Breast imaging update Breast imaging: choosing the right ...
The breast
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Transcript of The breast
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THE BREAST
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I. Introduction/General Information
A. Embryologically: belong to integument
B. Functionally: part of reproductive system
1. Respond to sexual stimulation
2. Feed babies
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Breast, continued …
C. Modified apocrine sweat glands
- apex of cell becomes part of secretion and breaks off
D. Present in males and females
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II. Anatomy
A. Position and Attachment1. Lateral aspect of pectoral region
2. Located between ribs 3 and 6/73. Extend form sternum to axilla4. Surrounded by superficial fascia5. Rest on deep fascia
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Breast Anatomy
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Position & attachment, continued ….
6. Fixed to skin & underlying fascia by fibrous C.T. bandsa. Cooper’s (Suspensory)
Ligamentsb. Ligaments may retract when
breast tumors are present
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Cooper’s Suspensory Ligaments
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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
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Retromammary Space
Retromammary Space
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Anatomy, continued …
B. Structure
1. Outer surface convex, skin covered
2. Nipple:
a. At fourth intercostal space
b. Small conical/cylindrical prominence below center
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Nipple location
4th intercostal
space
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Structure, continued …
c. Surrounded by areola: pigmented ring of skin
d. Thin skinned region lacking hair, sweat glands
e. Contains areolar glands
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Structure, continued …
3. Areola: contains dark pigment that intensifies with pregnancy
a. Circular and radial smooth muscle fibers
b. Cause nipple erection
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Areola
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Structure, continued …
4. Each breast consists of ~ 20 lobes of secretory tissue
a. Each lobe has one lactiferous ductb. Lobes (and ducts) arranged radially c. Embedded in connective tissue &
adipose of superficial fasciad. Lobes composed of lobulese. Lobules comprise alveoli
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Lobes and Lobules
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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
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Excretory (lactiferous) ducts
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Structure, continued …
6. Secretory epitheliuma. Changes with hormonal signalsb. Onset of menstruationc. Pregnancy (glands begin to
enlarge at 2nd month)d. After birth, 1st secretion is
colostrom (contain antibodies)
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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
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“Tail of Spence”
Axillary Tail
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Structure, continued …
8. Fatty Tissue: surrounds surface, fills spaces between lobes
a. Determines form & size of breast
b. No fatty deposit under nipple & areola
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Breast: Fatty Tissue
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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
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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
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Subclavian a.
Axillary a.
External mammary (thoracic) a.
Internal mammary (thoracic) a.
Arterial Supply to the Breast
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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
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Veins draining the Breast
Subclavian vein
External mammary vein
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Breast Anatomy, con’t…
3. Innervation: derived from:
a. anterior & lateral cutaneous nerves of thorax
b. spinal segments T3 – T6
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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) nodesb. Medial quadrants drain into
parasternal nodes
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Subclavian nodes
Axillary nodes
Lateral pectoral
nodes
Parasternal nodes
Lymph Nodes of the Breast
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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
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Lymph Nodes and Lymph Drainage
Axillary Nodes
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Routes of Metastasis
From medial lymphatics to parasternal nodesThen to mediastinal nodes
Across the sternum in lymphatics toopposite side via cross-mammary pathways
Then to contralateral breastFrom subdiaphragmatic lymphatics to
nodes in abdomenThen to liver, ovaries, peritoneum
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Subdiaphragmatic Lymph Channels
Channels to Contralateral Breast
Axillary Lymph Channels
Major Routes of Metastasis
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Structure, continued …
D. Anomalies1. Inverted nipple: congenital or due
to cancer2. Ectopic nipple:
a. “polythelia” or “hyperthelia”
b. additional nipples along milk line
3. Amastia 4. Micromastia
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Anomalies, continued …
5. Macromastia
6. Gynecomastia a. breast development of male in
areolar region
b. noted in males who smoke marijuana at puberty
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III. Diseases of the Breast
A. Most are readily detectable
B. Etiology unknown, influencing factors
1. Sex
2. Heredity
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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 cancerc. Pregnancy
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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
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Symptoms & Signs, continued …
5. Retraction sign: “dimpling” involving skin, nipple or areola6. Mobility of mass
a. Benign = movable 1) not attached 2) not invasive
b. Malignant = attached 1)May grow into bone
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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
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D. Benign breast conditions1. Infection = usually during or after
lactationa. Recurrent, subareolar abscessb. TB of the breast
2. Trauma = contusion3. Hypertrophy = seen in either sex
at adolescencea. Gynecomastia = in males
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Hypertrophy, continued …
b. Other causes
1) testicular or pituitary tumor2) cirrhosis 3) hypogonadism = not enough
testosterone4) estrogen administration for
prostate cancer
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Benign Conditions, continued
4. Tumors & cysts
a. Fibroadenoma = most
common benign breast
tumor
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Tumors and Cysts, con’t…
b. Breast Cyst1. Benign2. May be
aspirated if large
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Benign conditions, continued …
c. Fibrocystic breast changes
1) 20%+ of premenopausal women 2) discomfort, cysts3) treatment rarely required 4) More likely to not detect a developing cancer
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Tumors & cysts, continued ….
d. Intraductal papilloma
- may produce “chocolate” or
bloody discharge from nipple
e. Lipoma: common
- fatty tumors
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E. Carcinoma of the breast
1. Most common malignant tumor among women
2. 1/8 of women will develop breast cancera. 1/6 in Orange Countyb. 1/5 in San Francisco
3. Generally no discomfort
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Breast cancer originates in breast tissue and arises from the ductal tissue of the breast and,
less commonly, the lobulartissue. There are several forms of breast cancer based, in
part, on cellular and genetic characteristics,
Breast cancer originates in breast tissue and arises from the ductal tissue of the breast and,
less commonly, the lobulartissue. There are several forms of breast cancer based, in
part, on cellular and genetic characteristics,
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Types of Breast CancerTypes of Breast Cancer
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What is HER2-positive breast cancer?All cells have HER2 receptors, including healthy cells and cancer cells. In HER2-positive breast cancer, tumor cells have more HER2 receptors than normal. Too much HER2 makes these cancer cells grow and divide too rapidly.
NONCANCEROUS CELL
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What is HER2-positive breast cancer?All cells have HER2 receptors, including healthy cells and cancer cells. In HER2-positive breast cancer, tumor cells have more HER2 receptors than normal. Too much HER2 makes these cancer cells grow and divide too rapidly.
HER2-POSITIVE CANCER CELL
Cancer treatments called HER2-targeted therapies have been developed to target the HER2 receptor.
PERJETA is one of those HER2-targeted therapies.
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Progression to Breast Cancer
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Carcinoma of breast, continued …
4. Physical signs:a. Slowly growing, painless massb. May demonstrate retracted nipplec. May be bleeding from nippled. May be distorted areola, or breast contoure. Skin dimpling in more advanced stages with retraction of
Cooper’s ligaments
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Physical signs, continued …
f. Attachment of mass
g. Edema of skin 1)with “orange skin” appearance
(peau d’orange) 2) due to blocked lymphatics
h. Enlarged axillary or deep cervical
lymph nodes
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Breast Cancer, con’t…
5. Common sites for metastasisa. Lungs & pleurab. Skeleton system (skull, vertebral
column, pelvis)c. Liver
6. Atypical carcinomasa. Inflammatory carcinoma (hormonal,
chemotherapy) b. Paget’s disease of the breast