxifen, raloxifene), aromatase
inhibitors (e.g., anastrozole, letrozole, exemestane)
Risk Factors
Breast Cancer
Nonmodifiable Factors
Age: Risk increases with aging.
Gender: Female. More women than men develop breast cancer.
Genetic risk factors: Women with an inherited BRCA1 or BRCA2
mutation have a 35% to 85% chance of developing breast
cancer during their lifetime as compared to the average risk
of about 12%.
Personal history of breast cancer: Cancer in one breast increases
risk of developing a new cancer in the other breast.
Family history of breast cancer: Having one first-degree relative
(mother, sister, or daughter) with breast cancer approximately
doubles a woman’s risk and having two first-degree relatives
increases her risk fivefold.
Previous breast biopsies: Atypical hyperplasia or lobular cancer in
situ (LCIS) substantially increases breast cancer risk. Fibrocystic
changes without proliferative breast disease do not affect breast
cancer risk.
Race: White women are higher risk than other racial/ethnic groups.
Previous breast radiation: Radiation therapy to the chest area as
treatment for another cancer (such as Hodgkin disease or
non-Hodgkin lymphoma) significantly increases risk for breast
cancer.
Menstrual periods: Menarche before age 12 or menopause after
age 55 slightly increases risk.
Breast density: Breast tissue may be dense or fatty. Older
women whose mammograms show more dense tissue are at
increased risk.
Diethylstilbestrol (DES) therapy: Women who received
diethylstilbestrol in the 1940s through the 1960s during their
pregnancies have a slightly increased risk. Women exposed to
DES in utero—daughters whose mothers took DES while they
were pregnant—may have a slightly increased risk of breast
cancer after age 40.
Modifiable/Lifestyle Factors
Childbirth: Nulliparity or late age at birth of first child (after age 30)
is associated with an increased risk.
Hormone therapy: Use of combined estrogen and progesterone
hormone replacement therapy (HRT) after menopause (more
than 4 years of use) increases risk.
Alcohol: Risk increases with amount of alcohol consumed.
Obesity and high-fat diets: Obesity is associated with an increased
risk, especially for women after menopause. Having more fat
tissue can increase estrogen levels and increase the likelihood
of developing breast cancer.
Lack of physical activity: Women who are physically inactive
throughout life may have an increased risk of breast cancer.
From American Cancer Society, 2011; National Cancer Institute, 2012.

Family History
• Breast cancer: primary relatives, secondary relatives; type of
cancer; age at time of occurrence; treatment and results;
known BRCA1, BRCA2, or other mutation
• Other cancers: ovarian, colorectal, known hereditary cancer
syndromes (breast-ovarian cancer syndrome, HNPCC, Li-
Fraumeni syndrome, or Cowden syndrome)
• Other breast disease in female and male relatives: type of
disease; age at time of occurrence; treatment and results
Personal and Social History
• Age
• Breast support used with strenuous exercise or sports
activities
• Amount of caffeine intake; impact on breast tissue
• Breast self-awareness/self-examination: frequency; at what
time in the menstrual cycle; see Staying Well, “Breast Self-
Examination and Self-Awareness”
• Use of alcohol; daily amounts
• Use of anabolic steroids or marijuana
Staying Well
Breast Self-Examination and Self-Awareness
Breast self-awareness has largely replaced breast self-examination
(BSE) as a tool in the detection of breast cancer. The American Cancer
Society supports both options and recommends that women be
informed about the potential benefits and limitations associated
with BSE (ACS, 2014). The U.S. Preventive Services Task Force
(USPSTF, 2009) recommends against teaching BSE. The lesson
learned from a randomized clinical trial is that intensive teaching of
BSE does not improve its effectiveness (Thomas et al, 2002) and that
self-awareness may be more effective for detecting breast cancer
than structured BSE. Every woman should be familiar with her own
breasts and should report any breast change promptly to her health
care provider. Women can notice changes in their breasts by being
aware of how their breasts normally feel and feeling their breasts
for changes. As you discuss self-awareness, it would be an appropri-
ate time to review the accepted recommendations for early breast
cancer detection (Box 16-1) and to discuss the issues related to breast
cancer screening.
  Pregnant Women
• Sensations: fullness, tingling, tenderness
• Presence of colostrum and knowledge about how to care for
breasts and nipples during pregnancy
• Use of supportive bra
• Knowledge and information about breast-feeding
• Plans to breastfeed, experience, expectations, concerns
  Lactating Women
• Cleaning procedures for breasts: use of soap products that
can remove natural lubricants, frequency of use; nipple
preparations
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CHAPTER 16  Breasts and Axillae 355
• Use of breast-feeding bra
• Nipples: tenderness, pain, cracking, bleeding; retracted;
Examination and Findings
related problems with feeding; exposure to air
• Associated problems: engorgement, leaking breasts, plugged
duct (localized tenderness and lump), fever, infection; treat-
ment and results; infant with oral candidal infection
• Breast-feeding routine: length of feeding, frequency, rotation
of breasts, positions used
• Breast milk pumping devices used, frequency of use
• Cultural beliefs about breast-feeding
• Food and environmental agents that can affect breast milk
(e.g., chocolate, alcohol, pesticides)
• Medications that can cross the milk-blood barrier (e.g.,
cimetidine, clemastine, thiouracil); all medications—pre-
scription and nonprescription—should be evaluated for
potential side effects in the newborn.
  Older Adults
• Skin irritation under pendulous breasts from tissue-to-tissue
contact or from rubbing of undergarments; treatment
• Hormone therapy during or since menopause: name and
dosage of medication; duration of therapy
EXAMINATION AND FINDINGS
Equipment
• Small pillow or folded towel
• Ruler
• Flashlight with transilluminator
• Glass slide and cytologic fixative, if nipple discharge is
present
Adequate lighting is essential for revealing shadows and
subtle variations in skin color and texture. Adequate exposure is
also essential, requiring that the patient be disrobed to the waist.
Simultaneous observation of both breasts is necessary to detect
minor differences between them that may be significant. Stay
attentive for modesty concerns and convey the need for full expo-
sure. The presence of a chaperone may ease discomfort and
protect both the patient and the examining health care provider
and is recommended with adolescent patients.
Inspection
Breasts
As the patient sits with arms hanging loosely at the sides, inspect
each breast and compare it with the other for size, symmetry,
contour, skin color and texture, venous patterns, and lesions.
Perform this portion of the examination for both women and
men. With female patients, lift the breasts with your fingertips,
inspecting the lower and lateral aspects to determine changes in
the color or texture of the skin.
Women’s breasts vary in shape, from convex to pendulous or
conical, and often one breast is somewhat smaller than the other
(Fig. 16-4). Men’s breasts are generally even with the chest wall,
although some men, particularly those who are overweight, have
breasts with a convex shape.
Examination and Findings 356 CHAPTER 16  Breasts and Axillae

