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15. Reproductive > 11. The Breast > Flashcards

11. The Breast Flashcards

1
Q

What do the breasts consist of?

A

Glandular and supporting fibres embedded within a fatty matrix with blood vessels, lymphatics, and nerves.

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2
Q

Where are the mammary glands?

A

In the subcutaneous tissue overlying the pectoralis major and minor muscles.

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3
Q

What do the mammary glands consist of?

A

15-20 lobulated masses of tissues, with fibrous tissue connecting lobes and adipose tissue between them.

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4
Q

What makes up the lobes of mammary glands?

A

Lobules of alveoli, blood vessels, and lactiferous ducts.

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5
Q

What is the site of milk synthesis?

A

The alveoli lobules of the mammary gland lobes.

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6
Q

How is milk let down from mammary glands?

A

Myoepithelial cells and smooth muscle cells surround the alveoli.

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7
Q

Where do breasts extend form and to?

A

Lateral sternal edge to midaxillary line. 2nd rib to 6th rib.

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8
Q

What is colostrum?

A

The milk secreted in the first week after birth.

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9
Q

How much colostrum is secreted a day?

A

40ml/day in the first week.

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10
Q

What does colostrum contain?

A

More protein, fat soluble vitamins, and immunoglobulins. But less water soluble vitamins, fat, and sugar.

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11
Q

How does colostrum change to mature milk after 2-3 weeks?

A

IgG and total protein declines but fat and sugar rise.

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12
Q

How long is mature milk produced?

A

For as long as the baby suckles.

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13
Q

What is the energy value and pH of mature milk?

A

27mJ/liter, pH 7.0

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14
Q

What are the components of mature milk?

A

Water (90%), lactose (7%), fat (2%), proteins (lactoglobulin, lactalbumin, minerals vitamins).

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15
Q

How is fat, protein, and sugar synthesised into milk?

A

Fats synthesised in smooth endoplasmic reticulum, passes in membrane bound droplets towards lumen. Protein passes through Golgi apparatus, secreted by exocytosis. Sugar synthesised and secreted in alveolar cells.

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16
Q

How do mammary tissues develop under hormonal control?

A

From birth to puberty, only a few lactiferous ducts are present. Oestrogen at puberty cause sprouts and branching of the ducts to form cell masses that later become alveoli. They change with each menstrual cycle according to oestrogen and progesterone levels.

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17
Q

How do mammary tissues change in pregnancy?

A

High progesterone:oestrogen ratio favours development of alveoli, but no secretion. Hypertrophy of ductular-lobular-alveolar system and prominent lobules form. Alveolar cells differentiate to produce milk from mid gestation.

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18
Q

How is milk production hormonally controlled at birth?

A

Progesterone levels fall sharply so the breasts are more responsive to prolactin. Prolactin is secreted from anterior pituitary under control of hypothalamus. Suckling initiates and maintains secretion so milk is maintained continuously between feeds and accumulates in ducts.

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19
Q

How is prolactin secreted and controlled?

A

Secreted from anterior pituitary under hypothalamus control. Suckling causes a neuro-endocrine reflex by mechanical stimulation of receptors in the nipple. Impulses to brain stem cause hypothalamus to reduce secretion of dopamine and vaso-active intestinal peptide so prolactin secretion is promoted.

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20
Q

What causes milk let down?

A

Dramatic increase in oxytocin from posterior pituitary gland. This causes myoepithelial cells surrounding alveoli to contract, ejecting the milk.

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21
Q

How is suckling important for preventing post partum haemorrhage?

A

It causes release of oxytocin which causes the uterus to clamp down on open placenta blood vessels.

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22
Q

How is lactation stopped?

A

Lack of suckling stops milk production as prolactin secretion to produce and secrete oxytocin to remove milk is stopped. Lower prolactin levels and turgor-induced damage to breast stops production of milk.

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23
Q

What is the difference between physiological and pathological breast changes?

A

Physiological are from normal breast physiology, pathological are due to underlying breast pathology.

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24
Q

What are the physiological breast changes?

A

Prepubertal breast - few lobules.
Menarche (onset of puberty) - increase number of lobules and volume of interlobular stroma.
Menstrual cycle - follicular phase lobules inactive, after ovulation cell proliferation and stromal oedema, menstruation decrease size of lobules.
Pregnancy - increase in size and number of lobules but decrease in stroma and secretory changes.
Cessation of lactation - atrophy of lobules.
Increasing age - terminal duct lobular units decrease in size and number, interlobular stroma replaced by adipose tissue.

