In vivo efficacy of antimicrobe-impregnated saline-filled silicone implants

Bacterial colonization of mammary implants is a prelude to clinical infection and has been implicated in the etiology of capsular contracture. Antimicrobial impregnation of a variety of medical devices with the combination of minocycline and rifampin has recently emerged as a potentially effective method for preventing device colonization and device-related infection. The objective of this animal study was to examine in vivo the antimicrobial efficacy of minocycline/rifampin-impregnated, saline-filled silicone implants. A rabbit model of Staphylococcus aureus colonization and infection of subcutaneously placed implants was used. A total of 48 saline-filled silicone implants (24 antimicrobe-impregnated and 24 control unimpregnated implants) were suspended in a 106 colony-forming units/ml bacterial suspension of S. aureus for 30 minutes at room temperature, allowed to dry for 60 minutes, and then implanted subcutaneously in the back of 12 rabbits (two antimicrobe-impregnated and two control implants were placed in each rabbit). Rabbits were monitored daily, then killed either at 2 weeks (10 rabbits) or at 4 weeks (two rabbits) and cultured. The antimicrobe-impregnated implants were 12 times less likely to be colonized than control unimpregnated implants (two of 24 versus 23 of 24; p < 0.001), and they were a significantly less likely cause of implant-related infection (0 of 24 versus 22 of 24; p < 0.001) and implant-related abscess (0 of 24 versus 21 of 24; p < 0.001) than control implants. The minocycline/rifampin-impregnated implants routinely demonstrated zones of inhibition against S. aureus at the time of explantation. These results indicate that minocycline/rifampin-impregnated implants can significantly decrease the rate of bacterial colonization, implant-related infection, and implant-related abscess. Antimicrobe-impregnated implants also have the potential of reducing the likelihood of capsular contracture.     

A clinical comparison of the tendency to capsular contracture between smooth and textured gel-filled silicone mammary implants.

The aim of this prospective, controlled clinical investigation was to find out if there is a difference in the capsular contracture rate between silicone implants with a smooth or textured surface as the only difference. Twenty-five women with bilateral mammary hypoplasia underwent mammary augmentation. All got a textured implant on one side and a smooth implant on the other. The implants were placed subglandularly. Follow-up examinations were done on six occasions. Three parameters were used for estimation of the tendency to capsular contracture: (1) the patient's opinion on differences in hardness of the breasts, (2) the investigator's classification of capsular contracture, and (3) applanation tonometry. At the end of the follow-up period, after 1 year, all parameters showed with no doubt that the breasts augmented with textured implants had a lower tendency to develop contracting capsules than the breasts augmented with smooth implants.     

Similar growth pattern of mouse mammary epithelium cultivated in collagen matrix in vivo and in vitro

Mouse mammary ductal cells cultured in type I collagen gels give rise to three-dimensional multicellular outgrowths consisting of thin spikes which are often branched, and which may have pointed or blunt ends. The significance of these spikes to normal ductal morphogenesis has been unclear, since identical structures are not known to occur in vivo; conversely, it has not been possible to maintain in gel culture the highly structured end buds which are characteristic of ductal elongation in the animal. In order to evaluate whether the pattern of radiating spikes observed in collagen gel cultures results from chemical or physical peculiarities of the culture environment, a small volume of unpolymerized type I collagen solution was injected into mammary gland-free fat pads of young adult mice. After the bubble of collagen had polymerized, an implant of mammary ductal epithelium was introduced into the center of the gel. Histological examination of the implants after 3 to 6 days of growth revealed numerous small epithelial spikes, similar to those observed in gel culture, extending into the fibrous matrix. The early stages of regeneration of mammary implants placed in gland-free fat pads were then examined without the addition of exogenous collagen. In cases where the epithelium happened to contact a fibrous region of the fatty stroma, spikes were also seen to form in these natural collagenous substrates. Whether or not exogenous collagen was used, normal end buds were formed only when epithelial spikes contacted adipocytes. It was concluded that the three-dimensional pattern of radiating tubules in collagen gels in vitro is not merely an artifact of culture, but has a counterpart in vivo whereever regenerating mammary epithelium is surrounded by fibrous stroma. A model is presented in which the pattern of epithelial outgrowth is determined by the physical characteristics of the surrounding stroma; in collagen matrix a comparatively primitive and unspecialized type of morphogenesis occurs which may not require the participation of stromal cells. In contrast, epithelial-adipocyte interactions appear to be necessary for the formation of end buds and subsequent morphogenesis of fully structured mammary ducts.     

