1. HUMAN ANATOMY of
Dr KB Ashok, MBBS, AIIMS, New Delhi

2. THE BREAST

3. Introduction/General Information
A. Embryologically: belong to integument
B. Functionally: part of reproductive system
1. Respond to sexual stimulation
2. Feed babies

4. C. Modified apocrine sweat glands
Breast, continued …
C. Modified apocrine sweat glands
- apex of cell becomes part of secretion and breaks off
D. Present in males and females

5. A. Position and Attachment 1. Lateral aspect of pectoral region
II. Anatomy
A. Position and Attachment
1. Lateral aspect of pectoral region
2. Located between ribs 3 and 6/7
3. Extend form sternum to axilla
4. Surrounded by superficial fascia
5. Rest on deep fascia

6. Breast Anatomy

7. 6. Fixed to skin & underlying fascia by fibrous C.T. bands
Position & attachment, continued ….
6. Fixed to skin & underlying fascia by fibrous C.T. bands
a. Cooper’s (Suspensory) Ligaments
b. Ligaments may retract when breast tumors are present

8. Cooper’s Suspensory Ligaments

9. 7. Left breast is usually slightly larger
Position & attachment, continued …
7. Left breast is usually slightly larger
8. Base is circular, either flattened or concave
9. Separated from pectoralis major muscle by fascia, retro-mammary space

10. Retromammary Space
Retromammary Space

11. 1. Outer surface convex, skin covered 2. Nipple:
Anatomy, continued …
B. Structure
1. Outer surface convex, skin covered
2. Nipple:
a. At fourth intercostal space
b. Small conical/cylindrical prominence below center

12. Nipple location
4th intercostal space

13. d. Thin skinned region lacking hair, sweat glands
Structure, continued …
c. Surrounded by areola: pigmented ring of skin
d. Thin skinned region lacking hair, sweat glands
e. Contains areolar glands

14. a. Circular and radial smooth muscle fibers
Structure, continued …
3. Areola: contains dark pigment that intensifies with pregnancy
a. Circular and radial smooth muscle fibers
b. Cause nipple erection

15. Areola

16. a. Each lobe has one lactiferous duct
Structure, continued …
4. Each breast consists of ~ 20 lobes of secretory tissue
a. Each lobe has one lactiferous duct
b. Lobes (and ducts) arranged radially
c. Embedded in connective tissue & adipose of superficial fascia
d. Lobes composed of lobules
e. Lobules comprise alveoli

17. Lobes and Lobules

18. a. Form ampullae (collection sites of lactiferous sinuses)
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

19. Excretory (lactiferous) ducts

20. a. Changes with hormonal signals b. Onset of menstruation
Structure, continued …
6. Secretory epithelium
a. Changes with hormonal signals
b. Onset of menstruation
c. Pregnancy (glands begin to enlarge at 2nd month)
d. After birth, 1st secretion is colostrom (contain antibodies)

21. b. Passes under axillary fascia
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

22. “Tail of Spence”
Axillary Tail

23. a. Determines form & size of breast
Structure, continued …
8. Fatty Tissue: surrounds surface, fills spaces between lobes
a. Determines form & size of breast
b. No fatty deposit under nipple & areola

24. Breast: Fatty Tissue

25. 1. Arteries: derived from thoracic branches of three pairs of arteries
Structure, continued …
Vessels & nerves
1. Arteries: derived from thoracic branches of three pairs of arteries
a. Axillary arteries
1) continuous with subclavian a ) gives rise to external mammary ( lateral thoracic) artery

26. c. Intercostal arteries:
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

27. External mammary (thoracic) a. Internal mammary (thoracic) a.
Subclavian a.
Axillary a.
External mammary (thoracic) a.
Internal mammary (thoracic) a.
Arterial Supply to the Breast

28. Vessels & Nerves, continued …
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

29. Veins draining the Breast
Subclavian vein
External mammary vein

30. a. anterior & lateral cutaneous nerves of thorax
Breast Anatomy, con’t…
3. Innervations: derived from:
a. anterior & lateral cutaneous nerves of thorax
b. spinal segments T3 – T6

31. 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) nodes
b. Medial quadrants drain into parasternal nodes

32. Lateral pectoral nodes Parasternal nodes
Subclavian nodes
Axillary nodes
Lateral pectoral nodes
Parasternal nodes
Lymph Nodes of the Breast

33. d. NOTE: axillary nodes also drain lymph from arm
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

34. Lymph Nodes and Lymph Drainage
Axillary Nodes

35. Routes of Metastasis From medial lymphatics to parasternal nodes
Then to mediastinal nodes
Across the sternum in lymphatics to opposite side via cross-mammary pathways
Then to contralateral breast
From subdiaphragmatic lymphatics to nodes in abdomen
Then to liver, ovaries, peritoneum

36. Major Routes of Metastasis
Channels to Contralateral Breast
Axillary Lymph Channels
Subdiaphragmatic Lymph Channels

37. 1. Inverted nipple: congenital or due to cancer 2. Ectopic nipple:
Structure, continued …
Anomalies
1. Inverted nipple: congenital or due to cancer
2. Ectopic nipple:
a. “polythelia” or “hyperthelia”
b. additional nipples along milk line
3. Amastia
4. Micromastia

