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Breast Flashcards

1
Q

What is the breast?

A
  • present in males and females (rudimentary tissue only in males)
  • subcutaneous gland
  • (mammary gland)
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2
Q

Describe the structure of the secretory tissue of the breast

A
  • secretory tissue of the breast if made up of 15-25 lobes, each consisting of a compound tubulo-acinar gland which drains via a series of ducts leading to the nipple
  • aggregating duct system that goes into a single lactiferous duct which then proceeds to the nipple
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3
Q

What surrounds the secretory lobules?

A
  • dense fibrous tissue

- which in turn is surrounded by adipose tissue

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4
Q

Describe the basic structure of the non-lactating breast

A
  • amongst the fibrous connective tissue are some larger condensations that extend from the dermis of the skin to the deep fascia overlying the muscle of the anterior chest wall
  • forming essentially septa,
  • these are referred to as suspensory ligaments
  • often most pronounced in the upper breast and are thought to support the breast tissue
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5
Q

Name the basic functional secretory unit of the breast?

A

The terminal duct lobular unit

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6
Q

In the non-lactating breast, the terminal ductules lead where?

A
  • into an intralobular collecting duct which leads into the lactiferous duct for that lobe
  • the lactiferous duct leads to the nipple, passing through an expanded duct region near the nipple termed the lactiferous sinus
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7
Q

What is the lactiferous sinus?

A
  • expansion of the lactiferous duct

- believed to accumulate a small amount of milk for immediate release when baby latches

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8
Q

Name features of the lobule

A
  • both extralobular and intralobular ducts
  • rudimentary secretory acini
  • dense fibrocollagenous connective tissue surrounding the lobule
  • looser connective tissue surrounding the acini within the lobule (this allows rapid expansion in pregnancy)
  • adipose tissue between lobules
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9
Q

Describe the histology of the lobule

A
  • within the lobule the secretory epithelial cells line the acini and vary from cuboidal to columnar
  • the secretory cells of the acinus are surrounded by myoepithelial cells (MEp)
  • these are contractile epithelial cells which is turn are surrounded by the basal lamina
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10
Q

Describe the histology of ducts

A
  • larger ducts, such as a lactiferous duct are lined by an epithelium that varies from a thin stratified squamous to stratified cuboidal
  • myoepithelial cells are present
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11
Q

What is the nipple formed of?

A
  • the nipple has a wrinkled surface and is covered by a thin, highly pigmented keratinised stratified squamous epithelium
  • it has a core of dense irregular connective tissue mixed with bundles of smooth muscle
  • smooth muscle presses on ducts to help deliver milk and plays a role in erectile function
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12
Q

Describe the structure of the nipple

A
  • several lactiferous ducts
    (at apex of the nipple), each will serve one lobe of the breast
  • as the duct approaches the surface it becomes lined by stratified squamous epithelium, deeper it is lined by stratified cuboidal epithelium
  • sebaceous glands are present and these open directly onto the surface of the skin
  • secrete via holocrine secretion
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13
Q

Describe the changes to the mammary gland during the menstrual cycle

A

During the luteal phase the epithelial cells increase in height, the lamina of the ducts become enlarged and small amounts of secretions appear in the ducts

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14
Q

Describe the changes to the mammary gland in pregnancy

A
  • in the first trimester there is elongation and branching of the smaller ducts, combined with proliferation of the epithelial cells of the glands and the myoepithelial cells
  • in the second trimester glandular tissue continues to develop with differentiation of secretory alveoli. also, plasma cells and lymphocytes infiltrate the nearby connective tissue
  • in the third trimester secretory alveoli continue to mature, with development of extensive rough endoplasmic reticulum
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15
Q

What drives the mammary gland changes in pregnancy?

A

Oestrogen and progesterone

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16
Q

What is the composition of human milk?

A
  • 88% water
  • 1.5% protein (mainly lactalbumin and casein)
  • 7% carbohydrate (mainly lactose)
  • 3.5% lipid
  • with small quantities of; ions, vitamins and IgA antibodies
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17
Q

How are the different components of milk secreted?