Elvax 40P implants: Sustained,local release of bioactive molecules influencing mammary ductal development

Elvax 40P (EVX), an ethylene vinyl-acetate copolymer, has been well characterized as an implant material that causes no inflammatory response and is capable of the sustained, local release of a wide variety of undenatured macromolecules in vivo. To investigate the usefulness of this material in developmental studies we examined the effect of EVX implants containing either deoxycorticosterone acetate (DCA) or testicular hyaluronidase on alveolar differentiation and ductal growth in the mouse mammary gland. DCA implants produced localized alveolar differentiation on ducts, while implants containing Thase caused basal lamina disruption at the duct's growing tip, resulting in epithelial dysplasias. We conclude that EVX implants allow assessment of the primary (nonsystemic) effects of biologically active molecules on developing tissue and should therefore have a variety of interesting experimental uses.     

A comparison of conventional and low-bleed implants in augmentation mammaplasty.

We conducted a double-blind, retrospective comparison between low-bleed and non-low-bleed (conventional) mammary implants because no controlled study has shown a difference in the degree of capsular contracture between the two types of implants. Twenty-five patients had conventional implants and form group A; twenty-eight patients had low-bleed implants and form group B. All patients had submuscular augmentation. The mean Baker score was 1.51 for group A and 1.04 for group B for the entire patient population and 1.65 for group A and 1.07 for group B for patients with more than 1 year of follow-up. For the entire population, 34 percent of group A and 3.6 percent of group B had a Baker score of 2 or greater. For the population with more than 1 year of follow-up, 42 percent of group A and 7 percent of group B had a Baker score of 2 or greater. There was significantly (p less than 0.007) less contracture with the low-bleed implants for the entire population as well as for those patients with greater than 1 year of follow-up (p less than 0.015).     

Role of epidermal growth factor in the acquisition of ovarian steroid hormone responsiveness in the normal mouse mammary gland

The purpose of the present studies was to investigate the role of epidermal growth factor (EGF) in the acquisition of estrogen (E) and progestin (P) responsiveness in the mouse mammary gland in vivo. Using the Elvax 40P implant technique to introduce bioactive molecules directly into the mammary gland to produce a localized effect, we have made the novel observation that EGF implanted into glands of pubertal mice followed by E treatment resulted in the precocious acquisition of E-inducible progesterone receptors (PR). In sexually mature mice, EGF implants alone were able to increase PR. A neutralizing antibody specific for EGF blocked E-dependent stimulation of end-bud development and PR induction. Furthermore, the antiestrogen ICI 182,780 blocked the EGF-induced stimulation end-buds and PR induction, indicating that these EGF effects are mediated via estrogen receptors (ER). Immunohistochemical analysis showed that the endogenous EGF content of mammary glands of mature mice was higher than pubertal mice, that E implants caused a localized increase in mammary gland EGF content in both pubertal and mature mice, and that in mature mice E caused an increase in stromal cell EGF content. We have previously shown that the acquisition of E-inducible PR can be modulated by mammary stroma, and the present results indicate that mammary stroma could modulate hormonal responsiveness through control of local growth factor concentration. Taken together, these results provide evidence that E-dependent responses of mouse mammary gland in vivo, such as end-bud proliferation and PR regulation, may be mediated by EGF through an ER-dependent mechanism. J. Cell. Physiol. 174:251–260, 1998. © 1998 Wiley-Liss, Inc.     