A B C

D E

FIGURE 16-4  Variations in breast size and contour. A, Conical. B, Convex. C, Pendulous. D, Large pendu-
lous. E, Right larger than left.

The skin texture should appear smooth and the contour

should be uninterrupted. Alterations in contour are best seen on
bilateral comparison of one breast with the other. Retractions
and dimpling signify the contraction of fibrotic tissue that may
occur with carcinoma. A peau d’orange (orange skin) appearance
of the skin indicates edema of the breast caused by blocked
lymph drainage in advanced or inflammatory breast cancer (Fig.
16-5). The skin appears thickened with enlarged pores and
accentuated skin markings. Healthy skin may look similar if the
pores of the skin are large.
Venous networks may be visible, although they are usually
pronounced only in the breasts of pregnant or obese women.
Venous patterns should be symmetric. Unilateral venous pat- FIGURE 16-5  Peau d’orange appearance from edema. (From Gallager,
terns can be produced by dilated superficial veins as a result of 1978.)
increased blood flow to a malignancy. This finding requires
further investigation.
Other markings and nevi that are long-standing, unchanging, women the areola usually turns brown with the first pregnancy
or nontender are usually of little concern. Changes in or the and remains dark. In women with dark skin, the areola is brown
recent appearance of any lesions always signal the need for closer before pregnancy. A peppering of nontender, nonsuppurative
investigation. Montgomery tubercles is a common expected finding (Fig. 16-6).
The surface should be otherwise smooth. The peau d’orange skin
Nipples and Areolae associated with cancer is often seen first in the areola.
Inspect the areolae and nipples of both men and women. The Most nipples are everted, but one or both nipples may be
areola should be round or oval and bilaterally symmetrical or inverted (Fig. 16-7), with the nipple tucked inward. In these
nearly so. The color ranges from pink to black. In light-skinned instances, ask whether there is a lifetime history of inversion.

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 CHAPTER 16  Breasts and Axillae 357

Examination and Findings

A B

FIGURE 16-6  Montgomery tubercles. A, Light-skinned woman. B, Dark-skinned woman. (A, from Mansel
and Bundred, 1995.)

A B

FIGURE 16-7  A, Left nipple inverted; right nipple everted. B, Close-up of nipple inversion. (From Lemmi and
Lemmi, 2000.)

Fig. 16-19). The fibrotic tissue of carcinoma can also change the
axis of the nipple, causing it to point in a direction different from
that of the other nipple.

Video: Inspecting the Breasts in Different Positions

FIGURE 16-8  Nipple retraction laterally and swelling behind right
nipple in Asian woman with breast cancer. (From Mansel and Bundred,
1995.)
Recent unilateral inversion of a previously everted nipple sug-
gests malignancy.
Simultaneous bilateral inspection is necessary to detect nipple
retraction or deviation. Retraction is seen as a flattening or
pulling back of the nipple and areola, which indicates inward
pulling by inflammatory or malignant tissue (Fig. 16-8; also see
The nipples should be a homogeneous color and match that
of the areolae. Their surface may be either smooth or wrinkled
but should be free of crusting, cracking, or discharge. Areola
color varies from light pink to very dark brown or black (Fig.
16-9). Inflammation of the sebaceous glands in the areola can
result in retention cysts that are tender and suppurative.
Supernumerary nipples, which are more common in black
women than in white women, appear as one or more extra
nipples located along the embryonic mammary ridge (the “milk
line”) (Fig. 16-10). These nipples and areolae may be pink
or brown, are usually small, and are commonly mistaken for
moles (Fig. 16-11). Infrequently, some glandular tissue may
accompany these nipples. In some cases, supernumerary nipples
may be associated with congenital renal or cardiac anomalies,
particularly in whites.
Reinspection in Varied Positions
Reinspect the woman’s breasts with the patient in the following
positions:
• Seated with arms over the head or flexed behind the neck.
This adds tension to the suspensory ligaments, accentuates