A
  • lipid droplets are secreted surrounded by membrane and carrying a small amount of cytoplasm with it (apocrine secretion)
  • proteins in milk are made in the rR, packaged in the golgi apparatus and secreted via vesicles which merge with the apical membrane to release only their contents into the duct system (merocrine / exocytosis)
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18
Q

Describe the changes in the mammary gland following menopause

A
  • the secretory cells of the TDLUs degenerate leaving only ducts
  • in the connective tissue, there are fewer fibroblasts and reduced collagen and elastic fibres
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19
Q

Describe the blood supply to the breast

A
  • lateral mammary branches from lateral thoracic artery
  • medial mammary branched form internal thoracic artery
  • venous drainage by medial and lateral mammary veins
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20
Q

Describe the lymphatics of the breast

A
  • most lymph (>75%) to axillary nodes
  • remainder to parasternal nodes (some may also drain to abdominal nodes)
  • subareolar lymphatic plexus
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21
Q

Describe the assessment of a patient with breast disease

A
  • triple assessment
  • clinical; history and examination
  • imaging; mammography, ultrasound, MRI
  • pathology; cytopathology, histopathology
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22
Q

Describe the result classifications for breast FNA cytology

A 
C1 - unsatisfactory 
C2 - benign 
C3 - atypia, probably benign 
C4 - suspicious of malignancy 
C5 - malignant
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23
Q

Name diagnostic tests for breast histopathology

A
  • needle core biopsy
  • vacuum assisted biopsy (large volume)
  • skin biopsy
  • incisional biopsy of mass
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24
Q

Name therapeutic interventions in breast histopathology

A
  • vacuum assisted excision
  • excisional biopsy of cancer
  • resection of cancer; wide local excision, mastectomy
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25
Q

Describe the result classification for needle core biopsy

A 
B1 - unsatisfactory / normal 
B2 - benign 
B3 - atypia, probably benign 
B4 - suspicious of malignancy 
B5 - malignant 
B5a - carcinoma in situ 
B5b - invasive carcinoma
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26
Q

Name developmental anomalies of the breast (benign breast disease)

A
  • hypoplasia
  • juvenile hypertrophy
  • accessory breast tissue
  • accessory nipple (tends to be present on the milk line)
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27
Q

Name non-neoplastic benign breast conditions

A
  • gynaecomastia
  • fibrocystic change
  • hamartoma
  • fibroadenoma
  • sclerosing lesions; sclerosing adenosis, radial scar / complex sclerosing lesions
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28
Q

Name inflammatory benign breast conditions

A
  • fat necrosis
  • duct ectasia
  • acute mastitis / abscess
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29
Q

Name tumours of benign breast disease

A
  • phyllodes tumour

- intraduct papilloma

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30
Q

What is gynaecomastia?

A
  • breast development in the male

- ductal growth without lobular development

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31
Q

Name causes of gynaeocmastia

A
  • exogenous / endogenous hormones
  • cannabis
  • prescription drugs
  • liver disease
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32
Q

Describe the epidemiology of fibrocystic change

A
  • women aged 20-50 (majority 40-50)
  • very common
  • menstrual abnormalities
  • early menarche
  • late menopause
  • often resolve or diminish after menopause
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33
Q

Describe the presentation of fibrocystic change

A
  • smooth discrete lumps
  • sudden pain
  • cyclical pain
  • lumpiness
  • incidental finding
  • screening
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34
Q

Describe the pathology of fibrocystic change

A

Gross pathology;
- cysts; 1mm-several cm, blue domed with pale fluid, usually multiple, associated with other benign changes
- intervening fibrosis
Microscopic pathology;
- cysts; thin walled but may have fibrotic wall, lined by apocrine epithelium
- intervening fibrosis

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35
Q

Describe management of fibrocystic change

A
  • exclude malignancy
  • reassure
  • excise if necessary
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36
Q

What is a hamartoma?

