Breast Flashcards
What attaches the breast to the dermis? What is its function?
Suspension ligament of cooper: helps support the lobules of the gland
How many lobules does each breast contain?
15-20 lobules of glandular tissue
What is each lobule drained by?
Lactiferous duct
Describe the structure of the nipple.
Contains collagenous, dense connective tissue, elastic fibres and bands of smooth muscle.
The tips of the nipples are fissured with lactifeous ducts opening into them
What is gynaecomastia?
Postnatal development of rudimentary lactiferous ducts in males
What is the nervous supply to the breast?
Anterior and lateral cutaneous branches of 4-6th intercoastal nerves. Convey sensory fibres to the skin of the breast. Sympathetic fibres to the blood vessels and to the smooth muscle around the nipple.
Describe the lymphatic drainage of the breast.
Most from lateral quadrants: axillary lymph nodes
Some may drain directly to supraclavicular or inferior cervical nodes
Lymph from medial quadrants: parasternal or to opposite breast
What is the role of a sentinel lymph node (first draining node) in breast cancer?
Lymphatic mapping and staging patients
A radiolabelled colloid is used to locate the sentinel node
At the time of surgery, a vital blue dye is injected
Combination of radioisotope and she provides most accurate means of localising the node.
What is a fibroadenoma?
Benign breast tumour. Circumscribed mobile nodule in reproductive age. Freely mobile, nonpainful mass.
May regress with age if left untreated
What is an intraduct papilloma?
Benign breast tumour. Lactiferous ducts, nipple discharge.
Can show epithelial hyperplasia, which might be atypical.
What is cytology?
Microscopic examination of a thin layre of cells on a slide obtained by:
Fine needle aspiration
Direct smear from nipple discharge
Scrape of nipple with scalpel
Describe the technique of fine needle aspiration.
23G needle. 10ml syringe. Alcohol swab. Vial with saline for needle washings. Insert needle 45 degrees. Aspirate using in and out action applying negative pressure on syringe. Release pressure and remove needle.
What does a benign cytology look like?
- low/ moderate cellulartiy
- cohesive groups of cells
- flat sheets of cells
- bare ovel nuclei in background
- cells of uniform size
- Uniform chromatin pattern
What does a malignant cytology look like?
- high cellularity
- crowding/ overlapping of cells
- loss of cohesion
- nuclear pleomorphism
- hyperchromasia
- absence of bipolar nuclei
What is the cytology scoring system?
- C1 Unsatisfactory/ Insufficient cells for diagnosis
- C2 Benign
- C3 Atypia (probably benign)
- C4 Suspicious (probably malignant)
- C5 Malignant
When is fluid from a breast cyst analysed?
- fluid is bloodstained
- there is residual mass
What are the advantages of breast cytology?
- simple procedure (can be done at clinic)
- well tolerated by patients
- inexpensive
- immediate results
What are the limitations of cytology?
- flase negatives
- false positives
- invasion cannot be assessed
- grading cannot be done
- lesion can be missed
- technical (difficult to examine cells)
- interpretation
What are the complications of FNA?
Pain
Haematoma
Fainting
Infection, pneumothorax (rare)
What are the contraindications of FNA?
There are none
Why is a core biopsy undertaken?
- confirm invasion
- tumour typing and grading
- immunohistochemistry
How many lactiferous ducts does the breast have?
15-20 ducts
How many lobes does the breast have?
8-10 lobes
Where does carcinoma of the breast arise?
Lobular unit
What are the benign conditions of the breast?
- fibrocytic change
- fibroadenoma
- intraduct papilloma
- fat necrosis
- duct ectasia
What ia fibrocystic change?
Painful, lumpy area
Fibrosis, adenosis, cysts, apocrine metaplasia, ductal epithelial, hyperplasia
What is a fibroadenoma?
Circumscribed mobile nodule in reproductive age
Proliferation of epithelial and stromal elements
Most common breast tumour in adolescents
Non- painful mass
May regress if left untreated
How is fat necrosis caused in the breast?
Trauma
What is the pathology of a fibroadenoma?
Ducts distorted elongated
Slit-like structures intracanalicular pattern
Ducts not compressed
Pericanalicular growth pattern
What is a lactating adenoma?
Enlarging masses during lactation or pregnancy
Prominent secretory change
At what age is an intraduct papilloma common?
Middle aged women
What can fat necrosis in the breast stimulate>
Carcinoma
What is seen in hostology of fat necrosis of the breast?
Histocytes with foamy cytoplasm
Lipid filled cysts
Fibrosis, calcifiactions, egg shell on mammography
What is phyllodes tumour?
Fleshy tumour, leaf-like pattern and cysts on cut surface
Circumscribed, connective tissue and epithelial elements
1-15cm
Less than 1% of breast tumours
Benign, borderline, malignant
Metastases are hematogenous
How many females will breast cancer affect?
1 in 8
What are the macroscopic features of a breast carcinoma?
Hard lump, fixed mass, tethering to skin, dimpling of skin
What are the risk factors for breast cancer?
Female Age: increased risk with age Menstrual history Age at first pregnancy Radiation FH: first degree relative Personal history Hormonal treament Genetic factors
What genes are most commonly associated with hereditry breast cancer?
BRCA1: 20-40%
BRCA2: 10-30%
What are the two non-invasive breast carcinomas?