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 358 CHAPTER 16  Breasts and Axillae
Evidence-Based Practice in Physical Examination
Breast Cancer Screening
Examination and Findings
Are clinical breast examination (CBE), mammography, and magnetic
resonance imaging (MRI) effective in screening for breast cancer? A
clear distinction must be made between screening asymptomatic
women and the clinical assessment of women who have breast symp-
toms. The evidence is controversial and mixed.
CBE
The sensitivity of CBE in detecting breast cancer ranges from 40% to
69% and the specificity from 88% to 99% (USPSTF, 2012). No trial has
compared CBE alone with no screening. The sensitivity of the CBE
combined with mammography is greater than that of mammography
alone because CBE can detect cancer missed by mammography. Pro-
portions of breast cancers found by CBE but missed by mammography
range from 5.2% to 29%. The value of detecting breast cancers by CBE
that are not detected by mammography is not known. The results of
randomized trials using both modalities did not demonstrate improved
results over those using only mammography. The mortality rate in
women in whom breast cancer is missed by mammography and
detected by CBE was higher in women whose cancers were detected
by mammography alone (Barton and Harris, 2009).
Mammography
The sensitivity of mammography screening is 77% to 95%, whereas
specificity is 94% to 97% (USPSTF, 2012). However, estimates of the
sensitivity and specificity of mammography in detecting breast cancer
vary and multiple factors, including age, time since last examination,
breast tissue density, equipment, and the skill of the interpreting radi-
ologist can affect sensitivity and specificity. Sensitivity is lower among
A B
FIGURE 16-9  Variations in color of areola. A, Pink. B, Brown. C, Black.
dimpling, and may reveal variations in contour and symmetry
(Fig. 16-12, A).
• Seated with hands pressed against hips with shoulders
rolled forward (or alternatively have the patient push her
palms together): This contracts the pectoral muscles, which
can reveal deviations in contour and symmetry (Fig. 16-12,
B and C).
• Seated and leaning forward from the waist: This also causes
tension in the suspensory ligaments. The breasts should hang
equally. This maneuver can be particularly helpful in assessing
the contour and symmetry of large breasts because the breasts
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women who are younger than 50 years of age, have denser breasts, or
are taking hormone replacement therapy. Specificity is increased with
a shorter screening interval and the availability of prior mammograms.
A decision analysis performed for the USPSTF projected that biennial
screening produced 70% to 99% of the benefit of annual screening and
that screening between the ages of 50 and 69 years produced a pro-
jected 17% reduction in mortality compared with no screening (USPSTF,
2009). In comparison, using the same data, another analysis showed a
39.6% mortality reduction from annual screening in women 40 to 84
years old (Hendrick and Helvie, 2011).
MRI
MRI in high-risk women without cancer has a sensitivity of 71% to
100% and a specificity of 81% to 97%. Therefore MRI is used to supple-
ment mammography and clinical breast examination for screening of
women who are at high risk of developing breast cancer from genetic
mutations (see Box 16-1). Data from a systematic review indicate that
screening with both MRI and mammography might rule out cancerous
lesions better than mammography alone in women who are known or
likely to have an inherited predisposition to breast cancer (Warner et al,
2011). No studies have been done using MRI to screen women at
average risk. Therefore, for average-risk women, MRI is reserved for
diagnostic evaluation.
It is important to educate patients about the likelihood and signifi-
cance of both false-positive and false-negative test results and address
the associated issues of uncertainty, anxiety, and cost.
C
fall away from the chest wall and hang freely. As the patient
leans forward, support her by the hands (Fig. 16-12, D).
For all patient positions, the breasts should appear bilaterally
symmetrical, with an even contour and absence of dimpling,
retraction, or deviation.
Palpation
After a thorough inspection, systematically palpate the breasts,
axillae, and supraclavicular and infraclavicular regions. Palpation
of male breasts can be brief but should not be omitted.
 CHAPTER 16  Breasts and Axillae 359

Examination and Findings

A

FIGURE 16-11  A, Supernumerary nipple without glandular tissue.

B, Supernumerary breast and nipple on left side and supernumerary
FIGURE 16-10  Supernumerary nipples and tissue may arise along the nipple alone on right side. (B, From Mansel and Bundred, 1995.)
“milk line,” an embryonic ridge. (From Thompson et al, 1997.)

A C

B D

FIGURE 16-12  Inspect the breasts in the following positions. A, Arms extended overhead. B, Hands
pressed against hips. C, Pressing hands together (an alternative way to flex the pectoral muscles). D, Leaning
forward from the waist.

