Case discussion

Functional Anatomy
 15-20 lobes which are each composed of several lobules
 Cooper’s suspensory ligaments insert perpendicularly into the dermis
and provide structural support
 Extends from the level of the 2nd or 3rd rib to the inframammary fold at
the 6th or 7th rib
 Extends transversely from the lateral border of the sternum to the
anterior axillary line
 Posterior surface of the breast rests on the fascia of the:
1. Pectoralis major
2. Serratus anterior
3. External oblique
4. Upper extent of the rectus sheath
 Retromammary bursa may be identified on the posterior
aspect of the breast between the investing fascia of the
breast and the fascia of the pectoralis major muscles
 The axillary tail of Spence extends laterally across the
anterior axillary fold
 Upper outer quadrant > other quadrants
 Nulliparous – hemispheric configuration, distinct flattening
above the nipple
 Pregnancy and lactation – breast becomes larger and
increases in volume and density
 Senescence – breast becomes flattened, flaccid, and more
pendulous configuration with decreased volume
Blood Supply
 Principal blood supply:
1. Perforating branches of the internal mammary
artery
2. Lateral branches of the posterior intercostal
arteries
3. Branches from the axillary artery
 Highest thoracic, lateral thoracic, and pectoral
branches of the thoracoacromial artery
Veins
 Principal groups of veins:
1. Perforating branches of the internal thoracic vein
2. Perforating branches of the posterior intercostal
veins
3. Tributaries of the axillary vein
 Batson’s vertebral venous plexus may provide a
route for breast cancer metastases
Innervation
 Lateral cutaneous branches of the 3rd through 6th intercostal
nerves
 Sensory innervation of the breast and of the anterolateral chest
wall
 Exit the intercostal spaces between slips of the serratus anterior
muscle
 Cutaneous branches that arise from the cervical plexus
 Area of skin over the upper portion of the breast
 Intercostobrachial nerve
 Resection causes loss of sensation over the medial aspect of the
upper arm
Axillary Lymph Node Groups
1. Axillary vein group (lateral)
 4-6 nodes
 Medial or posterior to the vein
 Receive most of the lymph drainage from the upper extremity
2. External mammary group (anterior or pectoral)
 5-6 nodes
 Lie along the lower border of the pectoralis minor muscle contiguous with the
lateral thoracic vessels
 Receive most of the lymph drainage from the lateral aspect of the breast
3. Scapular group
 5-7 nodes
 Lie along the posterior wall of the axilla at the lateral border of the scapula
 Receive lymph drainage from the lower posterior neck, posterior trunk, and
posterior shoulder
4. Central group
 3-4 nodes
 Embedded in the fat of the axilla, immediately posterior to the
pectoralis minor
 Receive drainage from the axillary vein and external mammary
5. Subclavicular group (apical)
 6-12 nodes
 Posterior and superior to the upper border of the pectoralis minor
 Receive drainage from all of the other groups of axillary lymph nodes
6. Interpectoral group (Rotter’s lymph nodes)
 1-4 nodes
 Interposed between the pectoralis major and minor muscles
 Receive drainage directly from the breast
Axillary Lymph
Node Groups
Level I
• Nodes located lateral to the pectoralis minor
muscle
Level II
• Nodes located deep to the pectoralis minor muscle

Level III
• Nodes located medial to the pectoralis minor
Breast Cancer
 Most frequently diagnosed life threatening CA in
women
 Leading cause of cancer death in women
Invasive ductal carcinoma
 Invasive ductal carcinoma of the breast with productive
fibrosis accounts for 80% of breast cancers and presents
with macroscopic or microscopic axillary lymph node
metastases in up to 25% of screen-detected cases and up to
60% of symptomatic cases
 Occurs most frequently in perimenopausal or
postmenopausal women in the 5th to 6th decades of life
 Solitary, firm mass
 Poorly defined margins and its cut surfaces show a central
stellate configuration with chalky white or yellow streaks
extending into surrounding breast tissues
 Often arranged in small clusters
 Broad spectrum of histologic types with variable cellular and
nuclear grades
Risk Factors
 Hormonal
• Early menarche
• Nulliparity
• Age of first live birth
• Late menopause
• Obesity
 Non-Hormonal
• Radiation exposure
• Alcohol consumption
• High fat diet
SIGNS AND SYMPTOMS
 May be asymptomatic
 Presence of a lump/mass
 Skin dimpling/changes
 Abnormal discharge
PHYSICAL EXAM
 Presence of a lump
 Nipple inversion
 Skin tethering
 Ulceration
 Edema or peau d’orange
DIAGNOSIS
 Physical Examination
• Inspection
• Palpation
DIAGNOSIS
 Imaging techniques
• Mammography
• Ductography
• Ultrasonography
• MRI
 Breast biopsy
• Core-Needle biopsy
• Fine needle aspiration biopsy
SCREENING

 Women <40, monthly BSE & clinical breast exam

every 3 years is recommended beginning at age
20years
 Annual mammography beginning at age 40y/o

National Comprehensive Cancer Network

SCREENING
 Current recommendations
• Baseline mammography at age 35
• Annual mammographic screening beginning at age
40 years old
Breast Cancer Staging
 TNM Staging
TREATMENT
 SURGICAL
 -Excisional biopsy
 -Sentinel lymph node dissection
 -Breast conservation
 -Modified Radical Mastectomy
TREATMENT
 NON SURGICAL
 Radiation Therapy
 Chemotherapy
 Antiestrogen therapy
 Anti-HER-2/neu Antibody Therapy
Thank you!
Have a nice day!