the female breast functions primarily in providing a 

source of nutrition for the infant 

And all the morphological and physiological changes 

that occur throughout the life of the individual,

at least up until the age of 45 are directed 

towards this primary function.

And these changes in morphology and physiology are 

reflected and appear as 

variations in density on the 

demographic films.

And for this reason,

I think that it's of some importance for us to study some of these 

basic principles of normal physiology and I feel that 

they will help in the mammographies uh 

interpretation of demographic films.

There are basically three different types of tissue found within 

the breast.

The fibrous glandular and the adipose,

or fatty tissue.

The fibrous and glandular,

sometimes spoken of collectively as the fiber 

glandular components.

The relative amounts of the fiber glandular and the 

fattier adipose tissue varies considerably 

not only between individuals,

but also within the same individual during 

various times of their life.

And it's the relative degree and the relative 

amounts of the fiber glandular and the fattier 

adipose tissue,

which is responsible for the changes in the density 

has seen on a normal demographic film.

Now,

this is a diagram attic sketch of some of the 

structures which can be seen on the demographic 

film.

The breast itself has an 

anterior position respect to the pectoral major 

muscle and it's separated from this muscle by what is 

called the deep layer of the superficial fascia 

anterior to the gland 

itself is found.

The superficial layer of fashion and this is 

separated from the skin by a layer of 

subcutaneous fat.

The skin is relatively smooth throughout the course of the 

breast,

except in the aurelia region surrounding the 

nipple and here the the skin takes on a 

pigmented and somewhat wrinkled appearance and 

this reflects the presence of some of the underlying 

sebaceous glands and the african 

sweat glands.

The nipple itself has,

the Orpheus is for the active virus,

Ducks and the ducks.

The office which are found here,

would then spread back into the substance of this breast 

tissue.

And it's the difference Ducks,

along with the connected tissue associated with 

the ducks and the fashion which is 

responsible for producing these apparent 

incomplete lines or this Trebek 

Euler pattern as normally seen on the memo 

graphic film.

Now this is a diagram of a 

average mature breast and the relative 

degree of this pattern will vary depending upon the 

amount of fiber glandular tissue,

as well as amount of adipose tissue.

And this will change throughout the life of the individual 

arteries are not normally seen on a 

geographic film unless they're calcified.

On the other hand,

veins,

especially the superficial veins and 

especially in zero radiographic films are often 

identifiable,

especially in this superior portion of the breast.

Now,

if we look in a little greater detail at some of the fiber 

glandular structures,

the normal female breast is comprised of 

about 15 or 20 structures called lobes 

and those lobes are separated from one another by 

fashion.

And this connective tissue fash is responsible for 

part of this Trebek your appearance that is normally 

seen the main each 

particular lobe in the breast has one lactivists 

duct.

And as the active virus duct passes from the nipple 

it has a slightly expanded portion known as the ampule.

And from this point on the active virus duck undergoes 

tremendous ramification and bifurcation 

and the smaller ductile branches will 

then finally end in what is called the terminal 

docks or what some people speak of as the alveoli and some people 

call these the asinine portion of the gland,

the milk that is produced by the cells 

lining these smaller units would then pass 

through the ductal system,

eventually making their way through the main electrophoresis.

Duck for the exit at the point of the nipple.

Now this is a zero radiographic film showing some 

of the structures that we've seen on the diagram attic 

representations with zero radiography.

Because of the edge enhancement,

one can readily identify the layer of the 

skin and the subcutaneous fat.

We can also see in many cases some of the veins,

the superficial veins which of course along the 

superficial fat area.

The Trebek your pattern here is basically 

comprised of the fiber glandular components and 

again this pattern will vary considerably depending upon the 

amount of fiber glandular tissue with respect to the 

relative radio translucent fat that's 

interspersed between the structures.

Now the doctor systems can be appreciated on the 

normal demographic film and and zero radiography.

We can actually see some of these structures.

This is a relatively tropic breast and we can see the faint 

outlines of some of these ductal structures 

but we can even see him to a greater degree when the ducks are 

injected with a water soluble contrast media.

Now this particular examination was done to examine 

the cystic changes in this particular breast,

but purely from a morphological point of view,

I think it's important to point out the 

tremendous ramifications that occur with any complete 

dR system.

Now we have to remember that are about 15 or 20 

of these doctor systems in the normal breast.

And we can see when we have a tremendous proliferation 

of this system as occurs for example during 

pregnancy that there is a tremendous amount of 

fiber glandular tissue which is responsible for 

producing a very dense image on the 

mammogram.

Now this is a diagram of a histological 

section through some of the smaller 

units of the breast,

the lobes and the labels.

