The BREAST ANATOMY

Dr.ARUJ LATIF

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 LECTURE 1

10/24/20 CBMS2006 2
 Introduction to mammography.
 Anatomy.
 Breast cancer.
 Imaging modalities.
 Role of a mammographic technologist.
 Mammographic views.
 Reporting system.
 Additional information for a
mammography technologist.
 Artifacts.
 Male mammography .
 Conclusion.

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 Breast Cancer
Breast cancer is second only to lung cancer as
a cause of cancer deaths in women
• One out of every eight women
will be diagnosed with breast
cancer in 2011
• Fortunately, radical mastectomy
(surgical removal) is rarely
needed today with better
treatment options

4
Development of the Breast Ductal Tree
Occurs mainly after birth
Female Breast Anatomy

• The bulk of the breast

tissue is adipose tissue
interspersed with
connective tissue
• Breast ducts comprise
only about 10% of the
breast mass

– lobes
– ducts
– lymph nodes

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Stucture of the Breast

• Breast has no
muscle tissue
• There are muscles
underneath the
breasts separating
them from the ribs

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Breast Gland

• Each breast has 15 to 20

sections (lobes) arranged
like the petals of daisy

• Inside each lobe are many

smaller structures called
lobules
• At the end of each lobule
are tiny sacs (bulbs) that
can produce milk
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ANATO
MY
 Ducts

• Lobes, Lobules and bulbs,

are linked by a network of
thin tubes (ducts)
Duct
• Ducts carry milk from
bulbs toward dark area of
skin in the center of the
breast (areola)
Areola

Ducts join together into larger ducts ending at

the nipple, where milk is delivered
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 Lymphatic System
• Lymph ducts: Drain fluid
that carries white blood
cells (that fight disease)
Lymph node Lymph duct from the breast tissues
into lymph nodes under
the armpit and behind
the breastbone
• Lymph nodes: Filter
harmful bacteria and
play a key role in
fighting off infection
A network of vessels

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 Three Types of Vessels

1
Lobules Ducts Nipple Milk
3
Lymph Lymph
Waste
Nodes Vessels produc
ts

Bacteria
2 ent
r is hm
Blood Nou Cell life
Vessels

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 Signs and Symptoms

Most common:
lump or
thickening in
breast. Often
painless

Discharge Redness or pitting

or of skin over the
bleeding breast, like the
skin of an orange
Change in size Change in color
or contours of or appearance
breast of areola 13
 Noncancerous Conditions (1)
• Fibrocystic changes: Lumpiness, thickening and
swelling, often associated with a woman’s period
• Cysts: Fluid-filled lumps can range from very tiny
to about the size of an egg
• Fibroadenomas: A solid, round, rubbery lump that
moves under skin when touched, occuring most in
young women
• Infections: The breast will likely be red, warm,
tender and lumpy
• Trauma: a blow to the breast or a bruise can cause
a lump
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 Noncancerous Conditions (2)

• Microcalcifications: Tiny deposits of calcium

can appear anywhere in a breast and often
show up on a mammogram
– Most women have one or more areas of
microcalcifications of various sizes
– Majority of calcium deposits are harmless
– A small percentage may be precancerous or cancer
(biopsy is sometimes recommended)

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 Causes

• Some of the cells begin growing abnormally

• These cells divide more rapidly than healthy
cells do and may spread through the breast,
to the lymph or to other parts of the body
(metastasize)
• The most common type of breast cancer
begins in the milk-production ducts, but
cancer may also occur in the lobules or in
other breast tissue

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 LECTURE 2

10/24/20 17
 Normal Breast

Breast profile
A ducts
B lobules
C dilated section of duct to hold milk
D nipple
E fat
F pectoralis major muscle
G chest wall/rib cage

Enlargement
A normal duct cells
B basement membrane (duct wall)
C lumen (center of duct)

Illustration © Mary K. Bryson 18

 Ductal Carcinoma in situ (DCIS)

Ductal
cancer
cells

Normal
ductal
cell
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Illustration © Mary K. Bryson
 Invasive Ductal Carcinoma (IDC
– 80% of breast cancer)

Ductal cancer
cells breaking
through the
wall

• The cancer has spread to the

surrounding tissues
• Carcinoma refers to any cancer
that begins in the skin or other
tissues that cover internal
organs
Illustration © Mary K. Bryson 20
 Range of
Ductal
Carcinoma in
situ (DCIS)