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Examination and Findings 360 CHAPTER 16  Breasts and Axillae
FIGURE 16-13  Chest wall sweep. With the palm of your hand, sweep
from the clavicle to the nipple, covering the area from the sternum to the
midaxillary line.
FIGURE 16-14  Bimanual digital palpation. Walk your fingers across the
breast tissue, compressing it between your fingers and the palmar
surface of your other hand.
Patient in Seated Position
Chest Wall Sweep.  Have the patient sit with arms hanging
freely at the sides. Place the palm of your right hand at the
patient’s right clavicle at the sternum. Sweep downward from
the clavicle to the nipple, feeling for superficial lumps. Repeat
the sweep until you have covered the entire right chest wall.
Video: Palpating Lymph Nodes near the Breasts
Repeat the procedure using your left hand for the left chest wall
(Fig. 16-13).
Bimanual Digital Palpation.  Place one hand, palmar surface
facing up, under the patient’s right breast. Position your hand so
that it acts as a flat surface against which to compress the breast
tissue. With the fingers of the other hand, walk across the breast
tissue, feeling for lumps as you compress the tissue between your
fingers and your flat hand. Repeat the procedure for the other
breast (Fig. 16-14).
Lymph Node Palpation.  Palpate for lymph nodes in both
male and female patients. To palpate the axillae, have the patient
seated with arms flexed at the elbow. Support the patient’s left
lower arm with your left hand while examining the left axilla with
your right hand, as shown in Figure 16-15. With the palmar
surface of your fingers, reach deeply into the axillary hollow,
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FIGURE 16-15  Palpation of the axilla for lymph nodes.
pushing firmly so that you are gently rolling the soft tissue against
the chest wall and muscles of the axilla. From the apex, palpate
downward to the bra line and also along the inner aspect of the
upper arm down to the elbow. Reposition your fingers to palpate
the medial aspect along the rib cage and into the anterior wall
along the pectoral muscles. Reposition again to palpate the pos-
terior wall along the border of the scapula. Repeat the mirror
image of this maneuver for the right axilla.
Palpate the supraclavicular and infraclavicular areas for the
presence of enlarged nodes. Hook your fingers over the clavicle
and rotate them over the entire supraclavicular fossa. Have the
patient turn his or her head toward the side being palpated and
raise the same shoulder, allowing your fingers to reach more
deeply into the fossa. Have the patient bend the head forward to
relax the sternocleidomastoid muscle. These nodes are consid-
ered to be sentinel nodes (Virchow nodes), so any enlargement
is highly significant. Sentinel nodes are indicators for invasion of
the lymphatics by cancer. Move your fingers to the infraclavicular
area and palpate along the clavicle using a rotary motion with
your fingers.
Lymph nodes in these areas are not usually palpable in the
healthy adult. Palpable nodes may be the result of an inflamma-
tory or malignant process. Move your fingers to the infraclavicu-
lar area and palpate along the clavicle using a rotary motion with
your fingers. Nodes that are detected should be described accord-
ing to location, size, shape, consistency, tenderness, fixation, and
delineation of borders (see Chapter 9).
Patient in Supine Position
Have the patient raise one arm behind her head; then place a
small pillow or folded towel under that shoulder to spread the
breast tissue more evenly over the chest wall (Fig. 16-16). The
ideal position for examination is to have the nipple pointing
toward the ceiling. Women with large breasts may need to
roll slightly to achieve this position. Palpate each breast
separately.
Palpate all areas of breast tissue, feeling for lumps or nodules
(Box 16-2). Remember that the breast tissue extends from the
second or third rib to the sixth or seventh rib, and from the
sternal margin to the midaxillary line. It is essential to include

Box 16-2  Documenting Breast Masses
If a breast mass is felt, characterize it by its location, size, shape,
consistency, tenderness, mobility, delineation of borders, and retrac-
tion (see Figs. 16-21 and 16-22). Ultrasound can be used to confirm
the presence of fluid in certain masses. These characteristics are not
diagnostic by themselves but in conjunction with a thorough history,
they provide a great deal of clinical information for correlation with
findings from diagnostic testing.
Describe any breast mass or lump that you encounter using the
following characteristics:
• Location: clock positions and distance from nipple
• Size (in centimeters): length, width, thickness
• Shape: round, discoid, lobular, stellate, regular or irregular
• Consistency: firm, soft, hard
• Tenderness
• Mobility: movable (in what directions) or fixed to overlying skin
or subadjacent fascia
• Borders: discrete or poorly defined
• Retraction: presence or absence of dimpling; altered contour
All new solitary or dominant masses must be investigated with
further diagnostic testing.
FIGURE 16-16  Supine position for palpation.
Vertical strip
A B
FIGURE 16-17  Various methods for palpation of the breast. A, Palpate from top to bottom in vertical strips.
B, Palpate in concentric circles. C, Palpate out from the center in wedge sections.
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CHAPTER 16  Breasts and Axillae 361
the tail of Spence in palpation. Recall that the greatest amount
of glandular tissue lies in the upper outer quadrant of the breast,
Examination and Findings
with tissue extending from this quadrant into the axilla to form
the tail of Spence.
Palpate using your finger pads as they are more sensitive than
your fingertips. Palpate systematically, pushing gently but firmly,
toward the chest wall, as you rotate your fingers in a clockwise
or counterclockwise pattern. At each point, as you rotate your
fingers, press inward, using three depths of palpation: light, then
medium, and finally deep. The exact sequence you select for
palpation is not critical, but a systematic approach will help
ensure that all portions of the breast are examined. Figure 16-17
illustrates three methods that are commonly used. In the vertical
strip technique, begin at the top of the breast and palpate, first
downward, then upward, working your way down over the entire
breast. In the concentric circle technique, begin at the outermost
edge of the breast tissue and spiral your way inward toward the
Video: Breasts and Axillae: Following Patterns for
nipple. To use the wedge method, palpate from the center of the
breast in radial fashion, returning to the areola to begin each
spoke. Regardless of the method, glide your fingers from one
point to the next. Avoid lifting your fingers off the breast tissue
because doing so makes it easy to miss tissue.
Early lesions can be tiny and may be detected only through
meticulous technique. If a breast mass is felt, note its character-
istics and palpate its dimensions, consistency, and mobility (Fig.
16-18) and whether it causes dimpling or retraction (Fig. 16-19;
Breast Palpation
see Box 16-2). Also see Staying Well, “Breast Health.”
At the completion of the examination, return to the nipple
and with two fingers, gently depress the tissue inward into the
well behind the areola. Your fingers and tissue should move easily
inward (Fig. 16-20).
Nipple compression should be performed only if the patient
reports spontaneous nipple discharge (see Clinical Pearl, “Nipple
Compression”). Determine whether the discharge is bilateral or
unilateral. Use a magnifying glass to look closely at the nipple to
determine whether the discharge is from a single duct or multiple
Circular Wedge
C
Examination and Findings 362 CHAPTER 16  Breasts and Axillae