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25
Q

What are the pathological breast changes?

A

Disorders of development - milk line remnant as 3rd nipples, accessory axillary breast tissue.
Inflammatory conditions - acute mastitis, duct ectasia, fat necrosis.
Benign epithelial lesions - fibrocystic change, epithelial hyperplasia, papilloma.
Stromal tumours - fibroadenoma, phyllodes tumours, lipoma, hamartoma.
Gynaecomastia (man boobs).
Breast carcinoma.

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26
Q

What are the possible presentations of breast pain?

A

Cyclical and diffuse - often physiological.
Non-cyclical and focal - rupture cysts, injury, inflammation.
Occasionally presenting complaint in breast cancer.

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27
Q

What are the possible presentations of palpable breast masses?

A

Can be normal nodularity. Worrying if hard, craggy, and fixed - invasive carcinomas, fibroadenomas, custs.

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28
Q

What are the possible presentations of nipple discharge?

A

Spontaneous and unilateral is worrying. Milky with endocrine disorders or medication.

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29
Q

What are some mammographic abnormalities?

A

Densities from invasive carcinomas, fibroadenomas, cysts.

Calcifications - ductal carcinoma in situ, benign changes.

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30
Q

What are the incidences of the following conditions in relation to age?
Fibroadenoma, phyllodes tumour, breast cancer.

A

Fibroadenoma - any age in reproductive period, normally <30 years.
Phyllodes tumours - mostly in 6th decade.
Breast cancer - rare before 25 years unless familial, increasing incidence with age, 77% are over 50, average age is 64 years.

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31
Q

What is the triple approach to breast lesion investigation and diagnosis?

A

Clinical - history, family history, examination.
Radiographic imagining - mammogram and ultrasound scan.
Pathology - fine needle aspiration cytology and core biopsy.

32
Q

What is the cause of acute mastitis?

A

Normally a Staphylococcus aureus infection from cracks and fissures in lactation.

33
Q

What is the presentation of acute mastitis?

A

Erythematous painful breast, often fever. May have breast abscesses.

34
Q

How is acute mastitis treated?

A

Expressing milk and antibodies.

35
Q

What is duct ectasia?

A

Dilation and inflammation of lactiferous duct.

36
Q

What is the presentation of duct ectasia?

A

Often in 50s and 60s, peri-areolar mass and/or nipple discharge, can mimic carcinoma clinically.

37
Q

What is the presentation of fat necrosis of the breast?

A

Mass, skin changes, or mammographic abnormality with a history of trauma or surgery. Can mimic carcinoma clinically and mammographically.

38
Q

What is gynaecomastia?

A

Enlargement of the male breast.

39
Q

What is the presentation of gynaecomastia?

A

Unitlateral or bilateral, puberty or elderly, can mimic male breast cancer especially if unilateral.

40
Q

What are some causes of gynaecomastia?

A

Hormonal abnormality, cirrhosis of liver (oestrogen not metabolised), functioning testicular tumour, drugs - alcohol/marijuana/heroin/anabolic steroids.

41
Q

What are the fibrocystic changes in benign breast tumours?

A

Benign epithelial lesions, common, present as mass of mammographic abnormality, disappears after fine needle aspiration.

42
Q

What are the histological features of fibrocystic changes in benign breast tumours?

A

Cyst formation, fibrosis, apocrine metaplasia.

43
Q

What are the epithelial hyperplasia changes in benign breast tumours?

A

Benign epithelial lesions, proliferation of epithelial cells which fill and distend ducts and lobules.

44
Q

What are the changes in papilloma?

A

Benign epithelial lesions, benign tumours, growing finger-like projections outwards. Large duct in lactiferous ducts near nipple, small duct deeper in breast.

45
Q

How does papilloma present?

A

Nipple discharge which may be bloody, small + palpable mass.

46
Q

What are the histological features of papilloma?

A

Intraduct lesions consisting of multiple branching fibrovascular cores covered by myoepithelial and epithelial cells.

47
Q

What is a fibroadenoma?

A

Stromal tumour.

48
Q

How do fibroadenomas present?

A

Mass, usually mobile, or mammographic abnormality. Can have multiple and bilateral. Grows very large and replaced most of the breast.

49
Q

What are the macroscopic features of a fibroadenoma?

