THE BREAST

A REVIEW OF
1-EMBRYOLOGY 2-SURGICAL ANATOMY 3-PHYSIOLOGY 4-CLINICAL EXAMINATION (to evaluate a lump)

• The breast or mammary gland is
found in both sexes.

• Well developed in female after
puberty,

• Rudimentary in male • A modified sweat gland.

EMBRYOLOGY
• In 5th-6th wk of fetal development ventral bands of thickened • Two
ectoderm(MAMMARY RIDGES/MILK LINES) are evident

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

• ridges disappear after short time except in • each breast develops when an ingrowth of
ectoderm forms a primary tissue bud in

• Primary bud initiates the development 1520 secondary buds

• Epithelial cords develop from secondary
buds and extend into surrounding mesenchyme.

• Major(lactiferous)

ducts

develop,which

open into shallow mammary pit.

• Proliferation of mesenchyme transforms
the mammary pit into nipple.

CONGENITAL ABNORMALITIES OF BREAST

• AMASTIA:- bilateral absence of breast tissue and
nipple, When breast tissue is absent unilaterally pectoral muscles are often absent.

• POLYMASTIA:- (ACCESSORY BREAST)
More than one breast on one or both sides,anywhere along milk ridge

• SYMMASTIA:- webbing between the breasts across
midline

• POLYTHELIA:- (ACCESSORY NIPPLES)
Imperfect development of mammary rudiment,so that supernumerary nipples are situated irregularly over breast/or along milk ridge
•ATHELIA – absence of nipple •INVERTED NIPPLE:failure of mammary pit to elevate above skin level

HYPOPLASIA OF BREAST
• Poland syndrome • turner syndrome • fleischers syndrome
Iatrogenic causes

• trauma • radiation therapy
Accessory breast tissue may occur simulating lipoma

SURGICAL/ FUNCTIONAL ANATOMY
• Site:- lies in superficial fascia of pectoral region • A small extension called axillary tail of Spence
pierces deep fascia through foramen of langer & lies in axilla

• Extent:- vertical- 2nd to 6th ribs inclusive • Horizontal- from lateral border of sternum to
anterior axillary line.

Anatomy

Anatomy
1.15-20 lobes 2.lobe:lobules, small branch, and larger ducts. 3.Radial fashion 4.Peripheral portions of lobes often overlap

Anatomy

DEEP RELATION
• Breast rests on
- fascia of pectoralis major ms - serratus anterior - ext. oblique abdominis muscle - upper extent of rectus sheath

• Retromammary bursa identified on posterior aspect of
breast between investing fascia of breast & fascia of pectoralis ms.

• LIGAMENTS OF COOPER-The breast is anchored to the
overlying skin & to the underlying pectoral fascia by bands of connective tissue.

ARCHITECTURE OF GLAND
- Acini -> lobules -> lobes - Lobes arranged in radiating pattern & converge on nipple - Each lobe is drained by a duct. - 10 to 15 ducts open into nipple - Ducts surrounded by loose connective tissue,& fat gives roundness. - Larger ducts usually give rise to duct papilloma n duct ectasia. - Distal smaller development) ducts rise to fibroadenoma (during

- Cyst formation & sclerosing adenosis (involutional period) - Cancer intralobular portion of terminal ducts

NIPPLE AREOLA COMPLEX

• Epidermis

– pigmented. physiological changes

More

darker

with

• Areola- sebaceous,sweat,& accessory glands.produce
small elevations(MONTGOMERY TUBERCLE)


-ARTERIAL

BLOOD SUPPLY
1. perforating br of internal thoracic/mammary artery 2. lateral branches of posterior intercostal arteries 3. branches from axillary artery - superior thoracic - lateral thoracic - pectoral branch of thoracoacromial artery

VENOUS DRAIN 1- perforating br of internal thoracic vein 2- perforating br of posterior intercostal vein 3- tributaries of axillary vein ( MONDORS DISEASE ) NERVE SUPPLY