And we can see for example here we have a duck cut 

in cross section,

we can see some of the adipose tissue.

Again,

the amount will vary depending upon the individual,

the arteries and the veins and the connective tissue and the 

inter lobular connective tissue.

If we look more closely however,

at some of the small ducks in the so called 

lobby area,

we can see that the ducks themselves are lined by a 

local um neR epithelial type of 

cell.

Now this cell here 

undergoes tremendous proliferation and 

growth under the influence of estrogen and 

progesterone.

And it is at this point where we get the proliferation 

that is quite characteristic of the pregnant breast or the lactating 

breast.

Also these changes occur during various aspects of the 

menstrual cycle and we'll talk about these a little later in the 

day,

directly below the epithelial cells are found the 

mild epithelial cells and these contain smooth 

muscles and under the influence of 

oxytocin.

And during lactation these cells will contract 

which helps force the milk through the small ductal system,

eventually making their way to the nipple through elected first duct.

The inter intra lobular 

connective tissue here is somewhat expandable 

and allows for distention during hypertrophy Of these cellular 

elements.

This slide shows a category the chronological and 

physiological development of the breast.

What this slide doesn't show is basically this 

category is not dogmatic and that 

there is a wide variation at least from the demographic point of 

view in the appearance of the breast.

Now we can go to either end of the scale.

We can point to a breast at puberty And we can 

show that it has a typical ma'am a graphic appearance 

or we can go to the other end of the scale and look at an a trophic 

breast and say that it has a very somewhat typical 

appearance.

But when we get down into this region between the ages 

say of 20 and 45 years of age,

the breast on the individual can on the mammogram 

appear quite variable.

And this variability is due to many 

factors.

Basically,

it's due to the amount of the fiber glandular tissue with 

respect to the fat and many factors influence this.

For example,

the weight of the individual may be a 

factor of importance here.

Also the previous history that individual with respect to 

bearing Children.

So if we look at a young adult breast,

for example,

the woman who's had several Children,

the demographic appearance with respect to the contrast and 

the fiber glandular and fatty tissue may be 

somewhat similar to the post menopausal 

woman.

And this has to be kept in mind that there is this wide 

variation.

But even with this variation,

we can say that there is a trend in the relative 

appearance of these breasts,

usually at puberty and in the original breasts 

we have a tremendous amount of fiber glandular 

tissue with small amounts of fatty 

infiltration.

For this particular reason the breast appears relatively 

dense.

Starting with the young adult and going to the pre 

menopausal stage,

the breast starts incorporating some degree of fat and 

because of this,

there is a relative change in the 

amounts of the fiber glandular tissue with respect to 

the fatty and on the mammogram,

this gives a very definite appearance 

beginning at menopause and 

during the postmenopausal period there tends to 

be a decrease in the fiber glandular 

components and an increase in the deposition 

of fat and finally,

in the a trophy condition there seems to be a 

relative significant decrease in the amount of the 

fiber glandular elements and a relatively large amount of 

fatty infiltration.

And this gives a relative ground glass appearance 

to the breast.

Again,

there's quite a bit of variation here and some women,

especially in thin older women,

there can not be a lot of fatty infiltration 

and we can just have a regression of the fiber glandular 

tissue.

Of course,

in the pregnant and lactating woman,

the breast becomes enormously engorged due to proliferation of the 

glandular elements and for this reason the breast is 

very dense.

This diagram shows some of the changes.

This is a rudimentary duct and adipose 

tissue in a very young on developed 

breast during the early stages of development.

Then there is a increase in the fiber glandular 

components and there is beginning a deposition 

of adipose tissue.

This would appear mama graphically and on the 

radiograph,

it's a very dense breast.

Later in life at about the age of 35 or 40.

In the normal individual,

there tends to be an increased deposition of fat 

with respect to the fiber glandular tissue.

This type of breast would have sort of an average or medium 

density and later on in life in the a trophic 

condition,

there tends to be,

as we said,

a decrease in the amount of fiber 

glandular tissue.

This results in minimal contrast or 

minimal density and an increase 

in the deposition of fat.

So in a sense,

we have a relatively translucent radio 

translucent breast.

This actually diagnostically is one of the easiest breast 

for diagnostic purposes because of the large amount of 

the radio translucent fat.

Now these sections show the corresponding 

relationship between the glandular components and the fat 

in three different breasts.

This is a 30 year old woman that is born no 

Children.

And again,

we can see a relatively large amount of fiber glandular 

components,

especially in the mid region of the breast 

At the age of 50 and a menopausal woman.

