breast 1

Question 1

What is the breast tissue comprised of?

Answer 1

epithelium (glands and ducts)
stroma (connective tissue and fibrofatty tissue)
Major ductal system originates in the nipple (6-10 lactiferous ducts)

Question 2

What is in the mammary gland ?

Answer 2

10 lobes which contain lactiferous ducts and their branches and lobules aka glandular acini

Question 3

Describe the TDLU in the mammary gland?

Answer 3

Terminal ductal lobular unit

consists of lobules, terminal branches of ducts , surrounding connective tissue

Question 4

Where do most cancers arise from?

Answer 4

TDLU

Question 5

Explain the histological aspect of the breast in regard to ducts and lobules

Answer 5

•Ducts and lobules- 2 cell layer thickness
–Superficial layer- epithelial cells
–Deep cell layer- myoepithelial cells
•Basement membrane separates the ducts, ductules and acini from the interlobular and intralobular connective tissue (stroma)

Question 6

explain breast physiology

Answer 6

•At birth- Not fully formed
•Pre-pubertal
Branching ducts connected to nipple, no glandular component (=male breast)
•Post-pubertal
Terminal ducts give rise to lobules
Formation of interlobular connective tissue (fibrous and adipose tissue)
•Reproductive life- cyclic changes through menstrual cycle
Follicular phase- epithelial proliferation
Luteal phase- increases the number of acini, stroma- oedema
During menstruation- disappearance of stromal oedema, apoptosis and regression in the size of lobules
•Pregnancy and lactation
•Menopause- involution

Question 7

define congenital abnormalities in breast

Answer 7

Supernumerary nipples/breasts
•Most common congenital anomaly
•Heterotropic glands along the milk line
•May be involved by a pathologic process (breast carcinoma occurring in the axilla)

Question 8

how does breast disease present?

Answer 8

•Breast pain (mastalgia)
•Palpable mass
•Nipple discharge
•Mammographic abnormality
•Other presentations:
–Skin-(peau d’orange)-oedema due to lymphatic obstruction
–Nipple retraction

Question 9

What are you looking for in a breast lump?

Answer 9

is it discrete or diffuse lumpiness? 
Solid vs cystic
hard vs firm 
mobile vs fixed
single vs multiple
smooth vs irregular
bilateral vs cyclical

Question 10

When does one refer pt to further investigation ?

Answer 10

When lump remains after aspirate performed
Family hx
Lump a/w other symptoms 
new lump/new in pre-existing nodularity 
unresolving inflam 
persistent asymmetrical nodularity

Question 11

Describe the clinical assessment of a breast lump

Answer 11

•History & examination
–Inspection and palpation
–Examination of the axilla
•Ultrasound
–Cysts, outlines mass lesions, young patients, guided bx
•Mammography
–Difficult in younger women (also with HRT) because breast tissue is more dense
•MRI (high sensitivity but low specificity)
–Image implants
–Staging of lobular ca if conservative surgery is indicated
–Evaluation of high risk patients
–Monitoring following neo adjuvant chemotherapy
•Pathology

Question 12

What are the mammographic signs of malignancy?

Answer 12

•Densities
•Calcifications
–Small, irregular, clustered, linear or branching
•Architectural distortion
•Asymmetry

Question 13

Classify diseases of the breast

Answer 13

Inflammatory condition (acute and chronic)

• acute mastitis
• mammary duct ectasia
• periductal mastitis
• fat necrosis

Benign tumours and fibrocystic changes

• Intraductal papilloma
• fibroadenoma
• phyllodes tumor
• fibrocystic change/disease

Malignant
carcinoma

Question 14

What are examples of chronic inflammatory conditions of breast?

Answer 14

fat necrosis
mammary duct ectasia
periductal mastitis
granulomatous mastitis
lymphocytic mastitis

Question 15

Define acute mastitis

Answer 15

typically associated w lactation
involves staph aureus and strep - staph more diffuse reaction than strep
essentially the nipple cracks during lactation providing leeway for these organisms to enter breast parenchyma

Presents as fever, erythema, pain
Treated w antibiotics (dicloxacillin) (Rarely perform surgical drainage)

Question 16

Define Periductal mastitis

Answer 16

typically aw smoking .
Smoking causes Vit A deficiency and this causes squamous metaplasia of periductal cells. There is the secretion of keratin and this causes inflammation (chronic and granulomatous)
Presents with subareolar mass and nipple inversion
Tx with resection of involved duct

Question 17

Define mammary duct ectasia

Answer 17

a/w 5th/6th decades of female life
Thick secretions in large ducts, which block these ducts and they spill into surrounding tissue/stroma- chronic inflam and granulomas
Seen as a periareolar mass and thick nipple discharge
can mimic carcinoma on mammogram

Question 18

Define Fat necrosis

Answer 18

a/w trauma
seen typically in obese and post menopausal women
presents as necrotic parenchyma with fat laiden macrophages and foreign body giant cells
can mimic carcinoma on mammogram

Question 19

Define lymphocytic and granulomatous mastitis

Answer 19

•Lymphocytic mastitis:
–Often associated with type I insulin dependent diabetes (diabetic mastopathy)
–palpable mass, usually subareolar, often bilateral
•Granulomatous mastitis
–Idiopathic or associated with systemic granulomatous disease (eg sarcoidosis)

Question 20

Galactocoele definition

Answer 20

cystic dilatation of duct during LACTATION

can be come infected (seen in acute mastitis) w an abscess formation

Question 21

Define fibrocystic changes

Answer 21

morphological elements that involve the glandular and stromal parts of the breast
cysts: dilatation of ducts - aprocrine metaplasia
fibrosis of stroma
adenosis also occurs -increase in no of acini per lobule
Above described the non prolierative changes

Proliferative changes include

• epitheliosis- epithelial hyperplasia (more than 2 layers in glands and duct) - shares some architectural and cytological features to CIS
• sclerosing lesions
• intraductal papilloma

Question 22

Who does fibrocystic disease typically affect?

Answer 22

women 20-40

Question 23

Cause of fibrocystic disease?

Answer 23

progestorone/oestrogen imbalance

Question 24

Define sclerosing lesions

Answer 24

sclerosing adenosis- a/w increase in small ductules and acini and fibrosis of lobules 
radical scar/complex sclerosing lesion
-hard and irregular 
-complex histology
-larger
-palpable mass  

Can mimic carcinoma on radiology/histology

Question 25

Define intraductal papilloma

Answer 25

benign papillary growth in the lactiferous duct
presents w bloody/serous nipple discharge
can recur if inadequately excised

Question 26

Gynaecomastia

Answer 26

•Enlargement of the male breast
–Unilateral in 70%
–Oestrogen excess: cirrhosis, puberty, testicular tumours, treatment, idiopathic (older men)
–Drugs: Spironolactone, Chlorpromazine, Cimetidine, Androgens, alcohol, marijuana and heroin,
–Prolactin excess: pituitary-hypothalamus

Question 27

Carcinoma of male breast a/w what gene?

Answer 27

BRCA 2 mutation - 10%

Question 28

How does carcinoma of the male present?

Answer 28

presents as invasive carcinoma by the time of diagnosis
but this is a rare formation
usually occurs in OLDER men