A B C

FIGURE 16-18  A, Palpating for consistency of a breast lesion. B, Palpating for delineation of borders of
breast mass. C, Palpating for mobility of breast mass.

Breast
cancer

Skin
dimpling

A Flattening B
of nipple

FIGURE 16-19  A, Clinical signs of cancer. B, Nipple retraction and dimpling of skin. (B, From Lemmi and
Lemmi, 2000.)

FIGURE 16-20  Depressing nipple inward into well behind the areola.
Staying Well
Breast Health: Can Breast Cancer Be Prevented?
At this time there is no guaranteed way to prevent breast cancer. The
best preventive health strategy is to reduce known risk factors when-
ever possible. Maintaining a healthy weight, engaging in regular
physical activity, reducing alcohol intake to no more than one drink a
day for women, and avoiding the use of postmenopausal combination
hormone therapy are lifestyle changes that can decrease the risk of
breast cancer.
Women who are at increased risk of breast cancer may consider
chemoprevention. Tamoxifen has been shown to reduce the risk by
almost 50% in women who are at high risk (Fisher et al, 1998).
Raloxifene is equally effective in reducing the risk of invasive breast
cancer (Vogel et al, 2006). Women at very high risk may elect pro-
phylactic mastectomy, which has been shown to reduce the risk of
developing breast cancer by about 90% (Hartmann et al, 2001).

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 CHAPTER 16  Breasts and Axillae 363

Examination and Findings

A B C

D E F

FIGURE 16-21  Types of nipple discharge. A, Milky discharge. B, Multicolored sticky discharge. C, Purulent
discharge. D, Watery discharge. E, Serous discharge. F, Serosanguineous discharge. (From Gallager, 1978.)

ducts. Characteristics of concern include spontaneous discharge Males.  In most men, expect to feel a thin layer of fatty tissue
that is unilateral and from a single duct. Figure 16-21 shows overlying muscle. Obese men may have a somewhat thicker fatty
various types of nipple discharge. layer, giving the appearance of breast enlargement. A firm disk
of glandular tissue can be felt in some men.

Clinical Pearl   Infants

Nipple Compression
Nipple compression to provoke discharge is no longer performed as
part of routine clinical breast examination. Many benign circum-
stances including prior breast-feeding and nipple stimulation as a part
of sexual activity can result in nipple discharge when the nipple is
compressed.
Females.  The breast tissue of adult women will feel dense, firm,
and elastic. Expected variations include the lobular feel of glan-
dular tissue (soft nondiscrete bumps diffusely dispersed through-
out the breast tissue) and the fine, granular feel of breast tissue
in older women. A firm transverse ridge of compressed tissue
(the inframammary ridge) may be felt along the lower edge of
the breast. It is easy to mistake this for a breast mass. A cyclical
pattern of breast enlargement, increased nodularity, and tender-
ness is a common response to hormonal changes during the
menstrual cycle. Be aware of where the woman is in her cycle
because these changes are most likely to occur premenstrually
and during menses. They are least noticeable during the week
after menses. The procedure for examining the patient who has
had a mastectomy is described in Box 16-3.
The breasts of many well newborns, male and female, are enlarged
for a relatively brief time as a result of passively transferred
maternal estrogen. If you squeeze the breast bud gently, a small
amount of clear or milky white fluid, commonly called “witch’s
milk,” is sometimes expressed. The enlargement is rarely more
than 1 to 1.5 cm in diameter and can be easily palpated behind
the nipple. It usually disappears within 2 weeks and rarely lasts
beyond 3 months of age.
  Children and Adolescents
The right and left breasts of the adolescent female may not
develop at the same rate. Reassure the girl that this asymmetry
is common and that her breasts are developing appropriately.
Chapter 6 describes the stages of breast development. Breast
tissue of the adolescent female feels homogeneous, dense, firm,
and elastic. Although malignancy in this age group is rare, routine
examination provides an excellent opportunity for reassurance
and education for the girl and the parent.
Many males at puberty have transient unilateral or bilateral
subareolar masses. These are firm, sometimes tender, and are
often a source of great concern to the patient and his parents.
Reassure them that these breast buds will most likely disappear,

