THE BREASTTHE BREAST

A REVIEW OFA REVIEW OF

1-EMBRYOLOGY1-EMBRYOLOGY

2-SURGICAL ANATOMY2-SURGICAL ANATOMY

3-PHYSIOLOGY3-PHYSIOLOGY

4-CLINICAL EXAMINATION (to evaluate a 4-CLINICAL EXAMINATION (to evaluate a

lump)lump)

• The breast or mammary gland is found The breast or mammary gland is found

in both sexes.in both sexes.

• Well developed in female after puberty,Well developed in female after puberty,

• Rudimentary in maleRudimentary in male

• A modified sweat gland.A modified sweat gland.

EMBRYOLOGYEMBRYOLOGY

• In 5th-6th wk of fetal developmentIn 5th-6th wk of fetal development

• Two ventral bands of thickened Two ventral bands of thickened ectoderm(MAMMARY RIDGES/MILK LINES) are ectoderm(MAMMARY RIDGES/MILK LINES) are evidentevident

• Extent of milk line/mammary ridge-from base Extent of milk line/mammary ridge-from base of forelimb(future axilla) to region of hind of forelimb(future axilla) to region of hind limb(inguinal area) limb(inguinal area)

• ridges disappear after short time except in ridges disappear after short time except in pectoral region pectoral region

• each breast develops when an ingrowth of each breast develops when an ingrowth of ectoderm forms a primary tissue bud in ectoderm forms a primary tissue bud in mesenchyme.mesenchyme.

• Primary bud initiates the development 15-20 secondary Primary bud initiates the development 15-20 secondary

budsbuds

• Epithelial cords develop from secondary buds and Epithelial cords develop from secondary buds and

extend into surrounding mesenchyme.extend into surrounding mesenchyme.

• Major(lactiferous) ducts develop,which open into shallow Major(lactiferous) ducts develop,which open into shallow

mammary pit.mammary pit.

• Proliferation of mesenchyme transforms the mammary Proliferation of mesenchyme transforms the mammary

pit into nipple.pit into nipple.

• AMASTIA:- bilateral absence of breast tissue and AMASTIA:- bilateral absence of breast tissue and nipple,nipple,

When breast tissue is absent unilaterally pectoral When breast tissue is absent unilaterally pectoral muscles are often absent.muscles are often absent.

• POLYMASTIA:- (ACCESSORY BREAST)POLYMASTIA:- (ACCESSORY BREAST)

More than one breast on one or both sides,anywhere More than one breast on one or both sides,anywhere along milk ridgealong milk ridge

• SYMMASTIA:- webbing between the breasts across SYMMASTIA:- webbing between the breasts across midlinemidline

CONGENITAL ABNORMALITIES OF BREASTCONGENITAL ABNORMALITIES OF BREAST

• POLYTHELIA:- (ACCESSORY NIPPLES)POLYTHELIA:- (ACCESSORY NIPPLES)

Imperfect development of mammary Imperfect development of mammary rudiment,so that supernumerary rudiment,so that supernumerary nipples are situated irregularly over nipples are situated irregularly over breast/or along milk ridgebreast/or along milk ridge

•ATHELIA – absence of ATHELIA – absence of nipple nipple

•INVERTED NIPPLE:- INVERTED NIPPLE:- failure of mammary pit failure of mammary pit to elevate above skin to elevate above skin levellevel

HYPOPLASIA OF BREASTHYPOPLASIA OF BREAST

• Poland syndromePoland syndrome

• turner syndrometurner syndrome

• fleischers syndromefleischers syndrome

Iatrogenic causesIatrogenic causes

• traumatrauma

• radiation therapyradiation therapy

Accessory breast tissue may occur simulating lipoma Accessory breast tissue may occur simulating lipoma

SURGICAL/ FUNCTIONAL SURGICAL/ FUNCTIONAL ANATOMYANATOMY

• Site:- lies in superficial fascia of pectoral regionSite:- lies in superficial fascia of pectoral region

• A small extension called axillary tail of Spence A small extension called axillary tail of Spence

pierces deep fascia through foramen of langer & pierces deep fascia through foramen of langer &

lies in axillalies in axilla

• Extent:- vertical- 2nd to 6th ribs inclusiveExtent:- vertical- 2nd to 6th ribs inclusive

• Horizontal- from lateral border of sternum to Horizontal- from lateral border of sternum to

anterior axillary line.anterior axillary line.