Ductal carcinoma in situ
Lubular carcinoma in situ
What are the invasive breast carcinomas?
Invasive ductal carcinoma
Invasive lobular carinoma and variants
Special types
What is meant by an in-situ carcinoma?
Preinvasive: does not form a palpable tumour
Not detected clinically
Multicentricity and bilaterality
No metastatic spread (basement membrane)
Risk of invasion depending on grade
What are DCIS graded on?
Nuclear morphology
What are the various ‘special types’ of breast carcinoma?
Tubular carcinoma
Mucinous carcinoma
carcinoma with medullary features
Metaplastic carcinoma
What are the procedures used in diagnosing a breast carcinoma?
Clinical examination Radiology (mammogram, US, MRI) Fine needle aspiration cytology, FNA Needle core biopsy Wide local excision with adequate margins
What are microcalcifications?
Tiny deposits of calcium can appear anywhere in the breast and often show up on a mammogram
Most women have one or more areas of microcalcifications of various sizes
Majoirty of calcium deposits are harmless
A small percentage may be in precancerous or cancerous tissue
What are the two most important mammographic indicators of breast cancer?
Masses
Microcalcifications: can indicate an early cancer
What can be concluded from a breast tumour histology report?
Invasive vs non-invasive Histological type: ductal vs lobular Grade (aggressiveness under microscope) Size Margins Lymph nodes Oestogen/ progesterone receptor HER-2
Describe the ways in which breast cancer can spread.
Local: skin, pectoral muscles
Lymphatic: axillary and internal mammary nodes
Blood: bone, lungs, liver, brain
What is the best prognostic indicator in breast cancer?
Node status
What prognosis is associated with a younger age?
Poorer prognosis
What is HER 2?
A protein that helps breast cancer cells grow quickly. Higher than normal levels of HER 2 is HER 2 positive. These cancers grow and spread faster. They respond to treatment with drugs that target the HER 2 protein.
What molecular makers are used in testing breast tumours?
ER/ PR strong predictors of response to hormonal therapies
HER-2: about 20-30% positive-predicts response to trastizumab
What are the subtypes of tumour based on molecular classifiaction?
Basal-like Luminal A Luminal B HER 2 Normal/ breast like
What is paget’s disease of the nipple?
Result of intraepithelial spread of intraductal carcinoma
Large pale-staining cells within the epidermis of th enipple
Limited to the nipple or extend to the areola
Pain or itching, scaling and redness, mistaken for eczema
Ulceration, crusting and serous or blood discharge
What is gynecomastia?
Increase in subareolar tissue
No risk of malignancy
In 30-40% of adult males
What is gynecomastia associated with?
hyperthyroidism, cirrhosis of the liver, chronic
renal failure, chronic pulmonary disease, and hypogonadism, use of hormones - estrogens, androgens, and other drugs (digitalis, cimetidine, spironolactone, marihuana, and tricyclic antidepressants)
What are the presenting features of breast cancer?
Lump Mastalgia Nipple discharge Nipple changes (paget’s disease) Change in the size or shape of the breast Lymphoedema Dimpling of the breast skin
Why is mammography sensitivity reduced in younger women?
Presence of increased glandular tissue
What is meant by the sensitivity of a test?
The ability of a test to detect the disease if it is there
Describe the T staging of a breast tumour?
Tx Primary tumour cannot be assessed T0 Primary tumour not palpable T1 Clinically palpable tumour -size < 2 cm T2 Tumour size 2-5 cm T3 Tumour size > 5 cm T4a Tumour invading skin T4b Tumour invading chest wall T4c Tumour invading both T4d Inflammatory breast cancer
Describe the N staging of breast cancer.
N0 No Regional lymph nodes palpable
N1 Regional lymph node palpable- mobile
N2 Regional lymph node palpable- fixed
Describe the M staging of breast cancer.
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
What are the two main types of surgery in the treatment of breast cancer?
Breast conservation surgery
Mastectomy
What patients are suitbale for breast conservation surgery?
Tumour size clinically < 4 c m
Suitbale for chemotherapy
Single tumours
What lymph node will the tumour first spread to?
Sentinel lymph node
Biopsy to find lymphatic spread
What is done if the SLN is found to contain tumour?
Remove all nodes or give radiotherapy to all the axillary nodes
What are the complications of axilary treatment?
Lymphoedema Sensory disturbance Decrease ROM of the shoulder joint Nerve damage Vascular damage Radiation-induced sarcoma
What factors are involved with increased risk of disease recurrence?
Lymph node involvement Tumour grade Tumour size Steriod receptor status HEr2 status Lymphovascular invasion
What treatments are used as adjuvant treatments?
Radiotherapy (local)
Hormone therapy (systemic)
Chemotherapy (systemic)
Targerted therpaies (systemic)
When is hormone therapy given?
Oestrogen receptor positive tumours. Blocks stimulation of cell growth by oestrogen
What hormone therapies are used in oestrogen receptor positive tumours?
Tamoxifen
Armidex
Letrozole
Describe anti-HER2 therapy
Trastuzumab
Monoclonal antibody agaisnt HER 2 recpetor
Given to patients with over-expression of HER2 and chemptherapy
50% decrease risk of recurrence
33% increase in survival at 3 years
Where may breast cancer metastasis to?
Bone, lung, liver, brain, bone marrow, contralateral breast