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 364 CHAPTER 16  Breasts and Axillae

Box 16-3  Examining the Patient Who Has

Had a Mastectomy
Examination and Findings

• The patient who has had a mastectomy has special examination

needs. In addition to examining the unaffected breast in the
usual manner, you must examine the mastectomy site, with
particular attention to the scar. If malignancy recurs, it may be
at the scar site. Be aware that a woman who has had a
mastectomy may feel uncomfortable removing her bra and
prosthesis if she wears one.
• Inspect the mastectomy site and axilla for any visible signs of
swelling, lumps, thickening, redness, color change, rash, or
irritation to the scar. Note muscle loss or lymphedema that may A
be present, depending on the type and extent of the surgical
procedure.
• Palpate the surgical scar with two fingers, using small, circular
motions to assess for swelling, lumps, thickening, or
tenderness. Then palpate the chest wall using three or four
fingers in a sweeping motion across the area, being sure not to
miss any spots. Intercostal residual breast tissue may exist.
Position your fingers on either side of each rib and run your
fingers along the anterior ribs, using a stripping motion.
Remember to use your finger pads and not your fingertips.
Finally, palpate for lymph nodes in the axillary and C
supraclavicular and infraclavicular areas.
• If the patient has had breast reconstruction, augmentation, or a B
lumpectomy, perform breast examination in the usual manner,
with particular attention to any scars and new tissue. FIGURE 16-22  Breast changes in pregnancy. A, Note venous network,
Have this patient demonstrate her breast self-examination proce- darkened areolae and nipples, and vascular spider. B, Increased pigmen-
dures. Regular monthly breast self-examination is an essential com- tation and the development of raised sebaceous glands known as Mont-
ponent of continuing health care for these women. gomery tubercles. C, Marked pigmentation in woman with dark skin.
(B, C, From Symonds and Macpherson, 1994.)

usually within a year. They seldom enlarge to a point of cosmetic
difficulty.
Occasionally, pubescent males experience gynecomastia,
breast enlargement that is readily noticeable. Fortunately, it is
usually temporary and benign and resolves spontaneously. If the
enlargement is extreme, it can be corrected surgically for psycho-
logic or cosmetic reasons. In rare instances, biopsy is required to
rule out the presence of cancer. Gynecomastia can be associated
with the use of either prescription or illicit drugs, particularly
marijuana. Symptoms resolve after the drugs are discontinued.
  Pregnant Women
Many changes in the breasts occur during pregnancy. Most
become obvious during the first trimester. The woman may expe-
rience a sensation of fullness with tingling, tenderness, and a
bilateral increase in size. It is important to ascertain that the
woman is providing adequate support for her breasts with a
properly fitting bra. As her breasts continue to enlarge, she may
need to alter the size and style of the bra.
Generally, the nipples enlarge and are more erectile. As
the pregnancy progresses, the nipples sometimes become flat-
tened or inverted. A crust caused by dried colostrum can be
evident on the nipple. Inspect the breasts and expect to see
areolae that are broader and darker. Montgomery tubercles are
common (Fig. 16-22).
Palpation reveals a generalized coarse nodularity, and the
breasts feel lobular because of hypertrophy of the mammary
alveoli. Dilated subcutaneous veins may create a network of blue
tracing across the breasts.
During the second trimester, telangiectasias (called spider
angiomas or vascular spiders) may develop on the upper chest,
arms, neck, and face as a result of elevated levels of circulating
estrogen. The spiders are bluish in color and do not blanch with
pressure. Striae may be evident as a result of stretching as the
breasts increase in size.

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 CHAPTER 16  Breasts and Axillae 365

  Lactating Women   Older Adults

During lactation, it is important to assess whether the breasts The breasts in postmenopausal women may appear flattened,
are adequately supported with a properly fitting bra. Palpate elongated, and suspended more loosely from the chest wall as
the breasts to determine the degree of softness. Full breasts, the result of glandular tissue atrophy and relaxation of the
which are firm, dense, and slightly enlarged, may become suspensory ligaments. A finer granular feel on palpation replaces

engorged. Engorged breasts feel hard and warm and are
enlarged, shiny, and painful. Engorgement is not an unusual
condition in the first 24 to 48 hours after the breasts fill with
milk; however, its later development may signal the onset of
mastitis.
Clogged milk ducts are a relatively common occurrence in
lactating women. A clogged duct may result from either inade-
quate emptying of the breast or a bra that is too tight. The
clogged duct will create a tender spot on the breast that may feel
lumpy and hot. Frequent breast-feeding and/or expression of
the milk, along with local application of heat, will help open the
duct. A clogged duct left unattended may result in the develop-
ment of mastitis.
Abnormalities
the lobular feel of glandular tissue. The inframammary ridge
thickens and can be felt more easily. The nipples become smaller
and flatter.
Sample Documentation
History and Physical Examination
Subjective
A 42-year-old woman noticed a lump in her right lower breast last
week. Denies nipple discharge or skin changes. Reports normal mam-
mogram 2 years ago. Has never had a breast lump or breast biopsy.
Currently on last day of menses. Has breast tenderness just before
menses but denies breast pain today. No personal or family history of
breast cancer or related cancers.

