Breast anatomy

Cristina Luca
UMF Gr. T. Popa Iai Anatomy Department

In the adult female, the base of the breast extends: - from the 2nd to the 6th/7th rib; - from the sternal border to the midaxillary line. Possible extensions of mammary tissue: - UOQ: axillary tail of Spence (along the inferolateral edge of pectoralis major) enters a hiatus (of Langer) in the deep fascia of the medial axillary wall ; - posterior and medial; - occasionally, small projections of glandular tissue may pass through the deep fascia into the underlying muscle.

- it is located within the superficial fascia of the anterior chest wall, between its superficial and deep layers; - 2/3 of its base lies anterior to the pectoralis major muscle; - 1/3 lies anterior to the serratus anterior muscle; - between the superficial and deep fasciae, there is the Chassaignac retromammary bursa / submammary space.

The retromammary space. 1. Membranous layer of superficial fascia. 2. Retromammary space. 3. Muscle fascia.

Breast topography. From a dissection photograph. 1.Retinacula cutis. 2.Membranous layer. 3.Serratus anterior fascia. 4.Serratus anterior muscle. 5.Pectoral fascia. 6.Pectoralis major muscle. 7.Suspensory ligament of axilla. 8.Lobe of breast parenchyma. 9.Lactiferous duct. 10.Ampulla.

Retromammary (submammary) space: - between the deep, membranous layer of superficial fascia and the deep fascia (pectoralis fascia); - contains loose connective tissue and the posterior attachments of the suspensory ligament on the deep fascia; - allows some degree of movement on the deep pectoral fascia; - advanced mammary carcinoma may, by invasion, fix the breast to the pectoralis major; penetrating, retromammarian lymphatics cross this space on their way, to reach the internal mammary nodes and interpectoral nodes; - it is the space into which breast prostheses are inserted, and it is a relatively bloodless plane.

BREAST DEVELOPMENT Prenatal Development

- prenatal development is similar in both sexes; - the epithelial mammary bud appears at a gestational age of 35 days; - by day 37 the bud has become a mammary line extending from the axilla through to the inguinal region; - invagination of the thoracic mammary bud into the mesenchyme occurs by day 49, with involution of the remaining mammary line; - accessory breast tissue may be present in adults anywhere along the milk line, usually in the thoracic region (90%) but also occasionally in the axillary (5%) or abdominal (5%).

- nipple formation begins at day 56; - primitive ducts develop at 84 days with canalization occurring at about the 150th day; - the ectodermal ingrowth branches into 15 20 solid buds; by proliferation, elongation and further branching the alveoli are formed and the duct system defined; - the buds are surrounded by mesenchyme which forms the connective tissue, fat and vasculature and is invaded by the mammary nerves; - during the last two months of gestation the ducts become canalized and the epidermis at the point of original development of the gland forms a small mammary pit, into which the lactiferous tubules open; - perinatally the nipple is formed by mesenchymal proliferation.

The slide shows a transverse section with early branching of the MAJOR LACTIFEROUS DUCTS.

- The glandular portion of the breast develops from the ectoderm; The connective-tissue stroma of the breast forms from the mesoderm, which will form the dermis of the skin and the superficial fascia (tela subcutanea) as well. - The mammary glands form in the same manner as do sweat glands; they are often considered to be modified sweat glands.

VARIANT ANATOMY
There are many possible variants from normal breast development: - polythelia occurs when involution of the milk line is incomplete and an accessory nipple or nipples form - polymastia (formation of an accessory true mammary gland) also may occur when involution of the milk line is incomplete - accessory nipples and breast tissue most commonly develop in the axilla or inframammary fold, but they may occur anywhere along the embryologic milk line, from the axilla to the groin. Because they are pigmented, accessory nipples may be mistaken for moles.

- hypoplasia: underdevelopment of the breast - amazia: lack of breast tissue, but with the presence of a nipple; do not affect the appearance of the nipple-areolar complex - athelia: the nipple may not develop, although this occurs more commonly in accessory breast tissue - amastia: lack of both the breast tissue and the nipple no breast development - unilateral amastia is associated with absence of the major pectoral muscle (Poland syndrome) - bilateral amastia is associated with various other birth defects

- nipple retraction: only a slitlike area is pulled inward; - nipple inversion: the entire nipple is pulled inward.