38. a. breast development of male in areolar region
Anomalies, continued …
5. Macromastia
6. Gynecomastia
a. breast development of male in areolar region
b. noted in males who smoke marijuana at puberty

39. III. Diseases of the Breast
A. Most are readily detectable
B. Etiology unknown, influencing factors
1. Sex
2. Heredity

40. a. Menstruation – tenderness from fluid engorgement
Diseases of the breast, continued …
3. Endocrine influence
a. Menstruation – tenderness from fluid engorgement
b. Post-menopause ) decrease of fibro-cystic disease ) increase in cancer
c. Pregnancy

41. C. General symptoms & signs 1. Nipple discharge
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

42. 5. Retraction sign: “dimpling” involving skin, nipple or areola
Symptoms & Signs, continued …
5. Retraction sign: “dimpling” involving skin, nipple or areola
6. Mobility of mass
a. Benign = movable
1) not attached
2) not invasive
b. Malignant = attached
May grow into bone

43. a. Cysts = fluctuant; compressible
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

44. D. Benign breast conditions
1. Infection = usually during or after lactation
a. Recurrent, subareolar abscess
b. TB of the breast
2. Trauma = contusion
3. Hypertrophy = seen in either sex at adolescence
a. Gynecomastia = in males

45. b. Other causes 1) testicular or pituitary tumor 2) cirrhosis
Hypertrophy, continued …
b. Other causes
1) testicular or pituitary tumor
2) cirrhosis
3) hypogonadism = not enough testosterone
4) estrogen administration for prostate cancer

46. 4. Tumors & cysts a. Fibroadenoma = most common benign breast tumor
Benign Conditions, continued
4. Tumors & cysts
a. Fibroadenoma = most common benign breast tumor

47. 2. May be aspirated if large
Tumors and Cysts, con’t…
b. Breast Cyst
1. Benign
2. May be aspirated if large

48. c. Fibrocystic breast changes
Benign conditions, continued …
c. Fibrocystic breast changes
1) 20%+ of premenopausal women
2) discomfort, cysts
3) treatment rarely required
4) More likely to not detect a developing cancer

49. d. Intraductal papilloma
Tumors & cysts, continued ….
d. Intraductal papilloma
- may produce “chocolate” or bloody discharge from nipple
e. Lipoma: common
- fatty tumors

50. E. Carcinoma of the breast
Most common malignant tumor among women
1/8 of women will develop breast cancer
a. 1/6 in Orange County
b. 1/5 in San Francisco
3. Generally no discomfort

51. Progression to Breast Cancer

52. a. Slowly growing, painless mass
Carcinoma of breast, continued …
4. Physical signs:
a. Slowly growing, painless mass
b. May demonstrate retracted nipple
c. May be bleeding from nipple
d. May be distorted areola, or breast contour
e. Skin dimpling in more advanced stages with retraction of Cooper’s ligaments

53. f. Attachment of mass g. Edema of skin
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

54. 5. Common sites for metastasis
Breast Cancer, contd.
5. Common sites for metastasis
a. Lungs & pleura
b. Skeleton system (skull, vertebral column, pelvis)
c. Liver
6. Atypical carcinomas
a. Inflammatory carcinoma (hormonal, chemotherapy)
b. Paget’s disease of the breast

55. Quick Overview

56. PROSTATE GLAND

57. Introduction/General Information
Attached inferiorly to urinary bladder by ligaments
Posterior to pubic symphysis
Surrounds superior portion of urethra
Anterior to rectum (palpation, ultrasound)
Conical shape

58. 1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf G. Lightly encapsulated
Introduction, Prostate Gland, continued …
F. Walnut sized
1. 4 cm trans x 2 cm A/P x 3 cm Sup/Inf
G. Lightly encapsulated
1. Fibrous connective tissue
2. Smooth muscle
3. Capsule extends into lobes

59. Prostate Gland, Mid-sagittal Section
II. Prostate Gland: Detailed Anatomy
A. Largest male accessory gland
B. Located in subperitoneal compartment (between pelvic diaphragm & peritoneum)
Prostate Gland, Mid-sagittal Section

60. Prostate Gland: Detailed Anatomy
C. Enclosed in fascial sheath(prostatic sheath)
1. Inferiorly, sheath is continuous with superior fascia of urogenital diaphragm
2. Posteriorly, sheath forms part of retrovesical septum

61. 1. Fibrous portion contacts gland
Prostate Gland: Detailed Anatomy
D. Double Capsule
1. Fibrous portion contacts gland
2. External capsule formed by pelvic fascia
3. Venous plexus lies between

62. Male Reproductive System, Posterior View

63. E. Conical shape with base (sup), apex (inf), four surfaces
Detailed Anatomy, continued …
E. Conical shape with base (sup), apex (inf), four surfaces
1. Surfaces: posterior, anterior, right & left inferolateral
2. Base (vesicular surface): superior
a. Attached to neck of urinary bladder
b. Prostatic urethra enters middle of base close to anterior surface