Purification of a mammary-derived growth factor from human milk and human mammary tumors

A growth factor, mammary-derived growth factor 1 (MDGF1), has been purified to apparent homogeneity from human milk. The factor is a pepsin-sensitive, reducing agent-insensitive protein with a molecular mass of 62 kDa and a pI of 4.8. An apparently identical factor has been isolated from human mammary tumors, suggesting that MDGF1 might be made by and act as an autocrine growth factor for mammary cells. High affinity receptors for MDGF1 have been detected on mouse mammary cells, normal rat kidney cells, and A431 epidermoid cells (KD = 2 X 10(-10) M). MDGF1 at picomolar levels stimulates the growth of mammary cells and greatly amplifies their production of collagen, apparently via elevating collagen mRNA levels, an effect that is demonstrated for normal rat kidney cells. The responsiveness of mammary cells to MDGF1 is attenuated when the cells are grown on a basement membrane collagen substratum, a component of the extracellular matrix upon which these cells normally rest in vivo. MDGF1 thus may regulate the production of new basement membrane as mammary epithelium invades the stroma during proliferation.     

The correction of capsular contracture by conversion to "dual-plane" positioning: technique and outcomes

Little has been published regarding the treatment of patients with long-established capsular contracture after previous submuscular or subglandular breast augmentation. This study reviews 7 years of experience in treating established capsular contracture after augmentation mammaplasty by relocating implants to the "dual-plane" or partly subpectoral position. A retrospective chart review was performed on all patients who were treated for capsular contracture using this technique between 1993 and 1999. Data collected included the date of the original augmentation, the original implant location, date of revision and type of implant used, length of follow-up, outcome, and any ensuing complications. Different surgical techniques were used, depending on whether the prior implant was located in a subglandular or submuscular plane. All patients had revisions such that their implants were relocated to a dual plane, with the superior two thirds or so of the implant located beneath the pectoralis major muscle and the inferior one third located subglandularly. Of 85 patients reviewed, 54 had their original implants in a submuscular position and 31 had their initial augmentation in a subglandular position. Of the 54 patients whose implants were initially submuscular, 23 patients (43 percent) had silicone gel implants, 15 patients (28 percent) had double-lumen implants, and the remaining 16 patients (30 percent) had saline implants. Of the 31 patients whose implants were initially subglandular, 20 patients (65 percent) had silicone gel implants, three patients (10 percent) had double-lumen implants, and the remaining eight patients (26 percent) had saline implants. Fifty-one patients (60 percent) had replacement with saline implants (37 smooth saline, 14 textured saline), whereas 34 (40 percent) had silicone gel implants (seven smooth gel, 27 textured gel). The average time from previous augmentation to revision was 9 years 9 months. The average follow-up time after conversion to the dual-plane position was 11.5 months. Only three of 85 patients required reoperation for complications, all of which involved some degree of implant malposition. Of patients converted to the dual plane, 98 percent were free of capsular contracture and were Baker class I at follow-up, whereas 2 percent were judged as Baker class II. There were no Baker level III or IV contractures at follow-up. The dual-plane method of breast augmentation has proved to be an effective technique for correcting established capsular contracture after previous augmentation mammaplasty. This technique appears to be effective when performed with either silicone or saline-filled implants.     

Reconstruction of the breast after mastectomy for cancer.

Seventeen women who had had a mastectomy for cancer of the breast underwent reconstructions. Alloplastic implants were used in all. Preservation of the nipple and areola was possible in some of these patients. The normal (or uninvolved) breast sometimes required reduction in size or reshaping, to match as nearly as possible the reconstructed breast. The conditions suitable and unsuitable for mammary reconstruction, after mastectomy for cancer, are discussed.     