Postnatal Development
Lobule formation occurs (exclusively in females) after puberty when there is branching of ducts and development of lobules from terminal ducts. Thelarche, from puberty onwards, can be divided into five separate phases: 1. phase I: elevation of the nipple 2. phase II: glandular subareolar tissue is present (breast bud), nipple and breast projecting from the chest wall as a single mass 3. phase III: increase in diameter and pigmentation of the areola, with proliferation of palpable breast tissue 4. phase IV: pigmentation and enlargement in the areola, the nipple and areola forming a secondary mass (mound) anterior to the main part of the breast 5. phase V: there is development of a smooth contour to the breast

Five Tanner stages of normal pubertal breast development. a. Tanner stage 1: breast tissue in a 6year-old girl shows a small area of illdefined echogenic tissue in the retroareolar region (arrows) b. Tanner stage 2: breast tissue in a 13year-old girl reveals an echogenic nodule with a retroareolar, stellate, hypoechoic focus (*) c. Tanner stage 3: breast development in a 13-year-old girl demonstrates more echogenic, glandular tissue (arrows) with a central spider-shaped hypoechoic focus (* ) d. Tanner stage 4: breast development in a 16-year-old girl shows more echogenic fibroglandular tissue (arrows) with a central hypoechoic nodule (*); increased subcutaneous fat anterior to the glandular tissue compared with earlier stages e. Tanner stage 5: breast tissue in a 16year-old girl demonstrates echogenic fibroglandular tissue (arrows) without a central hypoechoic focus

Premature telarche refers to the precocious appearance of breast development in girls. The breast development has atypical appearance with relatively immature nipple development and is never more than Tanner Breast Stage III. Tuberous breast: - reduced parenchymal volume and herniation of breast parenchyma through the nipple-areolar complex - appears when the breast development is interrupted at the stage IV of the secondary mound; the areola has an characteristic appearance.

BREAST SKIN

The skin consists of epidermal, dermal and hypodermal layers. a). the epidermis is composed of five cell layers and is separated from the dermis by a thin basement membrane; b). the dermis - consists mainly of collagen and elastin with blood vessels, motor and sensory nerves and receptors, muscle fibers, hair follicles, and sebaceous glands; - on the deep aspect of dermis, the retinacula cutis (the continuation of fibrocollagenous septa, the so-called suspensory Cooper ligaments) are attached.

c). the fatty hypodermal layer (subcutaneous fat) - shares continuous collagen and elastin fibers with the overlying dermal layer; - contains the major vasculature supplying the skin; - the columns of subcutaneous fat extending toward the overlying dermis are named the caves of Kopans.

NIPPLE AREOLAR COMPLEX

- nipple areolar complex overlies the area between the 2nd and 6th ribs (the 4th intercostal space being typical for a nonpendulous breast); - the lactiferous ducts traverse the nipple, their 1520 orifices opening on to its wrinkled tip; - smooth muscle cells are present in and just deep to the nipple, disposed in a predominantly circular direction and radiating out from its base into the surrounding breast; - because the skin of the nipple is continuous with the epithelium of the ducts, cancer of the ducts may spread to the nipple (Paget breast disease) .

- the Montgomery glands embryologically transitional between sweat glands and mammary glands; - the Montgomery glands open at the Morgagni tubercles, which are small (12 mm diameter) raised papules on the areola; the nipple-areolar complex contains many sensory nerve endings and an abundant lymphatic system called the subareolar or Sappey plexus.

- the mammary ducts converge at the nipple in a radial arrangement; - like the number of lobes, the number of mammary ducts may vary; - a collecting duct typically measure about 2 mm in diameter; - the collecting ducts coalesce in the subareolar region into lactiferous sinuses (58 mm in diameter); - women occasionally detect a normal lactiferous sinus as a palpable finding at self-examination.

SUPPORTING STRUCTURES
- the breast develops between the two layers of superficial fascia and is enveloped by it; - the fibrous structures form around and support the developing duct network as it grows back into the soft tissues; - the supporting network forms planar sheets of fibrous tissue that course between the deep and superficial layers of superficial fascia; - the sheets of fibrous tissue compartmentalize incompletely the structures of the breast.

- fibrous connective tissue courses through the breast in various amounts that differ from individual to individual; - these structures were first described by Sir Astley Cooper and are known as Coopers ligaments; - the superficial extensions of Coopers ligaments, known as retinacula cutis, are attached to the deep surface of dermis; - these ligaments may be contracted by fibrosis in carcinoma, causing retraction or pitting of the overlying skin; - ducts can follow the retinacula cutis to the skin so that breast cancer can develop in the subcutaneous fat.

Anterior (superficial) and posterior (deep) layers of superficial fascia

- nonspecialized connective tissue is found throughout the breast between the lobule (interlobular connective tissue) - the specialized connective tissue is contained with and surrounds the terminal duct lobular unit (intralobular connective tissue) - the deep extensions of Coopers ligaments cross the retromammary space and reach the deep pectoral fascia.