Here,

we can see that the glandular components have become the decrease 

and there is an increase in the infiltration of 

fatty components.

And finally,

in this 84 year old woman there is almost a complete 

atrophy of the fiberglass components,

with almost a total replacement by fat.

This would be very dense in this region.

This particular breast would be relatively radio translucent.

So then the dense breast can be found anywhere from the age of 

14 to 50.

It's usually described as being non sagging and it has a 

uniform firmness on pal patient.

It may appear to spread out on the chest wall and lacking 

phoniness.

His tenseness is caused by the great thickness at the base.

This is an example.

This is a 24 year old girl.

And you can see here we have a very dense 

mammogram and this is again due to the 

increase in the fiberglass components with throughout too little fat 

infiltration.

At this point Between the ages of 

30 and 55,

the breasts usually most cases has an average 

density.

But again,

this can vary.

As we said,

the breast often appears to sag mildly.

It has a modular appearance on pal patient 

indicating portions of fatty and fiber glandular 

tissue.

And the average density of the breast will be noted under the age of 30.

When a subject has had several 

deliveries are when a notable weight gain and loss 

occurs.

And these are the factors here,

the previous history of childbearing and the weight of the 

individual,

which can vary tremendously.

The ma'am a graphic appearance in the destiny density of the 

breast with respect to the uh 

amounts of the fiber glandular and fatty 

tissue.

This is a normal radiograph,

conventional radiograph mammogram of the breast of 

a woman of about 40 years of age.

Again here and comparing it to the previous film on the 

very dense breast.

We can see infiltration of some fatty 

tissue on the zero radiographic film.

However,

we can even see more information.

We can begin to see the demarcation of the skin.

We can see the subcutaneous fat.

We can see the glandular components of the breast and the 

tubercular formation.

And we can also see here,

for example,

one of the larger veins which passes through the superior 

portion of the breast.

This is a 56 year old woman 

who has a very prominent fiber 

glandular developed breast.

This woman was now Liberace.

This is a zero radiograph of another 

patient,

10 years younger,

56 years of age,

who's had several deliveries.

And again,

there is a prominent Fabbro 

glandular doctor components 

present.

This will most likely in several years,

begin to atrophy and be replaced by fat.

And this is a conventional ma'am,

a graphic film showing about a 40 year old 

woman with a characteristic fiber 

glandular and fatty infiltrated breast.

Now between the ages of 55 and up,

the breast usually undergoes the trophic changes 

and usually the breast shows a 

definite sag.

It may be flabby and this all depends upon.

Again the weight of the individual.

The breast is usually soft on pal patient 

and it may possess scattered modularity 

indicating the remaining portions of the fiber 

glandular tissue.

Radio graphically this breast has what is many 

times called the relative ground glass 

appearance.

It's relatively radio translucent.

The fiber glandular structures are diminished in 

size and they're somewhat compressed.

They aren't prolific as we've seen in some of the earlier breast,

for example.

Now the arterial supply to the breast comes basically from 

three sources comes from the internal mammary artery.

The lateral thoracic artery and some of the 

branches of the intercostal 

arteries.

About 60% of the blood supply comes 

by way of the internal mammary artery which is a 

branch of the subclavian.

The internal mammary sends branches which run 

transverse lee across the media 

portion of the breast towards the aurelia area.

About 30% of the blood supply comes by way of 

the lateral thoracic artery,

which is a branch of the axillary vessel.

And this supplies the lateral upper quadrant 

portion of the breast,

About 10% of the blood supply.

Then especially to the lower lateral quarter impression of 

the breast comes by way of the intercostal 

arteries.

The arterial supply usually travels in 

a transverse and somewhat cranial direction across the 

breast,

which means that the upper portion of the breast usually has a much 

richer vascular supply than the lower portion 

of the breast.

There's also a tremendous amount of anastomosis,

especially around the real area between 

the internal mammary artery and the lateral 

thoracic and also between the lateral 

thoracic and intercostal.

And this means then that any part of the breast 

really supplied by multiple blood 

sources and if one particular source 

is interrupted,

then collateral circulation should be adequate enough to 

supply blood to that tissue 

area.

Normally.

Again arteries are not seen on the demographic film.

The venus pattern basically follows that of the arterial supply.

Three large veins empty from the breast.

The internal mammary vein,

the subclavian vein and the intercostal veins 

superficially.

There are two basic patterns that can be seen on the 

superficial venous drainage.

One is the relative transverse pattern in which the 

veins tend to converge across the sternum and 

empty into the internal mammary vein.

The second pattern called the longitudinal 

pattern.