Epithelium-dependent extracellular matrix synthesis in transforming growth factor-beta 1-growth-inhibited mouse mammary gland

Exogenous transforming growth factor beta (TGF-beta 1) was shown in earlier studies to reversibly inhibit mouse mammary ductal growth. Using small plastic implants to treat regions of developing mammary glands in situ, we now report that TGF-beta 1 growth inhibition is associated with an ectopic accumulation of type I collagen messenger RNA and protein, as well as the glycosaminoglycan, chondroitin sulfate. Both macromolecules are normal components of the ductal extracellular matrix, which, under the influence of exogenous TGF-beta 1, became unusually concentrated immediately adjacent to the epithelial cells at the tip of the ductal growth points, the end buds. Stimulation of extracellular matrix was confined to aggregations of connective tissue cells around affected end buds and was not present around the TGF-beta 1 implants themselves, indicating that the matrix effect was epithelium dependent. Ectopic matrix synthesis was specific for TGF-beta 1 insofar as it was absent at ducts treated with other growth inhibitors, or at ducts undergoing normal involution in response to endogenous regulatory processes. These findings are consistent with the matrix-stimulating properties of TGF-beta 1 reported for other systems, but differ in their strict dependence upon epithelium. A possible role for endogenous TGF-beta 1 in modulating a mammary epithelium-stroma interaction is suggested.     

Capsular contracture around saline-filled fine textured and smooth mammary implants: a prospective 7.5-year follow-up.

In a previous prospective randomized clinical study comparing in the same patient textured and smooth saline-filled mammary implants (Biocell) with large pore size (300 to 600 microm), we saw no difference in capsular contracture. This study was undertaken in a similar way to compare capsular contracture around smooth and textured saline-filled prostheses with pores of small size. During a period of 7.5 years, the breast hardness was followed up, and at the end of the study patient satisfaction was evaluated.Twenty healthy women with a mean age of 30 years were operated on for breast augmentation. Two surgeons performed all operations in a standardized way. Each patient received subglandularly a Siltex textured saline-filled prosthesis with a pore size of 30 to 70 microm in one breast, and a smooth saline-filled prosthesis in the other. The hardness of the breasts was evaluated after 0.5, 1, and 7.5 years using Baker grading and applanation tonometry. Eighteen patients completed 1-year and 7.5-year follow-up. Two breasts with smooth prostheses were contracted after 6 months (Baker III or IV). After 1 year, four patients with smooth prostheses and one with a textured prosthesis had capsular contracture (p = 0.34). Seven and one-half years after surgery, six patents with smooth and four with textured implants had contracture (p = 0.66). On two patients with smooth prostheses and one patient with a textured prosthesis, the capsule around the implant hardened between 6 and 12 months. Between 1 year and 7.5 years, three breasts with smooth and textured implants contracted and one with a textured implant softened.The patients reported on a Visual Analogue Scale (1 to 10) the impact of the augmentation on their quality of life to be 9 +/- 1. Four patients preferred the breast with the smooth prosthesis, three preferred the breast with the textured prosthesis, and the others found both breasts equal. This study showed no significant difference of contracture with smooth versus fine textured implants. The majority of the patients preferred the smooth implants. The patients reported that the breast augmentation had had an extremely high impact on their quality of life.     

Analysis In Vitro of Capacity of Fetal Fat Pad to Support Mammary Gland Embryogenesis

Fourteen-day fetal mammary fat pad precursor tissue (FP) has the capacity to support various fetal epithelia allowing them to accomplish their characteristic development in vivo , without their own mesenchyme (1). This capacity decreases with age of fetal fat pad and is lost postnatally. To analyse the molecular mechanism of such interaction, a method for in vitro duplication of organogenesis is necessary. In the present paper, a co-culture system of fetal epithelium with prospective mammary fat pad is described. The explanted mammary epithelium started budding, then grew out forming branched mammary ducts with end buds. Ultrastructurally, the developing ductal structures exhibited the typical mammary gland morphogenesis.
³H-Thymidine incorportion assessed by autoradiography showed that the mammary gland morphogenesis in vitro was due to the proliferation of epithelial cells, not merely to a change of the shape of the epithelium. This supportive capacity of 14-day FP also decreased with aging; explanted mammary epithelium did not grow into 17-day FP. When insoluble, non-living biomatrix was used in place of living FP the epithelium grew into the matrix but the resulting structures lacked characteristic morphology of epithelium on living fetal FP. The difference of capacity between 14-day and 17-day tissues was also lost.     

