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Breast Anatomy, Embryology and Development; Classification of Benign Breast Disease and Management of Fibrocystic Disease; Subcutaneous Mastectomy

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Breast Anatomy, Embryology and Development; Classification of Benign Breast Disease and Management of Fibrocystic Disease; Subcutaneous Mastectomy Breast Anatomy, Embryology and Development; Classification of Benign Breast Disease and Management of Fibrocystic Disease; Subcutaneous Mastectomy Plastic Surgery Seminar Series University of Toronto Daniel Martin November 1, 2006 Previous Author: Judy Ward Discussors: Dr. M. Musgrave Dr. M. Quan Table of Contents Anatomy…………………………………………………………………………… 3 Embryology……………………………………………………………………....... 6 Development………………………………………………………………………. 7 Physiology…………………………………………………………………………. 8 Congenital Anomalies …………………………………………………………....... 9 Benign Breast Disease…………………………………………………………....... 11 Fibrocystic Disease………………………………………………………… 11 Neoplasms and Proliferative lesions………………………………............. 14 Fibroadenoma and variants……………………………….……….. 14 Phyllodes Tumors..……………………………………………….... 15 Adenomas………………………………………………………….. 16 Papillomas……………...…………………………………………... 17 Microglandular Adenosis………………………………………….. 18 Radial Sclerosing Lesions…………………………………………. 19 Granular Cell Tumors……………………………………………… 19 Fibromatosis………………………………………………………... 19 Breast Infarct………………………………………………………. 20 Other………..……………………………………………………… 20 Inflammatory and Reactive lesions………………………………………… 20 Mammary Ductal Ectasia……………..……………………………. 20 Nonpuerperal Breast Abscesses……………………………………. 21 Mammary Fistula…………………………………………………... 22 Puerperal Mastitis and Abscess……………………………………. 22 Reaction to Foreign Material………………………………………. 23 Breast Trauma……………………………………………………………… 23 Hematoma………………………………………………………….. 23 Fat Necrosis………………………………………………………... 23 Mondor’s Disease………………………………………………….. 24 Miscellaneous……………………………………………………………… 24 Galactocele…………………………………………………………. 24 Subcutaneous Mastectomy…………………………………………………………. 25 References………………………………………………………………………….. 26 2 Anatomy · 2nd rib to inframammary fold at 6th rib · Lateral border sternum to midaxillary line · Axillary tail (of Spence) extends superolaterally into anterior axillary fold Contour · At maturity – glandular components take a protuberant conical form · Cone base roughly circular measuring 10-12cm diameter, 5-7cm in thickness · Variation in size, contour and density · Nulliparous – hemispheric, flattening above the nipple · Multiparity – larger, pendulous form with increase in volume and density · Senescence – flattened, flaccid, pendulous, decreased volume Composition · 15-20 lobes of glandular tissue (tubuloalveolar type) within superficial fascia · Upper half, particularly upper outer quadrant, contains greater volume of glandular tissue · Adipose tissue interposed and fibrous tissue connections between lobules · Subcutaneous connective tissue surrounds the gland and extend as septa between lobes and lobules · Deep layer of superficial fascia lies on posterior surface, adjacent to deep investing fascia of pectoralis major, serratus anterior, external oblique abdominal muscle and rectus shealth · Retromammary bursa – between deep layer of superficial fascia and deep fascia · Suspensory ligaments (of Cooper) – fibrous bands from deep fascia to skin 3 Nipple and Areola · Highly pigmented, variably corrugated · Keratinized stratified squamous epithelium · Smooth muscle bundle fibres arranged radially and circumferentially in connective tissue and longitudinally along lactiferous ducts extend into nipple · Areola – sebaceous glands, sweat glands, accessory areolar glands · Accessory glands produce small elevations of areola (Montgomery tubercles) · Nipple contains numerous sensory nerve endings and Meissner’s corpuscles, areola contains few Blood Supply 1. internal mammary artery via medial mammary branches (60%) 2. lateral thoracic artery via lateral mammary branches (30%) 3. 3rd to 5th posterior intercostal arteries via lateral mammary branches 4. thoracoacromial artery via pectoral branches 5. subscapular and thoracodorsal artery Venous Drainage · primary venous drainage is towards axilla 1. perforating branches of internal thoracic vein 2. tributaries of axillary vein 3. perforating branches of posterior intercostal veins Lymphatic Drainage · axillary nodes (primary drainage, >75%) – to subclavian lymph trunk · internal mammary (parasternal) nodes · both axillary and parasternal groups receive lymph from all quadrants of the breast Axillary nodes: 1. axillary vein group (lateral group) · medial or posterior to vein 2. external mammary group (anterior or pectoral group) · lower border of pec. minor contiguous with lateral thoracic vessels 3. scapular group (posterior or subscapular) · posterior axillary wall, lateral border of scapula, contiguous with subscapular vessels 4 4. central group · embedded within fat of axilla posterior to pectoralis