The superficial veins travel in a longitudinal cranial 

manner,

then asked the most above the super sternal notch and they empty 

into the lower neck veins and then finally into the 

internal jugular vein.

The lymphatic drainage of the breast,

of course is very rich and the 

lymphatic vessels take their origin in the 

intra lobular spaces 

lining the ductile components of the prank of 

the breast.

There are basically two different patterns 

of lymphatic drainage is superficial pattern and the 

deep plexus pattern.

The superficial pattern basically 

involves the medial aspects of the 

gland,

the skin,

the nipple and the aurelio area Lymphatic 

from these areas passed laterally to the 

anterior pectoral nodes.

These are sometimes called the um sub or 

the lower subclavian nodes,

There about five in number.

They're located uh anterior to 

and lying close approximation to the lateral 

thoracic artery at the lateral board of the petrol is major 

muscle.

The limp would then pass from these anterior petrol 

nodes up to the mid axillary loads and then 

finally make their way to the subclavian nodes.

The deep plexus has several drainage patterns.

One a deep drainage pattern 

through the deeper portions of the breast glandular 

tissue through the pectoral muscles to what are 

called the rotor nodes and then the lymph would 

pass to the subclavian nodes,

another deep plexus pattern causes 

uh immediately towards the 

sternum,

making contact along the internal memory 

artery with the internal memory nodes and then 

finally into the media spinal nodes.

There are several other pathways present.

One especially drains the lower portion 

of the breast.

This pathway passes down into the 

abdominal lymph nodes and eventually 

makes us away to the dub sub diaphragmatic and some 

of the nodes in the liver.

This there's another pathway which travels 

across the sternum,

such as lymphatic drainage from one breast,

can actually pass across the sternum and 

Eskimos with the lymphatic drainage and the other breast and eventually 

make their way to the axle.

So you can see there's a very 

complicated lymphatic drainage in 

the breast and one can relatively see how 

metastatic lesions can very easily spread by 

this drainage up into the axillary region across to 

the axle of the opposite breast,

and even down into the um sub 

diaphragmatic areas.

Now,

all of the morphological changes 

that occur in the breast.

Whether they occur during pregnancy or whether they occur even during the 

menstrual cycle are governed by the 

hormonal regulation and 

basically the two hormones which are relative importance are 

estrogen and progesterone.

And even though the changes that occur during 

the menstrual cycle cannot be appreciated on the 

mammogram.

We have seen that some of the changes that that do occur 

especially during pregnancy and lactation can be 

appreciated on the mammogram and I'd like to just point out some of these 

features during the normal 

development of the egg,

the ovary actually,

the graphene follicle produces relatively large amounts of 

estrogen and the estrogen that is produced 

mainly increases the vascular to the uterus 

and prepares the uterus to accept the fertilized 

egg.

But in addition to preparing the uterus for implantation of a 

fertilized egg,

the estrogen also stimulates the 

development of the ducts in the breast 

during ovulation.

And about the 14th day of the menstrual cycle,

the ovary releases the ovum 

and the graphene follicle becomes a corpus ludie.

Um And at this point a corpus ludie um is quite active 

in producing the second important hormone,

progesterone and progesterone reinforces 

the previous activity.

Estrogen not only with respect to the uterus but with respect 

to the breast in terms of increasing the 

proliferation of the doctor components in the breast.

If fertilization does occur and that they get 

implanted,

then the corpus louis um continues to pour out progesterone 

for a considerable period of time and during this time then 

the influence of the progesterone on memory 

glands is to increase the proliferation of the 

epithelial cells lining the duck,

increase the blood supply and basically increase the 

overall glandular portions of the breast on the demographic 

film.

This is represented by a very dense type of breast.

If pregnancy does not occur in about 

14 days after ovulation,

the progesterone level in the blood drops dramatically.

This initiates menstruation and it's also 

initiates during the menstrual cycle.

The derogatory changes that occur in the fiber glandular 

portions of the breast 

during pregnancy.

Of course the relative amounts of circulating 

yesterday progesterone are elevated and these are not only 

produced by the ovary but are also produced by some of the 

chorionic genetic trophic hormones.

One must realize,

of course that the activity of the ovary 

is really under the control of the pituitary 

gland and that the development of the graphene 

follicle and the production of estrogen and 

even the maintenance of the corpus 

ludie.

Um Under the influence of the follicle stimulating hormone 

and the lutin izing hormone.

And even to go further.

These hormones are under the direct influence of 

the releasing factors from the hypothalamus.

I have tried during a short period of time to give a basic introduction 

into some of the anatomical and physiological 

principles which I feel may be helpful in 

interpreting ma'am,

a graphic films.

Thank you