Estrogen and estrogen plus progestin act directly on the mammary gland to increase proliferation in a postmenopausal mouse model

Hormone replacement therapy (HRT) with ovarian hormones is an important therapeutic modality for postmenopausal women. However, a negative side effect of HRT is an increased risk of breast cancer. Surgical induction of menopause by ovariectomy (OVX) in mice is an experimental model that may provide insights into the effects of hormone replacement therapy on the human breast. We have developed a mouse model of early and late postmenopausal states to investigate the effects of HRT on the normal mammary gland. The purpose of this study was to determine if HRT-induced proliferation was due to the direct action of the hormones on the mammary gland, or mediated systemically by hormones or growth factors produced elsewhere in the body. Estrogen (E) or E plus the synthetic progestin, R5020, were implanted directly into the mammary glands of early (1 week post OVX) and late (5 week post OVX) postmenopausal mice instead of administration by injection. We report that responses of early and late postmenopausal mice to implanted hormones were the same as those observed previously with systemically administered hormones. Implanted E conferred an enhanced proliferative response in the late postmenopausal gland characterized morphologically by enlarged duct ends. E+R5020 implants induced similar degrees of cell proliferation in both postmenopausal states but the morphological responses differed. Ductal sidebranching was observed in early postmenopausal mice, whereas duct end enlargement was observed in late postmenopausal mice. The differences in morphological response to E+R5020 in 5 week post OVX were associated with an inability of E to induce progesterone receptors (PR) in the late postmenopausal gland. The responses of the late postmenopausal glands to E and E+P were very similar to that observed previously in immature pubertal glands in ovary-intact mice. In pubertal mice, PR cannot be induced by E unless the mammary gland is pre-treated with EGF-containing implants. Similarly, herein pre-treatment of the late postmenopausal mammary gland with EGF-containing implants restored PR induction by E. Thus, EGF may determine the sensitivity of the mammary gland to E and E+P in late postmenopause and at puberty.     

Label-retaining epithelial cells in mouse mammary gland divide asymmetrically and retain their template DNA strands

It has been postulated that the stem cells of somatic tissues protect themselves from mutation and cancer risk by selective segregation of their template DNA strands. Self-renewing mammary epithelial stem cells that were originated during allometric growth of the mammary ducts in pubertal females were labeled using [3H]-thymidine (3HTdR). After a prolonged chase during which much of the branching duct morphogenesis was completed, 3HTdR-label retaining epithelial cells (LREC) were detected among the epithelium of the maturing glands. Labeling newly synthesized DNA in these glands with a different marker, 5-bromodeoxyuridine (5BrdU), resulted in the appearance of doubly labeled nuclei in a large percentage of the LREC. By contrast, label-retaining cells within the stroma did not incorporate 5BrdU during the pulse, indicating that they were not traversing the cell cycle. Upon chase, the second label (5BrdU) was distributed from the double-labeled LREC to unlabeled mammary cells while 3HTdR was retained. These results demonstrate that mammary LREC selectively retain their 3HTdR-labeled template DNA strands and pass newly synthesized 5BrdU-labeled DNA to their progeny during asymmetric divisions. Similar results were obtained in mammary transplants containing self-renewing, lacZ-positive epithelial cells suggesting that cells capable of expansive self-renewal may repopulate new mammary stem cell niches during the allometric growth of new mammary ducts.     