minor 5. subclavicular group (apical) · posterior and superior to upper border of pectoralis minor 6. interpectoral (Rotter’s) group · between pectoralis major and minor Levels I – nodes lateral to or below lower border of pectoralis minor · external mammary, axillary vein, and scapular groups II – nodes deep to or behind pectoralis minor · central group III – nodes medial to or above upper border or pectoralis minor · subcalvicular group 5 Alternate Pathways – important when physiological routes obstructed - deep, substernal cross drainage to contralateral internal mammary chain - superficial presternal crossover - lateral intercostals - mediastinal - rectus abdominal muscle sheath to subdiaphragmatic and subperitoneal plexus – Gerota Pathway - direct spread to liver and retroperitoneal lymph nodes Innervation · lateral and anterior cutaneous branches of 2nd to 6th intercostal nerves · lateral branch of 4th intercostal nerve – dominant to nipple · upper portion of breast – anterior or medial branches of the supraclavicular nerve from cervical plexus Embryology Independent of Placental Hormones Fetal weeks Stage Development 5 Ectodermal primitive milk streak (galactic band) develops from axilla to groin In region of thorax, band develops to form mammary ridge, remaining band regresses 7-8 Milk hill Thickening in mammary anlage Disk Invagination into chest wall mesenchyme Globular Tridimensional growth 10-14 Cone Further invasion of chest wall mesenchyme results in flattening of ridge 12-16 Mesenchymal cells differentiate into the smooth muscle of the nipple and areola Budding Development of epithelial buds 16 Branching Epithelial buds branch to form 15-25 strips of epithelium (future secretory alveoli) · secondary mammary anlage then develops – differentiation of hair follicle, sebaceous gland and sweat gland elements (only sweat glands develop fully at this time) · special apocrine glands develop to form Montgomery’s glands around nipple Dependent on Placental Hormones Fetal weeks Stage Development 20-32 Canalization Canalization of the branched epithelial tissues 32-40 End-vesicle Parenchymal differentiation with development of lobular-alveolar structures that contain colostrum Lactiferous ducts open into a shallow pit which everts and gives rise to the nipple Nipple-areola complex develops and becomes pigmented Neonate · stimulated mammary tissue secretes colostral milk (witch’s milk) – can be expressed from the nipple for 4-7 days postpartum in most neonates of either sex · colostral secretion declines over 3-4 weeks – involution of breast after withdrawal of placental hormones Early Childhood · end vesicles become further canalized and develop into ductal structures by additional growth and branching · dense fibrous stroma and ducts lined by epithelium Development · puberty in girls begins at age 10-12 yrs. · Estrogen (immature ovarian follicles) o stimulate longitudinal ductal growth of ductal epithelium o Terminal ductules form buds that precede further breast lobules o Periductal connective tissue increases in volume and elasticity, with enhanced vascularity and fat deposition · Progesterone (mature ovarian follicles) o Stimulates acinar epithelium, reduces estrogen binding to epithelium, limits tubular proliferation o Together with estrogen, produce full ductular-lobular-alveolar development o Relative role of each hormone not clear · Microanatomy o Growing and dividing ducts that form terminal end buds (TEB) o TEBs form new branches, twigs and small ductules termed alveolar buds o Alveolar buds differentiate into ductules o Alveolus = resting secretory unit o Acines = fully developed secretory unit of pregnancy and lactation o Lobules – develop during the first few years after menarche; alveolar buds cluster around a terminal duct · Tanner staging of breast development 7 Physiology Menstrual Cylce - follicular phase: increasing estrogen stimulates epithelial proliferation - luteal phase: mammary ducts dilate, alveolar epithelial cells differentiate into secretory cells, increased mammary blood flow, increased interlobular edema - breast engorgement and pain may occur – cyclic mastalgia Pregnancy - ductular, lobular and alveolar growth occurs – estrogen, progesterone, placental lactogen, chorionic gonadotropin, increasing levels of prolactin - breast enlargement significant at 5-8 weeks – dilatation of superficial veins, heaviness, increasing pigmentation of nipple-areolar complex - second half of pregnancy – increasing breast size from increasing dilatation of alveoli with colostrums and hypertrophy of myoepithelial cells, connective tissue and fat Lactation - triggered by sudden loss withdrawal of placental hormones with continued production of prolactin - prolactin, in presence of growth hormone, insulin and cortisol, converts mammary epithelial cells from presecretory to secretory state - milk ejection – activation of sensory nerve endings in nipple-areolar complex
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