FEMALE ANATOMY AND PHYSIOLOGY

Part B – Female Breast

secondary sex characteristics = physical features,

other than genitals, that differ between the sexes

amount of mammary glands = constant

amount of fatty tissue varies

breast and nipple stimulation are an important source of

pleasure and arousal for many women

[pictures of internal anatomy of the breast]

mammary glands

[pictures of mammary glands]

fat

[pictures of fat in breast]

[pictures of one woman’s breasts:

pre-pregnancy

38 weeks pregnant

3 weeks after birth]

“My breasts were very small (size 36AA)…My breasts increased in size when the milk came in…Please

use my photos to show women that even small breasts like mine can provide the full amount of milk baby

needs and give so much enjoyment to both mum and baby.”

areola

[pictures of areola]

areolar bumps

[picture of areolar bumps]

nipple

[pictures of nipple]

inverted nipple

[picture of inverted nipple]

up to 10 perecent of women have at least one inverted nipple

a massage technique called the Hoffman may help evert them

accessory nipples occur in

5% of Japanese women

3.5% of Black women

<1% of Caucasion women

(some men also)

[picture of accessory nipple]

polythelia

polymastia

[pictures of extra nipples and extra breasts]

milk duct

[pictures of milk duct]

suspensory ligaments

[pictures of suspensory ligaments]

muscle

[pictures of chest muscles behind breasts]

A previous edition of your textbook p. 109:

Breast size and shape vary from woman to woman.

[pictures of the breasts of 4 different women]

8^th edition of your textbook p. 109

[pictures of the breasts of 4 different women]

10^th edition of your textbook p. 102

[pictures of the breasts of 3 different women]

[pictures of the breasts of 16 different women]

38C “regular” underwire bra

38C bra designed to push breasts up & together

[picture of the same woman wearing two different bras]

Breast size and shape vary from woman to woman.

[pictures of 4 women pre-breast-surgery]

22 y/o

no children

135 lb

saline implant

7 mo post-op

[picture of the same woman before and after getting breast implants]

augmentation

[pictures of breasts before and after implants]

[pictures of mammography process]

Implant follow-up studies required by the

FDA General & Plastic Surgery Devices Panel.

Report at 5 years into safety studies by manufacturers:

Inamed- 80% response rate:

900 augmentation patients -> 463 reoperation procedures

34% implant removal & replacement

19% capsular contracture

11% adjustment of saline fill

257 reconstruction patients -> 159 reoperation procedures

31% implant removal & replacement

18% scar revision / wound repair

13% implant removal without replacement

Family Practice News October 1, 2002 page 40

Later Surgeries Needed by as Many as 50% of Saline Implant Patients

Mentor Corp – 54% & 73% response rates:

1,264 augmentation patients -> 343 reoperation procedures

29% request for size or shape change

19% leakage, rupture, deflation

17% capsular contracture

11% wrinkling

416 reconstruction patients -> 232 reoperation procedures

16% request for size or shape change

15% leakage, rupture, deflation

29% capsular contracture

20% asymmetry

Family Practice News October 1, 2002 page 40

Later Surgeries Needed by as Many as 50% of Saline Implant Patients

capsular contracture

[picture of capsular contracture]

implant removal without replacement

[pictures of breasts after implants were removed]

implant deflation or rupture

[picture of two breasts varying significantly in size]

38 y/o

children

5’3” 130 lb

gel implant

1 mo post-op

also had lower

abdominoplasty

[pictures of woman before and after implants]

mastopexy

[pictures of mastopexy]

23 y/o

no children

220 lb

3 mo post-op

[pictures of woman before and after mastopexy]

[more pictures of mastopexy]

breast self exam

monthly (best after menstruation if still menstruating)

90% of breast lumps (mostly nonmalignant)

are found by women themselves (not their physicians)

examine: in shower, before mirror, lying down

include: all the breast, nipple and underarms

Average-size lump found by mammogram

Average-size lump found by doctor’s examination

Average-size lump found by woman who examines her breast each month

Average-size lump found by woman who doesn’t examine her breasts each month

[pictures of various circles representing comparative sizes

of average-size lumps detected by various screening methods]

1 cell -> 2cells (100days)

-> 4 cells (200 days)

-> 8 cells (300 days)

-> 16 cells (400 days)

-> visible on mammogram (9 years)

-> smallest palpable tumor (10 years)

-> average palpable tumor (11 years)

[picture of timeline for how quickly cancer grows]

Start by standing in front of a mirror. Look at

your breasts with your arms at your side, with your

arms raised behind your head and with your arms

on your hips with your chest muscles flexed.

[picture of woman looking at her breasts in the mirror]

peau d’orange – lymphedema due to

obstruction of lymphatic drainage by tumor

[picture of drawing and photo of peau d’orange]

retraction of skin – tumor involvement of Cooper’s ligaments

(suspensory ligaments)

[picture of drawing and photo of skin retraction]

[picture of breast including ligaments inside]

[photos of breast with visible retraction and breast with visible lump]

Lie down with a pillow under your left shoulder.

Put your left hand behind your head and feel your

left breast with the pads of your three middle

fingers on your right hand. Start at the outer edge

[picture of woman examining breast while lying down]

[picture of circular pattern of breast self exam]

patterns of palpation

concentric circles

radial pattern

up and down

[pictures of three patterns of palpation]

Clinical quadrants of the breast, with the percentage

of all cancers of the breast found in each.

