THE BREAST

I. Introduction/General Information
A. Embryologically: belong to integument

B. Functionally: part of reproductive system

1. Respond to sexual stimulation 2. Feed babies

Breast, continued

C. Modified apocrine sweat glands

- apex of cell becomes part of secretion and breaks off D. Present in males and females

II. Anatomy

A. Position and Attachment

1. 2. 3. 4. 5. Lateral aspect of pectoral region Located between ribs 3 and 6/7 Extend form sternum to axilla Surrounded by superficial fascia Rest on deep fascia

Breast Anatomy

Position & attachment, continued .

6. Fixed to skin & underlying fascia by fibrous C.T. bands

a. Coopers (Suspensory) Ligaments b. Ligaments may retract when breast tumors are present

Coopers Suspensory Ligaments

Position & attachment, continued

6. Left breast is usually slightly larger 7. Base is circular, either flattened or concave 8. Separated from pectoralis major muscle by fascia, retromammary space

Retromammary Space

Retromammary Space

Anatomy, continued

B. Structure 1. Outer surface convex, skin covered 2. Nipple: a. At fourth intercostal space b. Small conical/cylindrical prominence below center

Nipple location

4th intercostal space

Structure, continued

c. Surrounded by areola: pigmented ring of skin d. Thin skinned region lacking hair, sweat glands e. Contains areolar glands

Structure, continued

3. Areola: contains dark pigment that intensifies with pregnancy

a. Circular and radial smooth muscle fibers b. Cause nipple erection

Areola

Structure, continued

4. Each breast consists of ~ 20 lobes of secretory tissue

a. Each lobe has one lactiferous duct b. Lobes (and ducts) arranged radially c. Embedded in connective tissue & adipose of superficial fascia d. Lobes composed of lobules e. Lobules comprise alveoli

Lobes and Lobules

Structure, continued

5. Excretory (lactiferous) ducts converge toward areola

a. Form ampullae (collection sites of lactiferous sinuses)

b. Ducts become contracted at base of nipple

Excretory (lactiferous) ducts

Structure, continued

6. Secretory epithelium
a. Changes with hormonal signals b. Onset of menstruation c. Pregnancy (glands begin to enlarge at 2nd month) d. After birth, 1st secretion is colostrom (contain antibodies)

Structure, continued

7. Tail of Spence = axillary tail

a. prolongation of upper, outer quadrant in axillary direction b. Passes under axillary fascia c. May be mistaken for axillary lymph nodes

Tail of Spence
Axillary Tail

Structure, continued

8. Fatty Tissue: surrounds surface, fills spaces between lobes

a. Determines form & size of breast

b. No fatty deposit under nipple & areola

Breast: Fatty Tissue

Structure, continued

C. Vessels & nerves 1. Arteries: derived from thoracic branches of three pairs of arteries
a. Axillary arteries
1) continuous with subclavian a. 2) gives rise to external mammary ( = lateral thoracic) artery

Vessels & Nerves, continued

b. Internal mammary (thoracic) arteries

1) first descending branch of subclavian artery 2) supply intercostal spaces & breast 3) used for coronary bypass surgery

c. Intercostal arteries:
1) numerous branches from internal & external mammary arteries 2) supply intercostal spaces & breast

Arterial Supply to the Breast

Subclavian a.

Axillary a.

Internal mammary (thoracic) a.

External mammary (thoracic) a.

Vessels & Nerves, continued

2. Veins:
a. form a ring around the base of the nipple (circulus venosus) b. Large veins pass from circulus venosus to circumference of mammary gland, then to c. External mammary v to axillary v or d. Internal mammary v to subclavian v

Veins draining the Breast

Subclavian vein

External mammary vein

Breast Anatomy, cont

3. Innervation: derived from:

a. anterior & lateral cutaneous nerves of thorax b. spinal segments T3 T6

Structure, continued

4. Lymphatics: clinically significant!

a. Glandular lymphatics drain into anterior axillary (pectoral) nodes central axillary nodes apical nodes deep cervical nodes subclavicular (subclavian) nodes b. Medial quadrants drain into parasternal nodes