AnatomyAnatomy

AnatomyAnatomy

1.15-20 lobes

2.lobe:lobules, small branch, and larger ducts.

3.Radial fashion

4.Peripheral portions of lobes often overlap

AnatomyAnatomy

DEEP RELATIONDEEP RELATION• Breast rests onBreast rests on

- fascia of pectoralis major ms- fascia of pectoralis major ms

- serratus anterior- serratus anterior

- ext. oblique abdominis muscle- ext. oblique abdominis muscle

- upper extent of rectus sheath- upper extent of rectus sheath

• Retromammary bursa identified on posterior aspect of Retromammary bursa identified on posterior aspect of

breast breast between investing fascia of breast & fascia of between investing fascia of breast & fascia of

pectoralis ms. pectoralis ms.

• LIGAMENTS OF COOPER-The breast is anchored to the LIGAMENTS OF COOPER-The breast is anchored to the

overlying skin & to the underlying pectoral fascia by bands overlying skin & to the underlying pectoral fascia by bands

of connective tissue.of connective tissue.

ARCHITECTURE OF GLANDARCHITECTURE OF GLAND

- Acini -> lobules -> lobes- Acini -> lobules -> lobes

- Lobes arranged in radiating pattern & converge on nipple- Lobes arranged in radiating pattern & converge on nipple

- Each lobe is drained by a duct.- Each lobe is drained by a duct.

- 10 to 15 ducts open into nipple- 10 to 15 ducts open into nipple

- Ducts surrounded by loose connective tissue,& fat gives - Ducts surrounded by loose connective tissue,& fat gives

roundness.roundness.

- Larger ducts usually give rise to duct papilloma n duct - Larger ducts usually give rise to duct papilloma n duct

ectasia.ectasia.

- Distal smaller ducts rise to fibroadenoma (during - Distal smaller ducts rise to fibroadenoma (during

development)development)

- Cyst formation & sclerosing adenosis (involutional period)- Cyst formation & sclerosing adenosis (involutional period)

- Cancer intralobular portion of terminal ducts- Cancer intralobular portion of terminal ducts

NIPPLE AREOLA COMPLEXNIPPLE AREOLA COMPLEX

• Epidermis – pigmented. More darker with physiological changesEpidermis – pigmented. More darker with physiological changes

• Areola- sebaceous,sweat,& accessory glands.produce small Areola- sebaceous,sweat,& accessory glands.produce small

elevations(MONTGOMERY TUBERCLE)elevations(MONTGOMERY TUBERCLE)

• BLOOD SUPPLYBLOOD SUPPLY-ARTERIAL-ARTERIAL

1. perforating br of internal thoracic/mammary artery1. perforating br of internal thoracic/mammary artery

2. lateral branches of posterior intercostal arteries2. lateral branches of posterior intercostal arteries

3. branches from axillary artery3. branches from axillary artery

- superior thoracic- superior thoracic

- lateral thoracic- lateral thoracic

- pectoral branch of thoracoacromial artery- pectoral branch of thoracoacromial artery

VENOUS DRAINVENOUS DRAIN

1- perforating br of internal thoracic vein1- perforating br of internal thoracic vein

2- perforating br of posterior intercostal vein2- perforating br of posterior intercostal vein

3- tributaries of axillary vein3- tributaries of axillary vein

( MONDORS DISEASE )( MONDORS DISEASE )

NERVE SUPPLYNERVE SUPPLY

• Sympathetic nerves which reach via 2nd to 6th intercostal nervesSympathetic nerves which reach via 2nd to 6th intercostal nerves