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Invasive Lobular Carcinoma (ILC)

Lobular cancer
cells breaking
through the
wall
Illustration © Mary K. Bryson 22
CANC ER I S A W O RD
N OT A
S I E NC E
Cancer Can also Invade Lymph or Blood
Vessels-Metastatic breast cancer

Cancer cells
invade
lymph duct

Cancer cells
invade
blood vessel

Illustration © Mary K. Bryson 24

Factors determining risk
of developing Breast
Cancer

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 Breast Cancer Risk Factors
unalterable factors

Age
GENDER - All
Reproductive
women are
History
Family/Personal at risk
History

Menstrual
Race History
Radiation
Treatment with Genetic
DES Factors
Breast Cancer Risk Factors
that can be controlled
Obesity
All Not having
Exercise women are children
at risk

Breastfeeding
Birth Control
Hormone Pills
Alcohol Replacement
Therapy
 Causes of Hereditary
Susceptibility to Breast Cancer
5 to 10% of breast cancers can be attributed to inherited factors
Contribution to
Hereditary Breast
Gene Cancer
BRCA1 20%–40%
BRCA2 10%–30%
TP53 <1%
PTEN <1%
Undiscovered genes 30%–70%
Established Prognostic Markers for
Breast Cancer

•Axillary lymph nodes

•Tumor size
•Histological grade
•Histological tumor type
•Age
 LECTURE 3

10/24/20 CBMS2006 30
 Outline- Part 2

• How is breast cancer:

• Detected
• Diagnosed
• Treated

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Imaging
modalities(detection of
cancer)
Magram
Ultrasound
Tomosynthesis
 PET
Mammogram
 MR
Mammogram
 Breast
(DITI)thermography
 Mammography

• Use a low-dose x-ray system to examine breasts

• Digital mammography replaces x-ray film by
solid-state detectors that convert x-rays into
electrical signals. These signals are used to
produce images that can be displayed on a
computer screen (similar to digital cameras)
• Mammography can show changes in the breast up
to two years before a physician can feel them

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Mammography Equipment

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 Mammography technologist
 The Mammography Technologist,
under direct supervision, performs
specialized examinations of the breast
to help in the diagnosis and treatment
of breast disease in women patients.
 Ro l e of a Mammography
technologist
 Educate patients.
 Promote privacy and comfort of the
patient.
 Perform breast and axilla palpation.
 Take proper history of a patient.
 Produce high quality films for the
radiologist to evaluate.
 Informing the radiologist regarding any
suspicious lesion
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 Computer-Aided Diagnosis

• Mammography allows for efficient diagnosis

of breast cancers at an earlier stage
• Radiologists misdiagnose 10-30% of the
malignant cases
• Of the cases sent for surgical biopsy,
only 10-20% are actually malignant

National Cancer Institute

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 Standard
views:
raniocaudaview
Craniocaudal view
(CC
(CC
view)
view)

45* Medio lateral Oblique (MLO view)/

Lundgren’s view

RCC LCC RMLO LMLO

 Supplementary
views:

LAT LCV LFB LLM

Left Axillary Left Cleavage Left From Below Left Lateromedial
Tail

LLMO LML LRL LRM

Left Left Medio lateral Left Roll Lateral Left Roll Medial
 CC VIEW

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 Extended CC
Extended CC
view medially view laterally
rotated rotated
Magnification
view
Breast implant
Mammogram
 What Mammograms Show
Two of the most important mammographic
indicators of breat cancers
– Masses
– Microcalcifications: Tiny flecks of calcium – like
grains of salt – in the soft tissue of the breast that
can sometimes indicate an early cancer.