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

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

LYMPHATIC DRAINAGE

• Divided into SIX GROUPS
1- axillary(lateral) vein group 2- external mammary group(anterior or pectoral) along lower border of pectoralis minor and in relation with lateral thoracic vessels 3- scapular group(posterior or subscapular) along subscapular vessels 4- central group 5- apical/subclavicular 6- interpectoral(Rotters node)

Level of lymphatic drainage
• Level I- lymph nod located lateral to
pectoralis minor.(lateral axillary, external mammary, subscapular). • Level II- Deep to pectoralis minor. (central and interpectoral). • Level III- Medial to or above pectoralis minor. (subclavicular).

PHYSIOLOGY

Puberty Morphology
• Thelarche:
the development buds (TEBs) beginning of adult breast

• Ductal growth phase: Club-shaped terminal end • Lobuloalveolar phase: TEBs form alveolar buds. 910 alveolar buds empty into terminal ductal lobular units (TDLUs)

• In early puberty, the TDLU is termed

Puberty Morphology
• Under cyclic influence of ovarian hormones: some of the
Lob1 will undergo further division and differentiate into a lobule type 2 (Lob 2).

• In Lob 2 the alveolar buds become smaller but four times
more numerous than Lob1; these buds are termed ductules or alveoli.

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

Puberty menstrual cycle
• Early follicular phase: Day 3-7. dense
stroma, only one epithelial type. Minimum volume in 5-7 days. • Follicular phase: Day 8-14, progression of epithelial in to three cell type: luminal , myoepiethelial and intermediate cell. • Ovulation: Increase alveoli volume and number. • Secretory phase: Day 21-27, maximum size of the lobules • Menstrual phase: Day 28-32

Pregnancy - diminution of fibrous stroma - lobular hyperplasia - Hormones active are est prog & prolactin Lactation - prolactin & oxytocin Menopause - irregularity & functional nodularity

Steroid hormone receptors
• Estrogen receptor • Progestrone receptor
-may present in tumour tissue -activated when occupied by specific hormone ligand -activation of estrogen rec leads to the induction of numerous cellular genes,which encode critical enzymes & secrete peptide growth factors.

• Most important protien induced by

ER is the receptor for progesterone. • Progesterone serve as an indicator for the presence of functional ER • These receptors are of prognostic significance

Examination of breast

History Name Age / sex Residence Social status

Major complaints 1. Pain or lump in breast. 2. Discharge from nipple. 3. Ulcer over breast. - Age - Residence - Social status - Lump- mode of onset duration rate of growth

History continuedPain Discharge from nipple Retraction of nipple Loss of weight past history personal history family history

Physical examination local examination
• Position
sitting position semi-recumbent position recumbent position bending forward position

inspection
• With arms by side of body • With arms raised above her head • Hands on her hips • Pt bending forwards from the waist

breasts
• Position • Size & shape • Any puckering or dimpling • Any ulcer

Skin over the breast
• Colour & texture • Engorged veins • Peau d’ orange • Nodules

nipple
• Presence • Position • Number • Size & shape • Surface • discharge

Arm & thorax
• Cancer en cuirasse’ • Brawny edema of arm
axilla & supraclavicular fossa submammary fold must be inspected

palpation
Position Normal breast 1st With palmar surface of fingers with the hand flat Four quadrants Axillary tail Behind nipple

Examination of lump(if evident)
• Local temp & tenderness • Site as per quadrant • Number • Size & shape • Surface • Margin • Consistency

• Fluctuation • Transillumination test • Fixity to skin -tethered to skin • -fixed to skin • • Fixity to breast tissue • Fixity to underlying fascia & muscles • Fixity to chest wall & palpation of nipple

Examination of lymph nodes
• Axillary group of lymph nodes
-pectoral group -brachial group -subscapular group -central group -apical group

• Cervical lymph nodes
-supraclavicular nodes GENERAL EXAMINATION -liver -lungs & bones -rectal & vaginal examination