the breast- lecture 1

The breastBy

Dr. Imad Wajeh

Introduction

A. Embryologically: belong to integument (skin)

B. Functionally: part of reproductive system

C. Modified apocrine sweat glands - apex of cell becomes part of secretion and breaks off

Embryology

The mammary milk line

Embryology

At the fifth or sixth week of fetal development, two ventral bands of thickened ectoderm (mammary ridges, milk lines) are evident in the embryo. In most mammals, paired breasts develop along these ridges, which extend from axilla to the inguinal area.

Physiology

• The Breast is an apocrine gland modified for the formation of milk under normal physiological circumstances.

• The breast remains undeveloped in the female until puberty, when it enlarges in response to ovarian estrogen and progesterone, which initiate proliferation of the epithelial and connective tissue elements.

Physiology

The breast at different physiological stages. The central column contains three-dimensional depictions of microscopy structures. A. Adolescence. B. Pregnancy. C. Lactation. D. Senescence.

Physiology

• Hormonal Effects– Estrogen

• Development of the breast and lactiferous ducts

– Progesterone• Secretory acinar tissue – lobules

– Prolactin• Synergizes the effect of estrogen and progesterone

Breast Anatomy

• The breast extends from : 1. clavicle superiorly.2. Mid-sternal line medially.3. 7th or 8th rib inferiorly.4. Anterior axillary line & axilla laterally .• Base is circular, either flattened or concave.• Separated from pectoralis major muscle by fascia,

retromammary space.• Axillary tail: prolongation of upper, outer quadrant of the

breast in axillary direction.

Breast Anatomy

Breast Anatomy

Nipple:– Level at fourth intercostal space– Small conical/cylindrical prominence below

center– Surrounded by areola – Pigmented ring of skin– Thin skinned region lacking hair, sweat glands– Contains areolar glands

Breast Anatomy

Areola: • Contains dark pigment that intensifies with

pregnancy.• Circular and radial smooth muscle fibers,

cause nipple erection

Breast Anatomy

Breast Anatomy

Three tissue types:1. Glandular epithelium Alveoli ductules (10-100 Lobules) lactiferous

ducts (15-20 Lobes) ampulla2. Fibrous stroma and supporting structures( Cooper

ligaments) it is a fibrous continuations of the superficial fascia, which span the parenchyma of the breast to the deep fascial layers.

3. Fat surrounds surface, fills spaces between lobes

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy

Breast Anatomy

– Arterial supply1. Internal mammary artery2. Lateral thoracic artery

– Venous return1. Intercostals2. Axillary vein (primarily)3. Internal mammary vein

Breast AnatomyArterial supply

1. Internal mammary artery2. Lateral thoracic artery

Breast Anatomy

Breast Anatomy

Lymphatic:- It is primarily to the axilla 75%.There are 6 axillary lymph node groups:(1) the lateral group along axillary vein. (2) the anterior group along lat. thoracic vessels.(3) the posterior or subscapular group.(4) the central group, embedded in fat in the centre of the axilla . (5) the subclavicular group (apical).(6) the interpectoral group (Rotter’s).- Only minor portion is to the internal mammary lymph nodes.

Breast Anatomy

Lymphatic Routes of Metastasis

1. From medial lymphatics to parasternal nodes then to mediastinal nodes

2. Across the sternum then to contralateral breast3. From subdiaphragmatic lymphatics to nodes in abdomen to

liver, ovaries, peritoneum

Subdiaphragmatic Lymph Channels

Channels to Contralateral Breast

Axillary Lymph Channels

Major Routes of Metastasis

Breast Anatomy

Breast Anatomy

Nerves:1. Long thoracic nerve2. Thoracodorsal nerve3. Medial pectoral nerve4. Lateral pectoral nerve

Congenital abnormalities

1. Amazia2. Polymazia3. Supernumerary nipples

Amazia

Polymazia

• Relatively common• Found along “milk line”• Most identified during

pregnancy/lactation• Most common in axilla• Not dangerous

Polymazia

Supernumerary Nipples

• More common than supernumerary breasts

• Found along milk line• May darken during

pregnancy• Not dangerous

Supernumerary Nipples

Supernumerary Nipples

Presentation

Symptoms: 1. Lump 2. Painful lump or lumpiness 3. Pain 4. Nipple discharge 5. Nipple change 6. Miscellaneous

Examination of the breast

Inspection The surgeon inspects the woman's breast with her arms by her side, with

her arms straight up in the air, and with her hands on her hips (with and without pectoral muscle contraction).

Inspection- skin, areolas , nipples, discharge – Symmetry– size– Erythema– Ulceration– Edema– Retraction– Scar– Dilated veins

Examination of the breast

Examination of the breast

Examination of the breast

• Inspection of the breast with arms at sides. B. Inspection of the breast with arms raised.

• C. Palpation of the breast with the patient supine. D. Palpation of the axilla.

Examination of the breast

Investigations of the breast

1. Mammography + xerography, Ductogram, Ductoscope 2. Ultrasound3. Magnetic resonance imaging4. Needle biopsy/cytology, tissue biopsy.

Triple Assessment • Clinical examination • Imaging ( Mammography/ US if < 35years)• Pathology (FNAC/Core needle)

Triple Assessment

Mammography

Mammography and xeromammography

Thermogram

• Transmission of detectable heat from the breast is nonspecific, and in malignant lesions results from the hypervascularity that frequently accompanies carcinoma.

Mammography

Ductogram

Ductogram

Ultrasound

Ultrasound Appearance Breast Masses

Simple Cyst Complicated Solid

Complex

Breast Cyst

Fibroadenoma

MRI

MRI

Ductoscope