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THE BREAST

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I. Introduction/GeneralInformation

A. Embryologically: belongtointegument

B. Functionally: partofreproductivesystem

1. Respondto sexual stimulation

2. Feedbabies

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Breast (mammaryglands)

Specializedaccessory skinglands thatare

capableofsecretingmilk.

Theyare presentinboth sexes.

Inmales andimmaturefemales theyare similar

in structure. As childrenreach puberty,themale

glands failtodevelop whileovarianhormonesstimulatethefemaleglands todevelop. As a

result,thealveolarglands andducts enlarge

andfatis deposited.

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II. Anatomy

A. Positionand Attachment

1. Lateralaspectofpectoralregion2. Locatedbetweenribs 3 and 6/7

3. Extendform sternumtoaxilla

4. Surroundedby superficialfascia

5. Restondeep fascia

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Breast Anatomy

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Position & attachment,continued .

6. Fixedto skin & underlying

fasciabyfibrous C.T.bandsa. Coopers (Suspensory)

Ligaments

b. Ligaments mayretract when

breasttumors are present

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Coopers Suspensory Ligaments

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Position & attachment,continued

6. Leftbreastis usually slightlylarger

7. Baseis circular,eitherflattenedor

concave

8. Separatedfrom pectoralis major

musclebyfascia,retromammaryspace

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Breast shape

Breast shapeand sizedependupongenetic,racialanddietaryfactors,andtheage, parity

andmenopausal status oftheindividual. Breasts maybehemispherical,conical,variably

pendulous, piriform orthinandflattened.

The main bulk ofthe breasttissue is usually

localizedtoits upperouter quadrant. Thisquadrantis more often implicatedinbreastcancerand inmost benignlesions ofbreasttissue.

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Retromammary Space

Retromammary

Space

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Breast Implants

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The breast is composed of:

1. The mammary gland.

2. The nipple.

3. The areola.

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NIPPLE

B. Structure

1. Outersurfaceconvex, skincovered2. Nipple:

a. Atfourthintercostal space

b. Smallconical/cylindricalprominencebelow center

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Nipplelocation

4thintercostal

space

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AREOLA

c. Surroundedbyareola: pigmented

ringofskin

d. Thin skinnedregionlackinghair,

sweatglands

e. Contains areolarglands

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Areola

3. Areola: contains dark pigmentthat

intensifies with pregnancy

a. Circularandradial smoothmuscle

fibers

b. Causenippleerection

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Areola

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MAMMARY GLAND

4. Eachbreastconsists of~ 20lobes

ofsecretorytissue

a. Eachlobehas onelactiferous ductb. Lobes (andducts) arrangedradially

c. Embeddedinconnectivetissue &

adiposeofsuperficialfascia

d. Lobes composedoflobulese. Lobules comprisealveoli

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MammaryGland

5. Excretory (lactiferous) ducts converge

towardareola

a. Formampullae (collection sites of

lactiferous sinuses)

b. Ducts becomecontractedatbaseof

nipple

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fat

Lactiferous sinus

Lactiferous ductAlveoli

(alveolargland

Suspensory

ligament

(Cooper)

Lobe

lobules

Interlobularconnectivetiss

fat

nipple

nipple

areola

ntgomeryglands

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Excretory (lactiferous) ducts

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Structure,continued

6. Secretoryepithelium

a. Changes withhormonal signals

b. Onsetofmenstruation

c. Pregnancy (glands beginto

enlargeat2ndmonth)

d. Afterbirth,1st secretioniscolostrom (containantibodies)

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Stages ofdevelopment From birth until puberty, the breast consists oflactiferous ducts, with no alveoli.

At puberty,the ducts start to proliferate,and theirterminations form solidmasses ofcellsthefuturebreastlobules.

During pregnancy, secretingalveoli appear.During theearly weeks,ductal sproutingand lobular proliferationoccur,withincreased nipple and areolar pigmentation.

The alveoli now display alumen surroundedbythesecretory cells.

Inthelastdays ofpregnancy,thebreasts secretecolostrum,ayellow, sticky, serous fluid, whichis then replacedbytruesecre- tion ofmilk. When lactationceases,the glandulartissue returns toits resting state.

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Stages ofdevelopment Afterthemenopause,theglandulartissueof

thebreastatrophies,the connectivetissue

becomes less cellular,and the amountofcollagendecreases. In some women,markedfatty infiltrationofthe breastoccurs atthis stage; in others,the breasts shrinkconsiderably.

Neonates:Occasionally,gynaecomastia mayoccur inthe neonatalbreast, with dischargeofacolostrum-likematerial (witchs milk).

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Structure,continued

7. TailofSpence = axillarytail

a. prolongationofupper,outerquadrantinaxillarydirection

b. Passes underaxillaryfascia

c. Maybemistakenforaxillarylymph

nodes

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TailofSpence

Axillary Tail

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Structure,continued

8. Fatty Tissue: surrounds surface,fills

spaces betweenlobes

a. Determines form & sizeofbreast

b. Nofattydepositundernipple &

areola

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Breast: Fatty Tissue

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Structure,continued

C. Vessels & nerves

1. Arteries: derivedfromthoracicbranches ofthree pairs ofarteries

a. Axillaryarteries

1) continuous with subclaviana.2) gives risetoexternalmammary

( = lateralthoracic) artery

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Vessels & Nerves,continued

b.Internalmammary (thoracic) arteries

1) firstdescendingbranchof

subclavianartery

2) supplyintercostal spaces & breast

3) usedforcoronarybypass surgery

c. Intercostalarteries:

1) numerous branches frominternal

& externalmammaryarteries

2) supplyintercostal spaces & breast

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Subclaviana.