Lymph Nodes of the Breast

Subclavian nodes Axillary nodes Lateral pectoral nodes Parasternal nodes

Lymphatics, continued

c. Superficial regions of skin, areola, nipples: -form large channels & drain into pectoral nodes d. NOTE: axillary nodes also drain lymph from arm

Lymph Nodes and Lymph Drainage

Axillary Nodes

Routes of Metastasis

From medial lymphatics to parasternal nodes

Then to mediastinal nodes

Across the sternum in lymphatics to opposite side via cross-mammary pathways

Then to contralateral breast

From subdiaphragmatic lymphatics to nodes in abdomen

Then to liver, ovaries, peritoneum

Major Routes of Metastasis

Channels to Contralateral Breast

Axillary Lymph Channels

Subdiaphragmatic Lymph Channels

Structure, continued

D. Anomalies 1. Inverted nipple: congenital or due to cancer 2. Ectopic nipple:

a. polythelia or hyperthelia b. additional nipples along milk line

3. Amastia 4. Micromastia

Anomalies, continued

5. Macromastia
6. Gynecomastia
a. breast development of male in areolar region b. noted in males who smoke marijuana at puberty

III. Diseases of the Breast

A. Most are readily detectable
B. Etiology unknown, influencing factors

1. Sex
2. Heredity

Diseases of the breast, continued

3. Endocrine influence
a. Menstruation tenderness from fluid engorgement b. Post-menopause 1) decrease of fibro-cystic disease 2) increase in cancer c. Pregnancy

Diseases of the Breast, continued

C. General symptoms & signs 1. Nipple discharge

a. always significant if not pregnant. b. May be due to benign pituitary tumor.

2. Local pain, tenderness 3. Duration of lesion 4. Size, rate of growth

Symptoms & Signs, continued

5. Retraction sign: dimpling involving skin, nipple or areola 6. Mobility of mass

a. Benign = movable 1) not attached 2) not invasive b. Malignant = attached 1)May grow into bone

Symptoms & Signs, continued

7. Consistency of mass
a. Cysts = fluctuant; compressible b. Fibroadenoma = rubbery c. Carcinoma = firm, hard (like gravel)

8. Axillary area lymph node enlargement

D. Benign breast conditions 1. Infection = usually during or after lactation

a. Recurrent, subareolar abscess b. TB of the breast

2. Trauma = contusion 3. Hypertrophy = seen in either sex at adolescence

a. Gynecomastia = in males

Hypertrophy, continued

b.

Other causes 1) testicular or pituitary tumor 2) cirrhosis 3) hypogonadism = not enough testosterone 4) estrogen administration for prostate cancer

Benign Conditions, continued

4.

Tumors & cysts

a. Fibroadenoma = most common benign breast tumor

Tumors and Cysts, cont

b. Breast Cyst 1. Benign 2. May be aspirated if large

Benign conditions, continued

c. Fibrocystic breast changes

1) 20%+ of premenopausal women 2) discomfort, cysts 3) treatment rarely required 4) More likely to not detect a developing cancer

Tumors & cysts, continued .

d. Intraductal papilloma - may produce chocolate or bloody discharge from nipple e. Lipoma: common - fatty tumors

E. Carcinoma of the breast

1. Most common malignant tumor among women 2. 1/8 of women will develop breast cancer
a. 1/6 in Orange County b. 1/5 in San Francisco

3. Generally no discomfort

Progression to Breast Cancer

Carcinoma of breast, continued

4. Physical signs:
a. b. c. d. Slowly growing, painless mass May demonstrate retracted nipple May be bleeding from nipple May be distorted areola, or breast contour e. Skin dimpling in more advanced stages with retraction of Coopers ligaments

Physical signs, continued

f. Attachment of mass g. Edema of skin 1)with orange skin appearance (peau dorange) 2) due to blocked lymphatics h. Enlarged axillary or deep cervical lymph nodes

Breast Cancer, cont

5. Common sites for metastasis

a. Lungs & pleura b. Skeleton system (skull, vertebral column, pelvis) c. Liver

6. Atypical carcinomas
a. Inflammatory carcinoma (hormonal, chemotherapy) b. Pagets disease of the breast