Lisa wrote:
<I talked with the OB and we were able to get an ultasound done.
Rqadiologist report showed no ductal outlets. Filled sinuses/ milk streaks
were present and tracable but ended at nipple base.
 Is this Athelia? The mother has an areola and what appears to be an under
formed/ immature nipple area.......
 Mom has kindly given me permission to use the films and do a case study
but I am unsure if this is what is classified as " athelia" ?>


I don't have access to my references for the next 2 weeks. Many of them are in the bib of my May 2004 JHL article. I'd like to explore the case further with you when I get back to them, because this is a
subject of special interest to me. I am very interested in learning more about this radiologist's interpretation of the sinuses. The interpretation of ultrasounds of the sinus area during established lactation has been widely publicized (Hartmann et al). I have also found references about ultrasound and microscopic views of sinuses in the resting breast, but thus far I've been unable to find anything in print about ultrasound views and interpretations of sinuses during mid to late pregnancy or the very early lactation initiation period. 


(Microscopic evidence of lactiferous sinuses exists even in children and males, but the sinuses (in the resting breast of adult females,) are different in that they have thick elastic walls. (Montagna) The configuration of elastic tissue changes with repeated stretching. Therefore it's conceivable to me that sinuses may have a different appearance under the microscope or on ultrasound in different stages of female reproductive function.) 


I don't know the exact definition of athelia, but I suspect true athelia might be accompanied by amastia, for the following reasons.



Embryological development of the breast appears to begin from the
surface layer (ectoderm) inward into the middle layer (mesoderm) by
chemically induced pathways into the fatty tissue, which is
part of the mesoderm. Some time after secondary buds branch out off of the primary bud, there is a normal stage in which the nipple area becomes depressed or inverted for a while. About mid-pregnancy, the secondary buds begin to canalize, the process apparently proceeding in both directions from the midpoint-inward toward the chest wall and outward toward the skin. I have not yet found the reference (by Hogg) that explains this process, but would love to have it if anyone already has it. It has always been my assumption that the process continued straight on through the galactophores in the inverted nipple area to the surface. One possibility is that it failed to do so in the case of your client.


Near term, or beyond, (40-44 weeks) the mesodermal tissue begins to proliferate under the inverted nipple area, causing the nipple to evert and in the process, also elevates the sinuses/ducts closer to the surface under the areola. (The size/development of the nipple-areolar area is one of the criteria in assessment of an infant's gestational age. I have wondered what (if any) effect on the total eversion process might occur when premature birth shortens the exposure to placental hormones.)

Outer skin consists of squamous (flat, scalelike) epithelial cells. This type of cell continues inward, lining the walls of the galactophores as they pass through the inside the nipple. (The galactophores in the resting and the pregnant, and possibly the very early postpartum breast are normally plugged with desquamated squamous epithelial cells. Could this be why the "streak" appeared to end "at the nipple base" on the ultrasound?) 


Then, there is a distinct change in the type of lining cells at the point where each galactophore meets its corresponding sinus (squamo-columnar junction). The remaining ductal/glandular structures have a double walled lining consisting of two different kinds of epithelial cells. Myoepithelial cells occur on the outside of ducts and alveoli, while the inside layer consists of columnar cells, which can change shape as part of their physiological function. (Think of a marshmallow, that can change its shape with tension/compression.)

There is a very interesting article by a British surgeon E.?.?. (3 initials) Hughes in a journal of a Royal College of ??Surgery??, possibly in 1949. It is the only article I have ever found by him. It describes his microscopic observations on mammalian embryology and similar references by earlier embryologists.

Jean
***************
K. Jean Cotterman RNC, IBCLC
Dayton, OH USA

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