BREAST Flashcards
DESRIBE THE ANATOMY OF THE BREAST
Breast tissue is a modified sweat gland found in the superficial fascia of the anterior chest wall derived from
ectoderm, as branching epithelial cords
Vertically extends from 2nd to 6th rib in mid clavicular line and lies over pectoralis major, serratus anterior
and external oblique muscles
Horizontally from the sternum to mid axillary line. Lower medial quadrant gland
rests on external oblique aponeurosis, which separates it from rectus abdominis.
2
/3 lie on Pectoralis major, 1/3 on Serratus anterior
Outer part has prolongation into the the axilla called Axillary tail of Spence
It gets into the axilla though an opening in deep fascia = Foramen of Langer
Retromammary bursa/space is between deep layer of superficial fascia and
pectoral (deep) fascia allowing free mobility of breast.
Nipple is at level of 4th ICS just below centre/summit of breast, has circular and longitudinal muscles to
make nipple stiff or flat and is pierced by 15–20 lactiferous ducts. It’s supplied by 4
th intercostal nerve
Breast is anchored to overlying skin and to underlying pectoral fascia by bands of connective tissue called
ligament of Cooper (when these are affected by Ca they cause breast skin dimpling or growth attachment to
the skin or fix the breast to the pectoralis major by binding the breast to the pectoral fascia)
DESCRIBE THE HISTOLOGY OF THE BREAST
Bulk of breast is adipose tissue and ducts only contribute 10%
Breast parenchyma contains 15–20 lobes.
Each lobe has alveoli, lactiferous sinus and lactiferous duct (2–4
mm in diameter).
Alveolus is lined by cuboidal (in rest) and columnar (in lactation)
epithelium; smaller duct is by single layer of columnar epithelium;
larger ducts by many layered columnar; lactiferous duct is by
stratified squamous epithelium.
Alveoli →Lobules →Lobes
Three types of tissue: glandular epithelium, fibrous stroma with supporting structures and fat
Myoepithelial cells lie between epithelium and basement membrane from alveoli to duct
Areola skin is thin stratified squamous with sebaceous glands of Montgomery
Areola is circular pigmented area around nipple, rich in modified sebaceous glands, enlarge during preg
and lactation as Montgomery tubercles and secrete oily lubricant.
Contains more melanin and has sensory nerve ending
OUTLINE THE INNERVATION OF THE BREAST
Nerves-related (During MRM)
Long thoracic nerve - Bell supplies serratus anterior.
Thoracodorsal nerve supplies latissimus dorsi.
Medial pectoral nerve (from medial cord of brachial plexus) which
lies lateral, runs & winds from lateral margin of pectoralis minor.
Lateral pectoral nerve arises from lateral cord passes through pectori either middle or medial part
Nerve supply of breast is by anterior and lateral cutaneous branches of 4th to 6th intercostal nerves
OUTLINE THE BLOOD SUPPLY OF THE BREAST
Lateral thoracic artery (external mammary
artery) a branch of the 2nd part of the axillary
artery- 30%
Perforating cutaneous branches of the Internal
thoracic (mammary) artery to the 2nd 3rd and
4th costal spaces- 60%
Pectoral branch of the thoracoacromial artery
Lateral branch to the 2nd, 3rd and 4th intercostal arteries
Superior thoracic artery.
OULINE THE VENOUS DRAINAGE OF THE BREAST
external mammary vein a tributary of axillary vein
internal thoracic vein a tributary of the brachicephalic vein
intercostal veins which drain into the azygous vein
Forms a plexus around the nipple= Sappey’ s plexus
Also there is communication with the vertebral plexus of Batson through posterior intercostal veins
OUTLINE THE LYMPHATIC DRAINAGE OF THE BREAST
80% by the axillary group of lymph nodes (40-50 nodes)
Clinically :apical, lateral, anterior, posterior and medial
Apical nodes aka subclavicular or Halsted nodes
Anatomically : anterior(pectoral), lateral (humeral), posterior (subscapular),
apical, central (medial) and interpectoral node (Rotter’ s)
Interpectoral node (Rotter’s node)-signifies retrograde spread of tumour. It
lies betwn pectoralis major and minor
Minimal drainage to the internal mammary chain ( parasternal)
DESCRIBE THE LEVELS OF BREAST LYMPH NODES
There are three levels of Lymph nodes: level I below Pect. Minor, II behind and III above
Levels of the axillary nodes (Berg’s levels)
1. Level I: Below and lateral to the pectoralis
minor muscle—anterior, lateral, posterior
2. Level II: Behind the pectoralis minor muscle-
central, interpectoral
3. Level III: Above and medial to pectoralis -
minor muscle-apical or infraclavicular
HOW DO YOU TAKE HX FOR A BREAST LUMP?