64. Prostate Anatomy
Prostatic Urethra

65. a. Rests on superior fascia of urogenital diaphragm muscle
Detailed Anatomy, contined …
3. Apex: inferior
a. Rests on superior fascia of urogenital diaphragm muscle
b. Associated with sphincter urethrae
c. Contacts medial margins of levator ani muscles

66. 5. Anterior surface: narrow, convex 6. Inferiorolateral surfaces
Detailed Anatomy, continued …
4. Posterior surface: triangular, flat
5. Anterior surface: narrow, convex
6. Inferiorolateral surfaces
a. Meet with anterior surface
b. Rest on levator ani fascia above urogenital diaphragm

67. 1. Divisions are arbitrary, indistinct 2. Usually divided into
Detailed Anatomy, continued …
F. Lobes of the Prostate
1. Divisions are arbitrary, indistinct
2. Usually divided into
a. two lateral lobes
b. one median lobe
c. anterior and posterior lobes

68. Lobes of the Prostate, continued …
3. Median lobe
a. Lies posterior and superior to prostatic utricle and ejaculatory ducts
b. May project into urinary bladder
c. Utricle lies within lobe
1. Vestigial remains of uterine homolog
2. Sometimes called “uterus masculinis”

69. a. Comprise the greatest mass of the gland
Lobes of the Prostate, continued …
4. Lateral lobes
a. Comprise the greatest mass of the gland
b. Contain most secretory tissue
c. Are continuous posteriorly
5. Glandular tissue with varying amounts of fibrous tissue

70. Lobes of the Prostate, continued …
Prostate Gland in situ

71. 1. Arteries derived from:
Detailed Anatomy, continued …
G. Blood & lymph
1. Arteries derived from:
a. Internal pudendal artery
b. Inferior vesical artery
c. Middle rectal artery

72. a. Form venous plexus b. Drain into internal iliac veins
Blood & Lymph, continued …
2. Veins
a. Form venous plexus
b. Drain into internal iliac veins
c. Communicate with vesical & vertebral venous plexuses

73. a. Most terminate in internal iliac & sacral nodes (unable to palpate)
Blood & Lymph, continued …
3. Lymphatics
a. Most terminate in internal iliac & sacral nodes (unable to palpate)
b. From posterior: to external iliac nodes (unable to palpate)

74. 1. 30 - 50 different glandular elements a. Serous glands
Detailed Anatomy, continued …
Glandular tissue
different glandular elements
a. Serous glands
b ducts empty into prostatic urethra
2. Most are posterior & lateral to urethra

75. a. Thin, milky, alkaline (looks like skim milk)
Blood & Lymph, continued …
3. Prostatic secretions
a. Thin, milky, alkaline (looks like skim milk)
b. Discharged at ejaculation
c. Make up ~ 1/3 of semen

76. Prostate size changes 1. Small at birth 2. Enlarges at puberty
Detailed Anatomy, continued …
Prostate size changes
1. Small at birth
2. Enlarges at puberty
3. Maximum at about 13
4. Progressive enlargement after 40
5. Sometimes: undergoes atrophy

77. III. Pathology 1. Affects ~90% of men >50
A. Benign prostatic hypertrophy (BPH):
1. Affects ~90% of men >50

78. a. Nocturia 2. Common cause of urethral obstruction causes: b. Dysuria
BPH, continued …
2. Common cause of urethral obstruction causes:
a. Nocturia
b. Dysuria
c. Urgency
d. Back-pressure effects
e. Complete obstruction can occur

79. B. Prostate cancer 1. Most common cancer in males
Pathology, continued …
B. Prostate cancer
1. Most common cancer in males

80. 2. Metastasizes via blood (haematogenous)or lymph (lymphogenous)
Pathology, continued …
2. Metastasizes via blood (haematogenous)or lymph (lymphogenous)
3. Common sites: vertebrae, pelvis
a. Via venous plexus surrounding prostate
b. Bone or direct metastasis most common

81. Prostate Cancer: Routes of Metastasis

82. Prostatitis (accompanied by cystitis) 1. Inflammation of gland
Pathology, continued …
Prostatitis (accompanied by cystitis)
1. Inflammation of gland
2. Gland enlarges, becomes tender
3. Causes: gonorrhea? Other UTI’s? STD’s?
4. May require antibiotics, massage
5. Symptoms: chills, painful urination, back pain

83. Prostatic concretions (corpora amylacea [starch bodies])
Pathology, continued …
Prostatic concretions (corpora amylacea [starch bodies])
1. Small spherical or ellipsoid bodies
2. Number increases with age
3. May become calcified as male ages
4. May simulate carcinoma

84. Digital Rectal Exam

85. E. Rarely, prostatic abscesses develop
Pathology, continued …
E. Rarely, prostatic abscesses develop
1. Frequently caused by gonorrhea
2. May rupture through to rectum, bladder, perineum
3. Other causes:
a. Urethritis
b. Epididymitis

86. Quick Overview