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11.2 Flashcards

1
Q

Describe normal breast tissue

A

Modified sweat glands
Non-fucntional except during lactation.
Lobules = acini and intralobular stroma

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2
Q

Give 7 physiological breast changes that occur.

A

Prepubertal breast - Few lobules (M and F identical)

Menarche - Increase in number of lobules, increased volume of interlobular stroma.

Menstrual cycle:
Follicular phase - lobules inactive
After ovulation - cell proliferation and stromal oedema
Menstruation - decrease in lobule size

Pregnancy:
Increase in size and number of lobules
Decrease in stroma
Secretory changes

Cessation of lactation:
Atrophy of lobules but not to former levels

Increasing age:
Terminal duct lobular units decrease in number and size.
Interlobular stroma replaced by adipose tissue.

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3
Q

Give some pathological breast changes that can occur?

A

Changes or symptoms that come about due to underlying breast pathology.

Disorders of development
Inflammatory conditions
Benign epithelial lesions
Stromal tumours
Gynaecomastia
Breast carcinoma
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4
Q

What are the general clinical presentations of breast conditions?

A 
Pain
Palpable mass
Nipple discharge
Skin changes
Lumpiness
Mammographic abnormality
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5
Q

What is the pain like in breast physiology/disease?

A

Cyclical and diffuse - often physiological

Non-cyclical and focal - ruptured cysts, injury and inflammation

Occasionally presenting complaint in breast cancer

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6
Q

When is a palpable mass worrying? What could this be?

A

Hard, craggy, fixed

Invasive carcinoma, fibroadenoma, cysts

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7
Q

When is nipple discharge most concerning?

A

Spontaneous and unilateral

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8
Q

When can milky discharge occur?

A

Endocrine disorders - pituitary adenoma

Side effect of medication - OCP

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9
Q

When can bloody or serous discharge occur?

A

Benin lesions
Papilloma
Duct ectasia
Malignant lesions

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10
Q

Describe the breast screening programme

A

Mammogram every 3 years between 47-73 years.

Easier to detect lesions on older women breasts

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11
Q

What can be found on a mammogram?

A

Densities:
Invasive carcinoma, fibroadenoma, cysts

Calcifications
Ductal Carcinoma In Situ (DCIS), benign changes.

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12
Q

Describe the incidence of breast conditions in general. What is the most common benign tumour?

A

Symptoms and signs are common - mostly benign.

Fibroadenoma is most common benign tumour.

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13
Q

What is the incidence of fibroadenoma in relation to age.

A

Occurs at any age in reproductive period.

Often

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14
Q

When do phyllodes tumour usually present?

A

6th decade.

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15
Q

Give the incidence of breast cancer in relation to age.

Average age of diagnosis?

A

Rare before 25 (except familial)
Incidence increases with age
77% in women > 50 years
Average age of diagnosis is 64 years

UK:
45,500 new female cases and 300 new male cases per year.
12,500 deaths per year.

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16
Q

Give examples of disorders of development

A

Milk line remnants (3rd nipples)

Accessory axillary breast tissue (malignancy)

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17
Q

Give some inflammatory conditions of the breast.

A

Acute mastitis
Duct ectasia
Fat necrosis

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18
Q

Describe acute mastitis. What organism causes? When does it occur? How does it present? Treatment?

A

Usually Staph. aureus infection from nipple cracks and fissures.
Almost always during lactation.
Erythematous panful breast, pyrexia
May produce breast abscesses.
Treated by expressing milk and antibiotics.

19
Q

Describe duct ectasia. Patient presentation?

A

Dilation and inflammation of the lactiferous duct
Patients are in 50s/60s
May have perialeolar mass and or nipple discharge.
Can mimic carcinoma clinically.

20
Q

Describe fat necrosis.

A

Presenta as a mass, skin changes or mammography abnormality
Often history of trauma or surgery
Can mimic carcinoma clinically and mamographically

21
Q

Describe gynaecomastia.
When is ti seen?
What does it indicate? (Causes)
What substances can cause it?

A

Enlargement of the male breast.
Unilateral or bilateral
Seen at puberty and in elderly.
Can indicate hormonal abnormality, cirrhosis of the liver (oestrogen not metabolised effectively), functioning testicular tumour.
Alcohol, cannabis, heroin
Can mimic breast cancer, esp. if unilateral.

22
Q

Describe fibrocystic change of the breast. How may is present? Describe histology. Why might it cause worry?

A

Benign epithelial lesions
Very common
Mat present as mass or mammography abnormality
Mass often disappears after fine needle aspiration (FNA)
Histology:
Cyst formation, fibrosis, apocrine metaplasia
Can mimic carcinoma clinically and mamographically.