Hx taking
(a) Demographic Hx
(b) PC
(c) Hx of PC of a lump/ ulcer
- When it was 1st noticed?
- What brought it to the patient’s notice?
- What symptoms does it cause e.g. pain, nipple discharge? - Has it
changed? How much has it changed since it was 1st noticed?
- Has it ever disappeared or healed
- Does the patient have any other lumps/ulcers?
- What does the patient think caused it?
LIST THE PRESDISPOSING FACTORS FOR THE APPEARANCE OF A BREAST LUMP
Predisposing factors
1) Age of the patient
2) Parity- Nulliparity is a risk
3) Did she breast feed all children and for how long?
4) When was the last time to breast feed?
5) At what age did she have her 1st pregnancy or 1st child?
6) Age at menarche? Early menarche is a risk
7) Pre or post menopause- late menopause is a risk
8) If premenopausal- what is the menstrual pattern (regularity,
duration, quantity).
9) What breast symptoms after the menstrual cycle
10) Medication i.e. HRT (Hormonal replacement therapy), Radiation, Combined oral contraceptive
11) Hx of alcohol or smoking
12) Family Hx- in 1st degree relative
13) Diet- obesity/ increased BMI
(d) Medical Hx- BRCA1/BRCA2 gene mutation
-Hx breast ca- in contralateral breast
-Hx ca colon
-Hx ca ovary
-Hx radiation exposure
WHAT ARE THE METASTATIC SYMPTOMS OF A BREAST LUMP
-Back pain (bone metastasis esp. to lumbar spine)
-Dyspnea (lung metastasis)
-Jaundice or Abdominal distension (liver metastasis)
-Hard nodules on skin (MSS metastasis)
-Swelling of arm (s) (axillary lymphadenopathy)
OUTLINE THE EXAMINATION THE BREAST
Inspection
-Symmetry
-Site- position of lump
-Skin – color discoloration
-Puckering
-Peau de orange
-Ulceration
-Nipple discharge and appearance
-Edgar- Montgomery tubercle
-Calor
-Oedema
Ask patient to hold the waist
-Gross lumps
-Phyllodes
-Distended veins
Ask pt. to raise hands
-Look for skin tethering and nipple retraction
Palpation
-Flat of finger
-Begin with normal side
-Palpate for
i. Tenderness
ii. Temperature
If there is a lump or mass; check
-Site
-Size
-Shape
-Consistence
-Is it fixed or free mobile
-Palpate axillary lymph nodes and or supraclavicular
Ask if they have a lump anywhere also
General examination
-Arms for swelling
-P/A – -Hepatomegaly
-Ascites
-Nodules in pouch of Douglas
-Lumbar spine- hit back for tenderness and restricted movement
WHAT ARE THE Ds TO KEEP IN MIND WHEN INSPECTING THE NIPPLE?
Nipple (7 D‘s)
-Depression
-Discharge
-Discoloration
-Duplication
-Destroyed
-Deviated
-DisplacemenT
WHAT EXAMINATION FINDINGS SUGGEST BREAST CA?
-Hard, non-tender, irregular lump in LOQ
-Tethering/fixation of the lump
-Palpable axillary LN‘s
OUTLINE HOW BREAST DISEASE PRESENTS
a) Painless lump
b) Carcinoma
c) Cyst
d) Fat necrosis
e) Fibroadenoma
f) An area of Fibroadenosis
g) Lipoma of breast (intra-ductal papilloma)
h) Phylloides tumor (Brodie tumor) -
WHAT IS A PHYLLOIDES TUMOR?
Phylloides tumor (Brodie tumor) - Phyllodes tumors (from Greek:
phullon leaf), also cystosarcoma phylloides and phylloides tumor, are
typically large, fast-growing masses that form from the periductal stromal
cells of the breast. They account for less than 1% of all breast neoplasms.
They show a wide spectrum of activity, varying from almost a benign condition (85%) to a locally
aggressive and sometimes metastatic tumour. Depending on mitotic index and degree of pleomorphism they
are graded as low grade to high grade tumours (15%)