Audio Examination Summaries: Physical

Examine the nipples for signs of irritation (redness and ten- Objective

examination of the breasts and axillae

derness) and for blisters or petechiae, which are precursors of
overt cracking. Cracked nipples will be sore and may be bleeding.
Lighter-colored nipples are no more prone to damage from
breast-feeding than are darker nipples. Nipple damage from
breast-feeding is associated with placement of the nipple in the
infant’s mouth.
After pregnancy and lactation, there is regression of most
of these changes. The areolae and nipples tend to retain their
darker color, and the breasts become less firm than in their pre-
pregnant state.
Breasts: moderate size, conical shape, breasts symmetric with left
slightly larger than right. No skin lesions; contour smooth bilaterally
without dimpling or retraction; venous patterns symmetric. Nipples
symmetric without discharge; Montgomery tubercles bilaterally. Tissue
diffusely nodular particularly in upper quadrants. In left lower quadrant
of the right breast, a 3 cm × 3 cm × 2 cm soft mass, 5 cm from nipple.
Mobile, nontender, borders smooth. Nipples depress into wells easily.
No supraclavicular, infraclavicular, or axillary lymphadenopathy.
For additional sample documentation, see Chapter 26, pp.
628-631.

ABNORMALITIES
BREASTS
BREAST LUMPS
See the Differential Diagnosis table for characteristic differences between fibrocystic changes, fibroadenomas, and breast cancer. The differential signs
and symptoms will help guide the next step(s) for diagnosis.

DIFFERENTIAL DIAGNOSIS
Signs and Symptoms of Breast Masses
Characteristic Fibrocystic Changes Fibroadenoma Cancer
Age range (yr) 20 to 49 15 to 55 30 to 80
Occurrence Usually bilateral Usually bilateral Usually unilateral
Number Multiple or single Single; may be multiple Single
Shape Round Round or discoid Irregular or stellate
Consistency Soft to firm; tense Firm, rubbery Hard, stonelike
Mobility Mobile Mobile Fixed
Retraction signs Absent Absent Often present
Tenderness Usually tender Usually nontender Usually nontender
Borders Well delineated Well delineated Poorly delineated; irregular
Variation with menses Yes No No

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 366 CHAPTER 16  Breasts and Axillae

Fibrocystic Changes
Benign fluid-filled cyst formation caused by ductal enlargement
Pathophysiology Subjective Data Objective Data
• Usually bilateral and multiple • Tender and painful breasts and/or • Round, soft to firm, tense, mobile masses
Abnormalities

• Most common in women 30 to 55 years palpable lumps that fluctuate with menses with well-delineated borders
of age • Usually worse premenstrually • Usually tender
• Associated with a long follicular or luteal • Usually bilateral
phase of the menstrual cycle • Multiple or single

Fibroadenoma
Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit
Pathophysiology Subjective Data Objective Data
• May occur in girls and women of any age • Painless lumps that do not fluctuate with • Round or discoid, firm, rubbery, mobile
during their reproductive years the menstrual cycle masses with well-delineated borders
• After menopause, the tumors often • May be asymptomatic with discovery on • Usually nontender
regress. clinical breast examination or breast • Usually bilateral
imaging • Single; may be multiple
• Biopsy often performed to rule out carcinoma

Malignant Breast Tumors

Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules.
Pathophysiology
• Mutations to normal cells result in
uncontrolled cell division and tumor
formation; as the tumor grows and
invades surrounding tissue, metastases
occur through the lymph and vascular
systems.
• Peak incidence between ages 40 and 75
years, with the majority of malignant
breast tumors occurring in women older
than 50 years
Subjective Data
• Painless lump; change in size, shape, or
contour of breast
• Axilla may be tender if lymph nodes
involved
• May be asymptomatic with discovery on
clinical breast examination or breast
imaging
Objective Data
• May have palpable mass that is usually
single; unilateral, irregular, or stellate in
shape; poorly delineated borders; fixed; hard
or stonelike; and nontender
• Breast may have dimpling, retraction,
prominent vasculature
• Skin may have peau d’orange or thickened
appearance.
• Nipple may be inverted or deviate in position
(Fig. 16-23).

A B

FIGURE 16-23  A, Patient with lump and nipple retraction in left breast. B, Patient with altered nipple height resulting from breast
cancer in left breast. (From Mansel and Bundred, 1995.)

Fat Necrosis
Benign breast lump occurs as inflammatory response to local injury
Pathophysiology Subjective Data Objective Data
• Necrotic fat and cellular debris become • History of trauma to the breast (including • Firm, irregular mass, often appearing as an
fibrotic and may contract into a scar. surgery) area of discoloration (Fig. 16-24)
• Painless lump • May mimic breast malignancy on clinical
examination or breast imaging, requiring
biopsy for diagnosis

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 CHAPTER 16  Breasts and Axillae 367

Abnormalities
FIGURE 16-24  Fat necrosis presenting as a hard
mass in the breast following an episode of trauma
sufficient to cause bruising. (From Mansel and
Bundred, 1995.)