23
Q

Give some examples of stromal tumours of the breast

A

Fibroadenoma, phyllodes tumours, lipoma, leiomyoma, hamartoma

24
Q

Give 3 benign epithelial lesions of the breast:

A

Fibrocystic change
Epithelial hyperplasia
Papilloma

25
Describe epithelial hyperplasia
Proliferation of epithelial cells, which fill and distend ducts and lobules. Associated with slight increased risk of carcinoma. If atypical, higher risk.
26
Describe papilloma Where do they occur? How do they present? Describe the histology.
Benign tumours, growing finger-like projections outwards. Large duct papillomata are usually in lactiferous ducts, near nipple Smaller duct papillomata are situated deeper in the breast. Associated with slight increased risk of carcinoma. May present with nipple discharge (bloody) or small palpable mass. Histology - intraduct lesion consisting of multiple branching fibrovascular cores covered by myoepithelia epithelia.
27
Describe fibroadenoma of the breast. How does it present? Describe macroscopic appearance and histology?
Stromal tuour Presents with a mobile mass or mamographic abnormality Can be multiple and bilateral Can grow very large Macroscopically Well defined boundaries, rubbery, greyish white Histology Composed of a mixture of stromal and epithelial elements. Can mimic carcinoma
28
``` Describe Phyllodes tumours. Presentation. Types Histology. How can it be differed from fibroadenoma. How do malignant types behave? ```
Stromal tumour Present as masses or mammography abnormality. Benign, borderline and malignant types - most benign. Can be very large and involve entire breast. Histology Nodules of proliferating stroma, covered by epithelium. Stroma is more cellular and atypical than in fibroadenomas. Need to be excised with wide margin or may recur Malignant types behave aggressively and metastasise via blood.
29
What is the most common type of breast cancer? | Where are they most common?
95% adenocarcinoma. | Upper right quadrant.
30
What are the risk factors for breast cancer?
Related to hormone exposure: ``` Gender: female Long interval between menarche and menopause Reproductive history Breast feeding Obesity and high fat diet Exogenous oestrogens - HRT Geographic influence - USA/Eur Radiation Genetics ```
31
What genes cause lots of familial breast cancer when mutated? What kind of genes are these? What else do they cause?
``` BRCA1 and BRCA2 Tumour suppressor genes - Repair damaged DNA Also cause ovarian cancer 25% of familial cancers ```
32
What is another gene involved in familial breast cancer?
p53
33
How are breast carcinomas classified?
In situ and invasive | Ductal or lobular
34
Describe in situ carcinomas of the breast. | Where can and can't they spread to?
Neoplastic population of cells limited to ducts and lobules by basement membrane. Myoepithelial cells are preserved. Does not invade into vessels and so cannot metastasise. Cells can extend to nipple skin without crossing basement membrane: Paget's disease Unilateral red and crusting nipple
35
Describe a Ductal Carcinoma In Situ of the breast. Presentation. Spread. Histology?
Most often presents as mammography calcifications: - Clusters or linear and branching Can present as mass Can spread through ducts and lobules and be very extensive. Histologically shows central necrosis with calcification. Can progress to invasive.
36
What is Paget's disease
Cells of in situ carcinoma extend to nippily skin without crossing basement membrane. Unilateral and red crusting nipple Eczematous or inflammatory conditions of the nipple.
37
Describe an invasive carcinoma of the breast. | How does it present? Significance of palpation?
Carcinoma invaded beyond the basement membrane into stroma. Can invade vessels and therefore can metastasise to lymph nodes and other sites. Usually presents as mass or mammography abnormality. By the time it is palpable, more than half have axillary lymph node metastases.
38
What are the types of invasive ductal carcinoma?
No specifc type NST - 70-80% Well differentiated type: Tubules lined by atypical cells Poorly differentiated type: Sheets of pleomorphic tissue Invasive lobular carcinoma: Infiltrating cells in a single file, cells lack cohesion. Tubular Mucinous Medullary Papillary
39
What are the patterns of metastasis of breast cancer?
Lymph nodes via lymphatics Usually in ipsilateral axilla. Distant metastases via blood vessels Lungs, bones, liver, brain Invasive lobular can spread to odd sites: peritoneum, GI tract, ovaries, uterus
40
What factors determine breast cancer prognosis?
In situ vs invasive Histological subtype? IDC NST has poorer prognosis Tumour grade Tumour stage - TNM
41
Describe the investigation and diagnosis of breast lesions
Triple approach ``` Clinical History, family history, examination Radiographic Imaging Mammogram and ultrasound Pathology Fine needle aspiration cytology, core biopsy ```
42
Give some local/regional therapeutic approaches to breast cancer?
Breast surged - mastectomy or breast conserving surgery. Axillary surgery - depending on nodes Post-operative radiotherapy to chest/axilla
43
Give some systemic therapeutic approaches to breast cancer.
Chemotherapy Hormonal treatment: Tamoxifen if high amount of oestrogen receptors Herceptin treatment depending on Her2 receptor status
44
How can breast cancer survival be improved?
Early detection Awareness of disease, importance of family history, self-examination, mammography screening Neo-adjuvant chemotherapy Early treatment of metastatic disease. Use of newer therapies Herceptin Gene expression profiles Prevention in familial cases Genetic screening, prophylactic masectomies

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