Axillarya.

External

mammary

(thoracic) a.

Internal

mammary

(thoracic) a.

Arterial Supplytothe Breast

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Vessels & Nerves,continued

2. Veins:a. formaringaroundthebaseofthe

nipple (circulus venosus)b. Largeveins pass fromcirculus

venosus tocircumferenceof

mammarygland,thento

c. External mammary vtoaxillary vor

d. Internal mammary vtosubclavian v

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Veins drainingthe Breast

Subclavianvein

External

mammaryvein

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Breast Anatomy,cont

3. Innervation:derivedfrom:

a.anterior& lateralcutaneous

nerves ofthorax

b. spinal segments T3 T6

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Structure,continued

4. Lymphatics: clinically significant!

a. Glandularlymphatics draininto

anterioraxillary (pectoral) nodes centralaxillarynodes

apicalnodes

deep cervicalnodes

subclavicular(subclavian) nodesb. Medial quadrants draininto

parasternalnodes

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Subclavian

nodes

Axillary

nodes

Lateral

pectoral

nodes

Parasternal

nodes

LymphNodes ofthe Breast

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Lymphatics,continued

c. Superficialregions ofskin,areola,

nipples:-formlargechannels & draininto

pectoralnodes

d. NOTE: axillarynodes alsodrainlymphfromarm

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LymphNodes and LymphDrainage

Axillary

Nodes

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Routes ofMetastasis

Frommediallymphatics to parasternalnodes

Thentomediastinalnodes

Across the sternuminlymphatics to

opposite sideviacross-mammary pathways

Thentocontralateralbreast

From subdiaphragmaticlymphatics tonodes inabdomen

Thentoliver,ovaries, peritoneum

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Subdiaphragmatic Lymph Channels

Channels to Contralateral Breast

Axillary Lymph Channels

Major Routes ofMetastasis

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Structure,continued

D. Anomalies

1. Inverted nipple: congenitalorduetocancer

2. Ectopic nipple:

a. polytheliaorhyperthelia

b. additionalnipples alongmilk line

3.Amastia

4. Micromastia

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Anomalies,continued

5. Macromastia

6. Gynecomastiaa.breastdevelopmentofmalein

areolarregion

b. notedinmales who smoke

marijuanaat puberty

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III.Diseases ofthe Breast

A. Mostarereadilydetectable

B. Etiologyunknown,influencingfactors1. Sex

2. Heredity

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Diseases ofthebreast,continued

3. Endocrineinfluence

a. Menstruation tenderness fromfluidengorgement

b. Post-menopause

1) decreaseoffibro-cysticdisease

2) increaseincancer

c. Pregnancy

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Diseases ofthe Breast,continued

C.General symptoms & signs

1. Nippledischarge

a. always significantifnot pregnant.

b. Maybeduetobenign pituitarytumor.

2. Local pain,tenderness

3. Durationoflesion

4. Size,rateofgrowth

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Symptoms & Signs,continued

5. Retraction sign: dimplinginvolving

skin,nippleorareola6. Mobilityofmass

a. Benign = movable

1) notattached

2) notinvasiveb. Malignant = attached

1)Maygrow intobone

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Symptoms & Signs,continued

7. Consistencyofmass

a. Cysts = fluctuant;compressibleb. Fibroadenoma = rubbery

c. Carcinoma = firm,hard (likegravel)

8. Axillaryarealymphnodeenlargement

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D. Benignbreastconditions

1. Infection = usuallyduringorafter

lactation

a. Recurrent, subareolarabscessb. TB ofthebreast

2. Trauma = contusion

3. Hypertrophy = seenineithersexatadolescence

a. Gynecomastia = inmales

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Hypertrophy,continued

b. Othercauses

1) testicularorpituitarytumor

2) cirrhosis

3) hypogonadism = notenough

testosterone

4) estrogenadministrationfor

prostatecancer

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Benign Conditions,continued

4. Tumors & cysts

a. Fibroadenoma =mostcommon

benignbreast

tumor

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Tumors and Cysts,cont

b. Breast Cyst

1. Benign

2. Maybeaspiratedif

large

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Benignconditions,continued

c. Fibrocystic breast

changes

1) 20%+ofpremenopausal

women

2) discomfort,cysts

3) treatmentrarelyrequired

4)M

orelikelytonotdetectadevelopingcancer

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Tumors & cysts,continued .

d. Intraductal papilloma

- may producechocolateor

bloodydischargefrom

nipple

e. Lipoma: common

- fattytumors

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E. Carcinomaofthebreast

1. Mostcommonmalignanttumoramong

women

2. 1/8ofwomen willdevelop breastcancera.1/6 in Orange County

b.1/5in San Francisco

3. Generallynodiscomfort

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Progressionto Breast Cancer

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Carcinomaofbreast,continued

4. Physical signs:

a. Slowlygrowing, painless mass

b. Maydemonstrateretractednipple

c. Maybebleedingfromnipple

d. Maybedistortedareola,orbreast

contour

e. Skindimplinginmoreadvanced

stages withretractionofCoopers

ligaments

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Physical signs,continued

f. Attachmentofmass

g. Edemaofskin

1)with orange skinappearance

(peaudorange)

2) duetoblockedlymphatics

h. Enlargedaxillaryordeep cervical

lymphnodes

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Breast Cancer,cont

5. Common sites formetastasis

a. Lungs & pleura

b. Skeleton system (skull,vertebralcolumn,pelvis)

c. Liver

6. Atypicalcarcinomas

a. Inflammatorycarcinoma (hormonal,chemotherapy)

b. Pagets diseaseofthebreast