Acute involution in the tammar wallaby: identification of genes and putative novel milk proteins implicated in mammary gland function

Marsupials provide a suitable alternative model to studying mammary gland involution. They have evolved a different reproductive strategy from eutherians, giving birth to an altricial young and secreting milk that changes in composition during lactation. In this study, we used a marsupial-specific EST microarray to identify 47 up-regulated genes during mammary gland involution in the tammar wallaby (Macropus eugenii). These include the pro-apoptotic tumour necrosis factor receptor superfamily 21 (TNFRSF21) gene, whose expression in the mammary gland has not previously been reported. Genes encoding putative novel milk proteins which may protect the mammary gland from infection were also found to be up-regulated, such as amiloride binding protein 1 (ABP1), complement component 1QB (C1QB), complement component 4A (C4A) and colony stimulating factor 2 receptor β (CSF2Rβ). Our results show that the marsupial reproductive strategy was successfully exploited to identify genes and putative novel milk proteins implicated in mammary gland involution.     

Silicone gel-filled breast implant integrity: a retrospective review of 478 consecutively explanted implants

Concern has been expressed over the long-term integrity of silicone gel breast implants. There are no large series representing experience with these implants outside of the United States. A retrospective case note review of explanted silicone breast implants was performed; 478 implants have been explanted during the past 11 years and relate to the use of these devices since 1971. Loss of implant integrity was not simply related to its age in vivo. Failure was more likely with implants of the late 1970s and early 1980s (second generation) and with subpectoral placement. Implant failure was independent of capsular contracture as the indication for removal (p = 0.09). There is no evidence that the currently used textured silicone gel breast implants are subject to the same loss of integrity as previous examples of these devices. The life span of these implants, the first of which are approaching 10 years in vivo, is at present unknown. Information concerning the integrity of silicone gel breast implants is essential in the current climate for counseling of both new and old implant recipients.     

Comparative experience with smooth and polyurethane breast implants using the Kaplan-Meier method of survival analysis.

Smooth-walled silicone implants have been widely used in breast surgery. Capsular contracture, causing undesirable firmness and spherical deformity, has been a common problem. Recent studies suggest that polyurethane-covered breast implants are associated with a lower incidence of capsular contracture. The statistical methodology employed in some of these studies, however, may be subject to criticism. Between July of 1984 and June of 1990 (72 months), 427 polyurethane breast implants were used in 279 patients and 439 smooth prostheses were used in 250 patients for a variety of aesthetic and reconstructive procedures. The occurrence of capsular contracture was carefully monitored and then analyzed using the Kaplan-Meier method of survival analysis. This method is particularly well suited to analysis of these types of clinical data because it allows for the fact that contractures occur at varying intervals after surgery and that follow-up of patients is incomplete. The probability of capsular contracture with smooth-walled prostheses was found to be significantly greater than with polyurethane-covered implants in each group of patients studied (p less than 0.05). Other complications occurred at a similar rate regardless of prosthesis type. This study supports the belief that polyurethane breast implants have a lower contracture rate; furthermore, it introduces the Kaplan-Meier method for analyzing the outcome of alternative plastic surgical therapies.     

Aspergillus colonization associated with bilateral silicone mammary implants

A case of Aspergillus niger fungal colonization associated with bilateral inflatable silicone mammary implants is reported. Painful fibrous capsular contractures without clinical evidence of infection or inflammation characterized the presenting symptoms. Operative findings included a cheesy-white exudate that surrounded the implants and turbid fluid within the implants. All specimens yielded a heavy growth of Aspergillus niger. Special stains of the fibrous capsules were negative for fungal invasion. The etiology and pathogenesis of Aspergillus colonization in this patient are postulated.     

