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
Two

thickened
ectoderm(MAMMARY RIDGES/MILK LINES) are
evident

Extent of milk line/mammary ridge-from base of

forelimb(future axilla)
limb(inguinal area)

to

region

of

hind

ridges disappear after short time except in

pectoral region

each breast develops when an ingrowth of

ectoderm forms
mesenchyme.

primary

tissue

bud

in

 Primary bud initiates the development 15-20 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. More darker with physiological changes

sebaceous,sweat,&
accessory
glands.produce
Areolaelevations(MONTGOMERY TUBERCLE)

BLOOD SUPPLY

-ARTERIAL

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

small

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

beginning

of

adult

breast

Ductal growth phase: Club-shaped terminal end

buds (TEBs)

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