Ducts and Glandules Ducts injected with yellow, red, green, blue and black wax. The glandules from which the ducts begin are seen filled with wax.

Ligamenta suspensoria (Cooper's ligaments) is a network of fibrous connective tissue throughout the breast. It provides structural support for all the anatomical components and is responsible for giving the breast its characteristic shape.

Dissection of breast and anterolateral thoracic wall Superficial vessels and nerves; breast; pectoral fascia and muscles The fascia remains intact on the left side of the specimen. On the right side the fascia has been cut away except in the area occupied by the mammary gland. 1.Sternocleidomastoid muscle 2.Clavicle 3.Deltopectoral triangle 4.Deltoid muscle 5.Pectoralis major muscle 6.Cephalic vein 7.Axilla 8.Nipple (mammary papilla) 9.Subcutaneous fat of breast 10.Mammary body 11.External abdominal oblique muscle 12.Rectus abdominis muscle (covered by sheath of rectus abdominis muscle) 13.Superficial cervical fascia 14.Middle supraclavicular nerves 15.Anterior supraclavicular nerve 16.Upper pointer: Sternal angle Lower pointer: Anterior cutaneous branch intercostal nerve II 17.Pectoral fascia 18.Lateral cutaneous branch intercostal nerve IV 19.Serratus anterior muscle 20.Superficial fascia

Dissection of breast and anterolateral thoracic wall Right breast dissected in situ 1.Axillary fascia 2.Lateral thoracic artery and vein 3.Latissimus dorsi muscle 4.Thoracoepigastric vein 5.Nipple (mammary papilla) 6.Areola 7.Superficial fascia 8.Lateral cutaneous branch intercostal nerve VI 9.Serratus anterior muscle 10.Pectoralis major muscle 11.Mammary branch internal thoracic artery 12.Anterior cutaneous branch intercostal nerve II 13.Body of sternum 14.Mammary body 15.Cutaneous ligaments (this and other suspensory bands of the breast were divided in removing the skin) 16.Sheath of rectus abdominis muscle

Dissection of breast and anterolateral thoracic wall. Sagittal section of right breast. The breast of a 20 year old woman has been sectioned in a sagittal plane which passes through the nipple. The specimen is unfixed and, as a result of this, the lactiferous ducts are not clearly visible in the photograph. 1.Pectoral fascia 2.Mammary gland lobules 3.Pectoralis major muscle (cut across) 4.Pectoralis minor muscle (cut across) 5.Mammary body (gland lobules not distinguishable) 6.Suspensory ligaments of breast 7.Skin (cut section) 8.Lobule of fat 9.Nipple (mammary papilla) 10.Area occupied by lactiferous ducts

INTERNAL ORGANIZATION OF THE BREAST

1. Epithelial glandular tissue

of the tubulo-alveolar type; 2. Fibrous connective tissue (stroma) surrounding the glandular tissue; 3. Adipose tissue.

1. EPITHELIAL GLANDULAR TISSUE

- consists of branching ducts and terminal secretory lobules; - the ducts converge on to the 1520 larger lactiferous ducts which open on to the apex of the nipple; - each lactiferous duct is connected to a system of ducts and lobules enclosed and intermingled with connective tissue stroma, collectively forming a lobe; - the number of lobes is the same as the number of lactiferous ducts.

Mild fibrocystic changes

Maceration specimen of the duct system and lobules in a women of reproductive age: the duct system of the mammary lobes is splayed out in the periphery; few TDLUs are visible.

Intraductal papilloma

MAMMARY GLAND LOBE

- a lobe is the physiologic unit of the breast parenchyma; - the lobes grow into one another around their edges, vary greatly in size and often overlap other lobes, making attempted surgical segmentectomy difficult and susceptible to error; - it is usually not possible to identify the edge of a breast lobe on ultrasound; - the lobar ducts drain to the nipple in a generally radial fashion; - the peripheral portions of the ductal system may lie in planes other than the radial plane.

This breast slice shows complete atrophy of TDLU but the branching duct tree will remain forever.

- the longest and broadest lobes are loacated in the UOQ; - the longest lobe is directed toward the axillary recess; it may extend into the axilla and terminate in heterotopic glandular tissue; - the ducts in the UOQ are larger than in the IQ; - the lobes in the UIQ are easily missed and appear to be the first lobes to atrophy with aging; - some lobes cannot be distinguished from one another (overlap one another in LQ / form an overlapping arrangement in OQ); - the ducts maintain their arrangement for life.