NIPPLES AND AREOLAE

Intraductal Papillomas and Papillomatosis
Benign tumors of the subareolar ducts that produce nipple discharge
Pathophysiology Subjective Data Objective Data
• Epithelial hyperplasia produces a wartlike • Spontaneous nipple discharge • Single-duct unilateral nipple discharge
tumor in a lactiferous duct. • Usually unilateral provoked on physical examination
• 2 to 3 cm in diameter • Usually serous or bloody • Mass behind the nipple may or may not be
• May occur singly or in multiples present
• May need to be excised and examined to rule
out malignancy

Duct Ectasia
Benign condition of the subareolar ducts that produces nipple discharge
Pathophysiology
• Subareolar ducts become dilated and
blocked with desquamating secretory
epithelium, necrotic debris, and chronic
inflammatory cells.
• Occurs most commonly in menopausal
women
Subjective Data Objective Data
• Spontaneous unilateral or bilateral nipple • Single or multiductal, unilateral or bilateral
discharge nipple discharge provoked on physical
• Discharge often green or brown in color examination
• Discharge may be sticky • Mass behind the nipple may or may not be
present
• Breast may or may not be tender
• Nipple retraction may be present.

Galactorrhea
Lactation not associated with childbearing
Pathophysiology
• Elevated levels of prolactin, resulting in
milk production, occur as a result of
disruption of the communication between
the pituitary and hypothalamus glands.
• Common causes include pituitary
secreting tumors, hypothalamic-pituitary
disorders, systemic diseases, numerous
medications and herbs, physiologic
conditions, or local factors.
Subjective Data Objective Data
• Spontaneous nipple discharge, usually • Multiductal nipple discharge may or may
bilateral; usually serous or milky not be provoked on physical examination
• Possible related medical history: (Fig. 16-25).
amenorrhea, pregnancy, post abortion, • No mass
hypothyroidism, Cushing syndrome,
chronic renal failure
• Possible medication history:
phenothiazines, tricyclic antidepressants,
some antihypertensive agents, estrogens,
H2 receptor blockers, marijuana,
amphetamines, opiates
• Possible physiologic history: suckling,
stress, dehydration, exercise, nipple
stimulation

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Abnormalities 368 CHAPTER 16  Breasts and Axillae

FIGURE 16-25  Galactorrhea produced by a prolactin-secreting pitu-

itary tumor. (From Mansel and Bundred, 1995.)

Paget Disease
Surface manifestation of underlying ductal carcinoma
Pathophysiology Subjective Data Objective Data
• Migration of malignant epithelial cells from • Crustiness of the nipple, areola, and • Red, scaling, crusty patch on the nipple,
the underlying intraductal carcinoma via the surrounding skin areola, and surrounding skin (Fig. 16-26)
lactiferous sinuses into nipple skin • Pruritus of the nipple common • May be unilateral or bilateral
• Tumor cells disrupt the epithelial barrier, • Appears eczematous but, unlike eczema,
allowing extracellular fluid to seep out onto does not respond to steroids
the nipple surface.

FIGURE 16-26  Paget disease. (From Callen et al, 2000.)

Mastitis
Inflammation and infection of the breast tissue
Pathophysiology
• Most infections are staphylococcal, often
Staphylococcus aureus.
• Most common in lactating women after milk • Usually accompanied by chills, fever
is established, usually the second to third
week after delivery; however, it may occur at
any time.
• Abscess formation can result.
Subjective Data Objective Data
• Characterized by sudden onset of swelling, • Tender, hard breast mass, with an area of
tenderness, redness, and heat in the breast fluctuation, erythema, and heat
• May have discharge of pus (suppuration)
• Underlying pus-filled abscess may impart a
bluish tinge to the skin (Fig. 16-27).

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 CHAPTER 16  Breasts and Axillae 369

Abnormalities
FIGURE 16-27  Mastitis. (From Lemmi and Lemmi, 2000)

Gynecomastia
Breast enlargement in men
Pathophysiology Subjective Data Objective Data
• Result of increased body fat; hormone • Breast enlargement (Figs. 16-28 and • Smooth, firm, mobile, tender disk of breast
imbalance from puberty or aging; by 16-29) tissue located behind the areola
testicular, pituitary, or hormone-secreting • Relevant medication history • Usually nontender
tumors; by liver failure; or by a variety of • May be unilateral or bilateral
medications including anabolic steroids, • Amount of breast tissue varies; can be small
marijuana, some antihypertensives, some overgrowth of breast tissue around the areola
antipsychotics, or those containing and nipple, to larger, more “female”-looking
estrogens or antiandrogens breasts
• When testosterone levels are low relative
to estrogen, breasts grow larger and are
more noticeable.
• Increased body fat, which in turn
produces more estrogen, can also cause
breast enlargement.

FIGURE 16-28  Adult gynecomastia. (From Mansel and Bundred,

1995.)
FIGURE 16-29  Prepubertal gynecomastia, small and
subareolar. (Courtesy Wellington Hung, MD; Children’s
National Medical Center; Washington, DC.)

  Children
Premature Thelarche
Breast enlargement in girls before onset of puberty
Pathophysiology Subjective Data Objective Data
• Cause unknown • Breast enlargement • Degree of enlargement varies from very slight
• Breasts continue to enlarge slowly to fully developed breasts.
throughout childhood until full • Usually occurs bilaterally
development is reached during • Other signs of sexual maturation may be
adolescence. absent.

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