• Overlying skin supplied ant & lateral br of 4th 5th 6th intercostal Overlying skin supplied ant & lateral br of 4th 5th 6th intercostal

nervesnerves

LYMPHATIC DRAINAGELYMPHATIC DRAINAGE

• Divided into SIX GROUPSDivided into SIX GROUPS

1- axillary(lateral) vein group1- axillary(lateral) vein group

2- external mammary group(anterior or pectoral) along lower border of 2- external mammary group(anterior or pectoral) along lower border of

pectoralis minor and in relation with lateral thoracic vesselspectoralis minor and in relation with lateral thoracic vessels

3- scapular group(posterior or subscapular) along 3- scapular group(posterior or subscapular) along subscapular vesselssubscapular vessels

4- central group4- central group

5- apical/subclavicular5- apical/subclavicular

6- interpectoral(Rotters node)6- interpectoral(Rotters node)

Level of lymphatic drainageLevel of lymphatic drainage

• Level I- lymph nod located lateral to Level I- lymph nod located lateral to pectoralis minor.(lateral pectoralis minor.(lateral

axillary, axillary, external mammary, external mammary, subscapular).subscapular).

• Level II- Deep to pectoralis minor. Level II- Deep to pectoralis minor. (central (central and interpectoral).and interpectoral).

• Level III- Medial to or above pectoralis Level III- Medial to or above pectoralis minor. (subclavicular).minor. (subclavicular).

PHYSIOLOGYPHYSIOLOGY

Puberty MorphologyPuberty Morphology

• Thelarche: the beginning of adult breast Thelarche: the beginning of adult breast

development development

• Ductal growth phase: Club-shaped terminal end Ductal growth phase: Club-shaped terminal end

buds (TEBs)buds (TEBs)

• Lobuloalveolar phase: TEBs form alveolar buds. 9-Lobuloalveolar phase: TEBs form alveolar buds. 9-

10 alveolar buds empty into terminal ductal 10 alveolar buds empty into terminal ductal

lobular units (TDLUs)lobular units (TDLUs)

• In early puberty, the TDLU is termed In early puberty, the TDLU is termed

Puberty MorphologyPuberty Morphology

• Under cyclic influence of ovarian hormones: some of the Under cyclic influence of ovarian hormones: some of the

Lob1 will undergo further division and differentiate into a Lob1 will undergo further division and differentiate into a

lobule type 2 (Lob 2). lobule type 2 (Lob 2).

• In Lob 2 the alveolar buds become smaller but four times In Lob 2 the alveolar buds become smaller but four times

more numerous than Lob1; these buds are termed ductules more numerous than Lob1; these buds are termed ductules

or alveoli.or alveoli.

• Lobs during late teens but then decline after the mid Lobs during late teens but then decline after the mid

twenties. twenties.

Puberty menstrual cyclePuberty menstrual cycle• Early follicular phase: Day 3-7. dense Early follicular phase: Day 3-7. dense

stroma, only one epithelial type. Minimum stroma, only one epithelial type. Minimum volume in 5-7 days.volume in 5-7 days.

• Follicular phase: Day 8-14, progression of Follicular phase: Day 8-14, progression of epithelial in to three cell type: luminal , epithelial in to three cell type: luminal , myoepiethelial and intermediate cell.myoepiethelial and intermediate cell.

• Ovulation: Increase alveoli volume and Ovulation: Increase alveoli volume and number.number.

• Secretory phase: Day 21-27, maximum Secretory phase: Day 21-27, maximum size of the lobulessize of the lobules

• Menstrual phase: Day 28-32Menstrual phase: Day 28-32

PregnancyPregnancy

- diminution of fibrous stroma- diminution of fibrous stroma

- lobular hyperplasia- lobular hyperplasia

- Hormones active are est prog - Hormones active are est prog

& prolactin& prolactin

Lactation - prolactin & oxytocinLactation - prolactin & oxytocin

Menopause - irregularity & functional Menopause - irregularity & functional nodularitynodularity

Steroid hormone Steroid hormone receptorsreceptors• Estrogen receptorEstrogen receptor• Progestrone receptorProgestrone receptor -may present in tumour tissue-may present in tumour tissue -activated when occupied by specific -activated when occupied by specific

hormone ligandhormone ligand -activation of estrogen rec leads to the -activation of estrogen rec leads to the

induction of numerous cellular induction of numerous cellular genes,which encode critical enzymes & genes,which encode critical enzymes & secrete peptide growth factors.secrete peptide growth factors.