- a lobe is traversed by the main lactiferous duct which run almost through the center of each lobe; - a lobe is centered on the lactiferous duct, around which the lobules and the TDLUs are arranged at right angles (brush border arrangement, directed toward the skin); there are usually five rows of lobules (according to Teboul) that arise circumferentially from each lobar duct; - the superficial aspect of a lobe is separated from the skin by fat and they are backed by fatty tissue;

- the rows of lobules that lie anterior to the lobar duct tend to be longer than the posterior rows of lobules because the extralobular terminal duct is longer in the anterior TDLUs; - there are more anterior rows of lobules, and each anterior row generally has more lobules than the posterior rows; there are generally more lobules anterior to the lobar duct than there are posterior to the duct; - a few lobules are terminal lobules and are oriented horizontally rather than vertically; - anterior TDLUs that lie immediatelly deep to the Coopers ligaments tend to be larger than those that lie between Coopers ligaments.

- The lobe corresponds to a hyperechogenic area with different ductal axis visible within it, the largest one at the top of the lobe, the smallest in its depth - The lobules correspond to small hypoechogenic structures located along and mainly at the front part of the ducts

The age-related variations of the lobar morphology are numerous with two basic extremes: - the young womens breast lobes rich in glandular tissue, with minimal amount of fatty tissue; - the adult type breast lobe of women with a balance between the amount of parenchyma and fat.

- most of the lobes undergo involution, which is only partial in premenopausal women and more advanced in postmenopausal women; - with progression of the involution, structures of the lobe may disappear leaving behind delicate residual connective structures, the lobar skeleton or may be totally lost.

Schematic classification of mammary ducts by their location in the breast. a. Viewed from the front, the duct sectors are numbered 1-8 in a clockwise direction. Red: subcutaneous ducts (outer shell). Yellow: ducts of the inner shell. Green: central ducts. b. Ducts of the outer shell in two planes. The numbers 1-8 indicate location. For example, a duct in sector 8 is subcutaneous, located in upper part of the breast, and is not localized to a specific quadrant. A duct in sector 1 is subcutaneous and located in the UIQ.

lateral LQ

craniocaudal

lateral UQ

craniocaudal

c. Ducts of the inner shell. A duct in sector 4 is located in the lower part of the breast and and is not localized to a specific quadrant. A duct in sector 1 is located in the UIQ. d. Central ducts.

MAMMARY GLAND LOBULE

The basic functional unit in the breast is the lobule; a lobule and its terminal duct forms the terminal ductal lobular unit (TDLU). The TDLU consists of 10-100 acini, that drain into the terminal duct. The terminal duct drains into larger ducts and finally into the main duct of the lobe (or segment), that opens into the nipple. The breast contains 15-20 lobes; each lobe contains 20-40 lobules.

Microanatomy of normal adult female breast tissue showing extralobular ducts, terminal ducts, and lobules, the latter composed of groups of small glandular structures, the acini.

- maceration specimen of a TDLU: the plastic-filled lactiferous ducts and lobules (TDLUs) in the periphery; - microradiograph, histologic section and sonographic appearance of the TDLU.

Cancers are known to arise in the immature breast tissue Type 1. Some Type 1 lobules mature at puberty into Type 2 lobules. Scientists recognize Types 1 and 2 lobules as cancer-vulnerable. Estrogen causes breast tissue to grow. It stimulates Types 1 and 2 lobules to multiply. Abortion leaves a woman with more Types 1 and 2 lobules. Only a 3rd trimester process in pregnancy protects a woman from estrogen overexposure and matures her breast tissue into cancer-resistant, milk producing breast tissue (Types 3 & 4 lobules). A full term pregnancy leaves a woman with an increase in cancerresistant breast lobules. That's why women with more children have a lower lifetime risk for the disease. A woman is the most vulnerable to carcinogens between the time that her menstrual periods begin and her first full term pregnancy occurs. With every menstrual period, estrogen stimulates Types 1 and 2 lobules.

- the lobules contain the terminal ducts and their associated acini, which are hypoechoic on ultrasound; - the acini are embedded in a loose intralobular stroma which also appears hypoechoic on ultrasound and may proliferate in response to hormones and regresses with aging; - while intralobular stroma is located within the lobules and is hypoechoic, the space between the lobules is occupied by tough interlobular stroma, which appears hyperechoic at ultrasound, and fatty tissue, neither of which is responsive to hormones.

- each lobule consists of several blind-ending branches or expansions, the alveoli (acini), converging on an alveolar duct; - acinus (columnar epithelium) is surrounded by basket cells and intralobular stroma; - a glandular duct has multiple peripheral TDLUs.