[picture of right breast and armpit with superimposed statistics]

60% in upper outer quadrant

12% in upper inner quadrant

12% in nipple and areola area

10% in lower outer quadrant

6% in lower inner quadrant

[picture of lymph vessels and lymph nodes]

sarcoma

[picture of sarcoma so large that it has erupted through the skin]

adenocarcinoma

[picture of adenocarcinoma so large that it has erupted through the skin]

Paget’s carcinoma

[picture of the appearance of the nipple affected by Paget’s carcinoma]

infiltrating carcinoma

[pictures of infiltrating carcinoma]

fibroadenoma

[picture of fibroadenoma]

small cysts

increased fibrous tissue

[pictures of fibrocystic breasts]

larger cysts

more fibrous tissue

[pictures of fibrocystic breasts]

multiple large cysts

[pictures of large cysts]

mammography – process of making X-ray of breast

mammogram – image of breast on film

mammography can detect cancer that is not palpable

routine screening by mammography

usually starts at age 40

next step may be:

repeat physical exams

repeat mammograms

needle aspiration

needle or open biopsy

[picture of mammography process]

Yes, I did have my mammogram today… why do you ask?

[cartoon of woman with flattened breasts sticking out in front of her]

[picture of mammogram of right breast]

right breast of woman

containing palpable fibroadenoma

[picture of mammogram of left breast]

left breast of same woman

containing non-palpable carcinoma

********************************************************

breast density and age

[picture of mammogram that is densely white all over]

under 30

[picture of mammogram that has lots of dense white areas]

30 to 40

[picture of mammogram with one area that is cloudy white]

mid-40s

[picture of mammogram with no densely white areas]

over 55

glandular tissue appears white

fatty tissue appears dark

********************************************************

fibroadenoma cyst

[pictures of two mammograms]

ductal carcinoma in situ

[picture of mammogram]

lead time bias

Does early diagnosis let you survive longer?

Or does early diagnosis just give you a longer time to know

that you’ve got the disease?

[picture of timeline]

length bias

A mammogram done every two years will catch

most of the slow growing tumors

but only a few of the fast growing ones.

[picture of screening time intervals]

selection bias

women whose mother or sister had breast cancer

are more likely to get cancer AND more likely to get a mammogram

[picture of women going towards or away from mammography location]

overdiagnosis bias

If only 30% of pre-cancers turn into cancers

then doing mastectomies on all pre-cancers

will appear to cure 70% of them

[picture of three” really cured” women (or not)

and six women who “appear cured” – never were at risk]

causes of breast lumps:

fibroadenomas – benign solid rounded tumors

cysts – benign fluid filled sacs

malignant tumors – cancer

approximately 80% of lumps are benign

(benign = non-cancerous)

breast cancer affects approximately:

1/9 of North American Women

risk factors:

age above 50

family history of breast cancer

no pregnancies

>14 alcoholic drinks/wk

first child after 30

never breast fed

menarche before 12

very short or long menstrual cycles

menopause after 50

obesity

previous breast cancer

sedentary lifestyle

Genetic Testing for Breast Cancer

Reprinted from UpToDate in Family Practice

October 2001 Edition

Susan W Fletcher MD

Claudine Isaacs MD

Beth N Peshkin MS CGC

breast cancer genes

BRCA1 17q21

BRCA2 13q12-13

P53 (Li-Fraumeni) 17p13.1

Cowden 10q22-23

Androgen receptor Xq11.2-12

Ataxia-telangiectasia 11q22-23

HRAS1 VNTR 11p15.5

HCHK2 22q12

BRCA1 & BRCA2 are responsible for less than 1/5^th of the

familial risk of breast cancer

BRCA1 & BRCA2 are autosomal dominant genes that are

thought to be tumor suppressor genes

risk of cancer in women

with deleterious BRCA1 or BRCA2 mutations

breast cancer 50y/o F 70y/o F

general 38-51% 67-85%

Ashkenazi Jews 33% 56%

Icelandic women 17% 37%

contralateral breast in

women with breast cancer 48% 64%

ovarian cancer (BRCA1) 29% 44%

BRCA1: colon CA (4x) prostate CA (3x)

BRCA2: male breast CA

Several hundred mutations have been reported

within BRCA1 and BRCA2

panel of BRCA1 & BRCA2 mutations $2,680

single specific mutation test $315

panel of 3 mutations most common in

people descendent from Ashkenazi Jews $375

(BRCA1: 185delAG, 538insC; BRCA2: 617delT)

breast cancer treatment

radiation therapy

chemotherapy

hormone therapy

immunotherapy

surgery (see following slides)

lumpectomy (surgical removal of a lump of tissue)

mastectomy (sugical removal of all or part of breast)

radical mastectomy

(breast, underlying muscle, and lymph nodes)

simple mastectomy

(breast with nipple and areolar tissue,

and a sample of lymph nodes)

in general, the earlier breast cancer is caught,

the less radical the treatment required

lumpectomy

[picture]

partial mastectomy

[picture]

simple or total mastectomy

[picture]

modified radical mastectomy

[picture]

complex decongestive therapy (CDT) for lymphedema

performed with the assistance of a certified lymphedema therapist

1) manual lymph drainage (40 to 90 minute sessions)

2) compression bandaging (initially worn nearly 24 hours/day)

3) exercise

4) meticulous skin care to reduce risk of infection

[picture of arm before and after CDT]

breast reconstruction

nipple and areola can be made

normal breast can be reduced in size to match reconstructed

skin (and muscle) can be transferred to breast area

from the back or the abdomen

with or without use of implants

[picture of mastectomy scar, picture of reconstructed breast]

implant problems

capsular contraction due to scar tissue

debated problems with silicone implants

(various studies give conflicting results)

autoimmune diseases

chronic inflammation

neurologic damage

toxic reactions