• Most important protien induced by Most important protien induced by ER is the receptor for progesterone.ER is the receptor for progesterone.

• Progesterone serve as an indicator Progesterone serve as an indicator for the presence of functional ERfor the presence of functional ER

• These receptors are of prognostic These receptors are of prognostic significancesignificance

Examination of breastExamination of breast

• HistoryHistoryName Name Age / sexAge / sexResidenceResidenceSocial statusSocial status

Major complaintsMajor complaints1. Pain or lump in breast.1. Pain or lump in breast.2. Discharge from nipple.2. Discharge from nipple.3. 3. UUlcer over breast.lcer over breast.

- Age- Age- Residence- Residence- Social status- Social status- Lump- mode of onset- Lump- mode of onset

durationdurationrate of growthrate of growth

History continued-History continued-

PainPain

Discharge from nippleDischarge from nipple

Retraction of nippleRetraction of nipple

Loss of weightLoss of weight

past historypast history

personal historypersonal history

family historyfamily history

Physical examinationPhysical examination local examination local examination

• PositionPosition

sitting positionsitting position

semi-recumbent positionsemi-recumbent position

recumbent positionrecumbent position

bending forward positionbending forward position

inspectioninspection

• With arms by side of bodyWith arms by side of body

• With arms raised above her headWith arms raised above her head

• Hands on her hipsHands on her hips

• Pt bending forwards from the waistPt bending forwards from the waist

breastsbreasts

• PositionPosition

• Size & shapeSize & shape

• Any puckering or dimplingAny puckering or dimpling

• Any ulcerAny ulcer

Skin over the breastSkin over the breast

• Colour & textureColour & texture

• Engorged veinsEngorged veins

• Peau d’ orangePeau d’ orange

• NodulesNodules

nipplenipple

• PresencePresence

• PositionPosition

• NumberNumber

• Size & shapeSize & shape

• SurfaceSurface

• dischargedischarge

Arm & thoraxArm & thorax

• Cancer en cuirasse’Cancer en cuirasse’

• Brawny edema of armBrawny edema of arm

axilla & supraclavicular fossaaxilla & supraclavicular fossa

submammary fold must be inspectedsubmammary fold must be inspected

palpationpalpation

PositionPosition

Normal breast 1Normal breast 1stst

With palmar surface of fingers with the With palmar surface of fingers with the hand flathand flat

Four quadrantsFour quadrants

Axillary tailAxillary tail

Behind nippleBehind nipple

Examination of lump(if Examination of lump(if evident)evident)

• Local temp & tendernessLocal temp & tenderness

• Site as per quadrantSite as per quadrant

• NumberNumber

• Size & shapeSize & shape

• SurfaceSurface

• MarginMargin

• ConsistencyConsistency

• FluctuationFluctuation

• Transillumination testTransillumination test

• Fixity to skinFixity to skin

• -tethered to skin-tethered to skin

• -fixed to skin-fixed to skin

• Fixity to breast tissueFixity to breast tissue

• Fixity to underlying fascia & musclesFixity to underlying fascia & muscles

• Fixity to chest wall & palpation of nippleFixity to chest wall & palpation of nipple

Examination of lymph nodesExamination of lymph nodes

• Axillary group of lymph nodesAxillary group of lymph nodes

-pectoral group-pectoral group

-brachial group-brachial group

-subscapular group-subscapular group

-central group-central group

-apical group-apical group

• Cervical lymph nodesCervical lymph nodes

-supraclavicular nodes-supraclavicular nodes

GENERAL EXAMINATIONGENERAL EXAMINATION

-liver-liver

-lungs & bones-lungs & bones

-rectal & vaginal examination-rectal & vaginal examination