Normal appearing breasts with abundant stroma and bilateral fibroadenomas in a 15 year old girl

TDLUs in the early second half of the cycle

TDLUs during the phase of the cycle

premenstrual

2. INTRALOBULAR AND INTERLOBULAR CONNECTIVE TISSUE

Specialized, loose intralobular connective tissue: - is derived by downgrouth of papillary layer of dermis - is contained with and surrounds the TDLU - contains no elastic tissue - proliferates in response to hormones and regresses with aging - has the same echogenicity as the lobular acini

Nonspecialized, dense interlobular connective tissue: - is found throughout the breast between the lobules - contains elastic tissue - is not responsive to hormonal stimulation - appears hyperechoic at ultrasound

3. ADIPOSE TISSUE

- comprises the premammary and retromammary fat - is typically present in the interlobar stroma, and not amongst the lobules - is absent posterior to the nippleareolar complex - is highly variable in amount - reflects the body fat of the patient

The premammary fat: - is absent posterior to the nipple-areolar complex - is perforated by the retinacula cutis - the typical fatty lobes are interrupted by the Coopers ligaments, which connect the fascia and the anterior surface of the breast lobes.

The retromammary fat: - the posterior surface of a lobe is bristled up by the posterior Coopers ligaments ( mirror pattern of the front lobe surface), which cross the fatty tissue on their way to the deep layer of the fascia.

ARTERIAL SUPPLY

1. The axillary artery supplies blood to the breast via several branches: the supreme thoracic, the pectoral branches of the thoraco-acromial artery, the lateral thoracic and the subscapular artery; 2. The internal thoracic artery gives perforating branches to the anteromedial part of the breast; 3. The 2nd to 4th intercostal arteries give perforating branches more laterally in the anterior thorax. The 2nd perforating artery is usually the largest, supplying the upper region of the breast, and the nipple, areola and adjacent breast tissue.

A. The breast may be supplied with blood from the internal thoracic, the axillary, and the intercostal arteries in 18 percent of individuals.
B. In 30 percent, the contribution from the axillary artery is negligible. C. In 50 percent, the intercostal arteries contribute little or no blood to the breast. In the remaining 2 percent, other variations may be found.

VENOUS DRAINAGE

Around the areola there is a circular venous plexus (of Haller). From this and from the glandular tissue, blood drains in veins accompanying the arterial blood supply, i.e. to the axillary, internal thoracic and intercostal veins. Great individual variation may occur. The venous blood is received into the large veins that receive blood also from the vertebrae and thoracic cage, spread of malignancy by veins can thus involve these bones.

LYMPHATIC DRAINAGE
From the subareolar plexus (of Sappey) there are efferent vessels draining to the following: the contralateral breast the internal mammary lymph node chain, and thence via: 1. the mediastinal lymph nodes to the para-aortic lymph nodes, bronchomediastinal trunks, thoracic duct and right thoracic duct 2. inferiorly, the superior and inferior epigastric lymphatic routes to the groin

 the axillary lymph nodes, the predominant site of drainage from the breast. These number from 2040; based on the relation of the nodes to pectoralis minor, there are 3 levels: - those lying below pectoralis minor are the low nodes (level 1), - those behind the muscle are the middle group (level 2), - the nodes between the upper border of pectoralis minor and the lower border of the clavicle are the upper or apical nodes (level 3). In addition, between pectoralis minor and major there may be one or two other nodes (Rotter's nodes).

Drainage pattern from the upper outer quadrant. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

Drainage pattern from the lower outer quadrant. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

Drainage pattern from the upper inner quadrant. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

Drainage pattern from the lower inner quadrant. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

Drainage pattern from the center. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

Drainage pattern from the whole breast. A: All breast lesions. B: Palpable breast lesions. C: Nonpalpable breast lesions. D: Intercostal space location of the sentinel node in case of drainage to the internal mammary chain region. Arrow, interpectoral region.

- Both palpable and nonpalpable lesions may drain toward the IMC, although the latter more frequently, regardless of the quadrant. - Nonpalpable lesions in the UOQ, UIQ, and LIQ have less often drainage to the axilla compared with the palpable breast lesions. - All lesions from the center drain to the axilla. - The outer quadrants show drainage to the IMC in 14.4%, which is less than the inner quadrants (37.4%). - Nonpalpable tumors drain more frequently to the IMC, irrespective of the quadrant. - The LIQ has less drainage to the axilla compared with the other quadrants, but more to the IMC. - The lateral side of the breast often drains to the IMC as well (1030%). - Deeper located tumors are less accessible to palpation. So, the depth of the tumor may be the explanation of the difference in drainage to extra-axillary sentinel nodes between palpable and nonpalpable lesions (internal mammary nodes and interpectoral nodes are supplied by retromammarian lymphatics).