A

Well defined boundaries, rubbery, greyish/white.

50
Q

What are the histological features of fibroadenomas?

A

Mixture of stromal and epithelial elements.

51
Q

What are phyllodes tumours?

A

Stromal tumours. Benign, borderline, and malignant types.

52
Q

How do phyllodes tumours present?

A

Masses or as mammographic abnormalities. Can be very large and involve the entire breast.

53
Q

What are the histological features of phyllodes tumours?

A

Nodules of proliferating stroma covered by epithelium. Stroma more cellular and atypical than fibroadenomas.

54
Q

How are phyllodes tumours treated?

A

Excised with a wide margin to prevent recurrence.

55
Q

What are most major risk factors related to for breast cancer?

A

Hormone - oestrogen exposure.

56
Q

What are some risk factors for breast cancer? (max 10)

A

Gender - females have higher oestrogen.
Longer interval between menarche and menopause - longer exposure to oestrogens.
Reproductive history - number of births (inversely proportional risk) and age at first birth (proportional).
Breast feeding.
Obesity and high fat diet.
Exogenous oestrogens - HRT slightly increased, OCP doesn’t affect risk.
Geographic risk - high incidence in USA and Europe.
Atypical changes on previous biopsy.
Radiation - proportional risk.
Genetics - 3% of all and 25% of familial are BRCA1 BRCA2 mutations, 20 years older diagnosis than sporadic cases.

57
Q

How are breast cancers classified?

A

90% are adenocarcinomas. Divided into in situ and invasive. Ductal or lobular.

58
Q

What is in situ carcinoma of the breast?

A

Neoplastic population of cells limited to ducts and lobules by basement membrane. Myoepithelial cells preserved.

59
Q

How far can in situ carcinomas of the breast spread?

A

Can’t metastasise as doesn’t invade into vessels. Can extend to nipple skin - Paget’s disease, unilateral red and crusting nipple.

60
Q

How do ductal carcinoma in situ of the breast present?

A

Mammographic calcifications - clusters of linear and branching, as a mass.

61
Q

How does DCIS of the breast spread?

A

Through ducts and lobules, very extensive.

62
Q

What are the histological features of DCIS of the breast?

A

Central necrosis with calcification.

63
Q

What can DCIS of the breast progress to?

A

Invasive carcinoma.

64
Q

What is invasive carcinoma of the breast?

A

Carcinoma invaded beyond the basement membrane into the stroma.

65
Q

How do invasive carcinomas of the breast spread?

A

Invade vessels so metastasise to lymph nodes and other sites.

66
Q

How do invasive carcinomas of the breast present?

A

A mass or mammographic abnormality.

67
Q

When invasive carcinoma of the breast presents as a mass, what percentage of patients will have axillary lymph node metastases?

A

> 50%.

68
Q

What proportion of breast invasive carcinomas are made up by invasive ductal cell, no specific type (IDC-NST)?

A

70-80%.

69
Q

What are the two differentiation types of IDC-NST?

A

Well-differentiated - tubules lined by atypical cells.

Poorly differentiated - sheets of pleomorphic cells.

70
Q

What is the histological presentation of invasive lobular carcinoma of the breast?

A

Infiltrating cells in a single file, cells lack cohesion.

71
Q

What are the types of invasive carcinoma?

A

IDC-NST, invasive lobular, tubular, mucinous, medullary, papillary.

72
Q

What are the two patterns of metastasis of breast cancer?

A

Lymph nodes via lymphatics, usually in ipsilateral axilla.

Distant metastases via blood vessels to lungs, bones, liver, brain.

73
Q

What are the factors determining breast cancer prognosis?

A

In situ vs invasive. Histological subtype, IDC NST has poorer prognosis. Tumour grade. Tumour stage.

74
Q

What is the triple approach to investigation and diagnosis of breast cancer?

A

Clinical - history, family history, examination.
Radiographic imaging - mammogram and ultrasound.
Pathology - fine needle aspiration cytology and core biopsy.

75
Q

What are the local and regional therapeutic approaches in breast cancer?

A

Breast surgery - mastectomy or breast covering surgery.
Axillary surgery - if node involved.
Post-operative radiotherapy to chest and axilla.

76
Q

What are the systemic therapeutic approaches in breast cancer?

A

Chemotherapy, hormone treatment (tamoxifen if high amount of oestrogen), herceptin (if Her2 receptors found)

15. Reproductive (12 decks)

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