On murine mammary epithelial stem cells: discovery, function, and current status

Cell-surface markers expressed on mammary stem cells and progenitors have helped to establish a preliminary mammary cell lineage hierarchy. Further characterization of these cells depends on overcoming several technical obstacles.Remarkable progress has been made in the past decade in the isolation and characterization of mouse mammary stem cells and progenitors, as nicely reviewed in the article by Visvader and Smith (2011). Following in the footsteps of the hematopoietic system and analogous to bone marrow transplantation, the mammary gland can be reconstituted following transplantation of cells into the cleared mammary fat pad (see review by Medina 2011). Taking advantage of these similarities as well as the availability of genetically engineered mice (GEM), our laboratory initially used magnetic bead and fluorescence-activated cell sorting (FACS) and SCA enhanced green fluorescent protein (EGFP) knock-in mice to identify mammary gland progenitors (Welm et al. 2002). We also attempted to identify and isolate quiescent cells using a BrdU label retention strategy that had been successfully applied in the epidermal and intestinal epithelium. Subsequently, the identification of several cell-surface markers expressed on mammary stem cells and progenitors has resulted in an explosion in the field, and helped to define a preliminary mammary cell lineage hierarchy. These studies on the normal mammary gland have also provided the basis for hypotheses into potential mechanisms accounting for the heterogeneity of breast cancer subtypes (Behbod and Rosen 2004).One intrinsic difference between the hematopoietic system and the mammary gland, however, is the requirement for tissue dissociation in the latter case to facilitate the isolation of single cells required for FACS sorting. Even when using freshly isolated cells, there is a concern that these rather lengthy dissociation protocols may alter the expression of cell-surface molecules and properties of cells following disruption of the mammary gland architecture. Even short-term cell culture of primary mammary epithelial cells may alter the expression of cell-surface molecules. At present, single gene markers of mammary stem cells have not been identified, so the application of knock-in mice, e.g., the use of LGR5-EGFP to identify intestinal stem cells and perform lineage-tracing experiments (Barker et al. 2007), has not been feasible. One alternative approach may be to use pathway reporters, as recently described by Zeng and Nusse (2010), who used an axin-lacZ knock-in mouse to identify cells with canonical Wnt signaling with increased mammary repopulating activity. We have used a similar approach in a p53-null mouse mammary cancer model following lentiviral transduction with a Wnt reporter construct to identify cells with enhanced canonical Wnt signaling. These cells displayed a significant overlap with cell-surface markers in the basal-like tumors shown to enrich for tumor-initiating cells (Zhang et al. 2010).The use of multiple pathway reporters with different fluorescent reporters may provide a new approach to complement the current dependence on cell-surface markers. Fluorescent reporters also have the potential to help precisely visualize and model the location of mammary stem cells and progenitors in situ using multiphoton and other sophisticated microscopic techniques. The ability to visualize single stem cells in their niche environment and to follow both symmetric versus asymmetric division ultimately will be required for the next advances in the field. Recent studies on the paracrine effects of the steroid hormones, estrogen and progesterone, on mammary gland stem cells and progenitors illustrate the need to understand the spatial relationships among the various epithelial and stromal cell types present in the mammary gland. These studies will need to include cells from the immune system such as macrophages, neutrophils, etc., and derivatives of mesenchymal stem cells. Hopefully, in the near future it may be feasible to reconstitute and study these interactions in vitro, but for the present time this can be studied in GEM models. In addition, there is increasing evidence for the coexistence of quiescent and active adult stem cells in mammals (Li and Clevers 2010), but these distinct populations and their spatial and temporal relationships in the mammary gland remain to be discovered. Application of single-cell analysis using newly developed microfluidic platforms has the potential to help elucidate the potential heterogeneity of signaling pathways and gene expression in mammary stem cells and progenitors. Finally, there is a critical need for lineage-tracing experiments in the normal mammary gland to validate the proposed hierarchy for stem cells and progenitors, as well as to identify the cells of origin for different subtypes of breast cancer. Comparative studies of the murine and human stem cell populations in both the normal mammary gland and different breast cancer subtypes hold enormous potential for the future. Thus, despite the remarkable progress in this field, much remains to be done.