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 Detection of Malignant Masses
Malignant masses have a more spiculated
appearance

malignant benign 54
Mammographic
Mammographic
abnormalities
abnormalities which
whichmay
may
indicate
indicatebreast
breast cancer
cancer

Spiculated
Spiculate
mass
d mass
Architectural
distortion
Asymmetric
density
Mammogram – Difficult Case*

• Heterogeneously dense breast

• Cancer can be difficult to
detect with this type of
breast tissue
• The fibroglandular tissue
(white areas) may hide the
tumor
• The breasts of younger
women contain more glands
and ligaments resulting in
dense breast tissue
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Mammogram – Easier Case*

• With age, breast tissue

becomes fattier and has
fewer glands
• Cancer is relatively easy
to detect in this type of
breast tissue

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 Different Views
Side-to-Side
MRI - Cancer can have a unique
appearance – many small irregular
white areas that turned out to be
cancer (used for diagnosis)

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Top-to-Bottom
Calcification Features

• The morphology of individual

calcification, e.g., shape, area,
and brightness
• The heterogeneity of
individual features
characterized by the mean,
the standard deviation, and
the maximum value for each
feature.
• Cluster features such as total
area, compactness
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 Micro
calcifications
 Male
mammogram
 Male
mammogram
 Diagnosis and Treatment

• . Patient feels a breast mass or has an

abnormal radiologic screening exam
• . Surgical biopsy or aspiration
• . Observation (LCIS), lumpectomy or
mastectomy
• . Staging
• . Delivery of adjuvant therapies—radiation
and/or chemotherapy,hormonal therapies

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 Tumor characteristics
• Invasive vs. Non-invasive .
• Histologic Type-Ductal (85%) vs. Lobular .
• Grade (estimate of the aggressiveness
under microscope) .
• Size .
• Margins .
• Lymph Nodes .
• Estrogen/ Progesterone Receptor (2/3
positive) .

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 Stage 0 --carcinoma in situ
Stage I – tumor < 2 cm, no
nodes
Stage II – tumor 2 to 5 cm,
Stages +/-nodes
of Stage III – locally advanced
Breast disease, fixed or matted lymph
Cancer nodes and variable tumor size
Stage IV – distant
metastases (bone, liver, lung,
brain)
 What now?
Stage 0-III
Risk of recurrence is individual
What can we do to reduce the risk of
recurrence in the breast, and
systemically ?

Meet with Radiation Oncologist and

Medical Oncologist

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 How is breast cancer treated?

3. ADJUVANT THERAPY: Medical therapy

to decrease the chance of tumor
recurrence - to improve the chances for
cure
Chemotherapy - many different therapies
Hormonal therapy - tamoxifen, aromatase
inhibitors
4. RADIATION THERAPY - to prevent
tumor recurrence in the remaining breast
tissue; required for breast preserving
therapy
 Adjuvant Therapy
Radiation Therapy (local)
Chemotherapy (systemic)
Hormonal agents (systemic)
Each therapy adds to reduction of
recurrent disease.
Therapy is individualized,
discussion with health care
provider.
 BREAST CONSERVING THERAPY
(BCT)

Breast cancer
screening programs

BREAST Better Quality

Increase mass
CONSERVING of life
awareness
SURGERY

Patients with earlier Better psycho-social

stages presenting Adjustment
to clinic
 Chemotherapy Drugs
Adriamycin, Epirubicin
Taxol, Taxotere
Navelbine
Cytoxan

Methotrexate, 5-fluorouracil
Intravenous
Nausea, hair loss, low blood counts, cardiac toxicity,
bladder toxicity, nerve damage
Given for adjuvant or recurrent disease. 73
 Summary
• The breast is a dynamic organ- undergoes cyclical proliferative
changes throughout life under the influence of hormones and
growth factors- so may be likely to be more altered by
environmental carcinogens

• Key function for ER and PR in breast cells. The same hormones

that are important for breast growth during pregnancy are
also important for breast cancer.

• ER function in signaling through other growth factor receptor

pathways becomes very important in cancer. Production of
estrogen through alternate sources keeps E supply ongoing in
postmenopausal women.
• What’s best for your patients?
 Digital imaging preferred
 Experienced Radiologists and Techs
 Proper imaging protocols
 Timely reporting to physicians using
BI- RADS format and easy to
understand patient information

10/24/20 75
 CONCLUSION
 Screening mammography can detect
precancerous changes in breast.
 Early detection results in a high cure rate of
breast cancer.
 Mammography is the only tool which has
reduced death rates due to breast cancer.
 Even basic screening can be terrifying to
patients. Sometimes the most important
service we provide is REASSURANCE
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 CONT…..
 Breast Cancer is a common but mostly treatable
disease
 Screening is the key to early diagnosis but only
works if patients trust that it is safe and effective
(and it is!)
 It is our job to: Educate patients, order
appropriate imaging, provide consistent follow-
up and communicate.
 This is a team effort!

10/24/20 77
T hank
you