A

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution

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37
Q

Describe the epidemiology of fibroadenomas

A
  • common
  • usually solitary (10% multiple)
  • commoner in African women
  • peak incidence in 3rd decade
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38
Q

Describe the clinical features of fibroadenomas

A
  • painless, firm, discrete, mobile mass
  • ‘breast mouse’
  • solid on ultrasound
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39
Q

Describe the pathology of fibroadenomas

A
  • circumscribed
  • rubbery
  • grey white colour
  • biphasic tumour / lesion’ epithelium, stroma
  • localised hyperplasia
  • proliferation of intralobular stroma
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40
Q

Describe the treatment of fibroadenomas

A
  • diagnose
  • reassure
  • excise
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41
Q

What are the two forms of sclerosing lesions?

A
  • sclerosing adenosis

- radial scar / complex sclerosing lesion

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42
Q

What are sclerosing lesions?

A
  • benign, disorderly proliferation of acini and stroma
  • can cause a mass or calcification
  • may mimic carcinoma
43
Q

Describe the features of sclerosing adenosis

A
  • pain. tenderness or lumpiness / thickening
  • asymptomatic
  • age 20-70
  • benign
  • negligible risk of subsequent carcinoma
  • often seen with other changes in the breast
44
Q

Describe the epidemiology of radial scars

A
  • wide age range
  • common; 67% multicentric, 43% bilateral
  • incidental finding
  • mammographically detected
45
Q

Describe the pathology of radial scars

A
  • 1-9mm
  • stellate architecture
  • central puckering
  • radiating fibrosis
  • fibroelastic core
  • radiating fibrosis containing distorted ductules
  • fibrocystic change
  • epithelial proliferation

Note; complex sclerosing lesion >10mm

46
Q

Describe the treatment of radial scar

A
  • mimic carcinoma radiologically
  • in situ or invasive carcinoma may occur within these lesions
  • excise or sample extensively by vacuum biopsy
47
Q

How can fat necrosis occur?

A
  • local trauma; seat belt injury
  • frequently no history
  • warfarin therapy
48
Q

Describe pathophysiology of fat necrosis

A
  • damage and disruption of adipocytes
  • infiltration by acute inflammatory cells
  • ‘foamy’ macrophages
  • leakage of fat into tissue
  • subsequent fibrosis and scarring
49
Q

Describe management of fat necrosis

A
  • confirm diagnosis

- exclude malignancy

50
Q

Describe clinical features of duct ectasia

A
  • affects sub-areolar ducts
  • pain
  • acute episodic inflammatory changes
  • bloody and or purulent discharge
  • fistulation
  • nipple retraction and distortion
51
Q

What can duct ectasia go on to cause?

A
  • sub-areolar duct dilatation
  • periductal inflammation
  • periductal fibrosis
  • scarring and distortion
52
Q

Describe management of duct ectasia

A
  • treat acute infections
  • exclude malignancy
  • stop smoking
  • excise ducts
53
Q

What are the two main aetiologies for acute mastitis / asbcess?

A
  • duct ectasia; mixed organisms, anaerobes

- lactation; staph aureus, strep pyogenes

54
Q

Describe management of acute mastitis / abscess

A
  • antibiotics
  • percutaneous drainage
  • incision and drainage
  • treat underlying cause
55
Q

What is a phyllodes tumour?

A
  • age 40-50

- slow growing unilateral breast mass

56
Q

Describe pathology of phyllodes tumour

A
  • cystosarcoma phyllodes
  • biphasic tumour
  • stromal overgrowth
  • behaviour depends on stromal features; benign, borderline, malignant (sarcomatous)
57
Q

Name the different forms of papillary lesions

A
  • intraduct papilloma
  • nipple adenoma
  • encapsulated papillary carcinoma
58
Q

Describe the clinical features of intraduct papilloma

A
  • age 35-60
  • nipple discharge +/- blood
  • asymptomatic at screening; nodules, calcification
59
Q

Describe the pathology of intraduct papilloma

A
  • sub-areolar ducts
  • 2-20mm diameter
  • papillary fronds containing a fibrovascular core
  • covered by myoepithelium and epithelium
  • epithelium may show proliferative activity (usual type hyperplasia, atypical ductal hyperplasia, ductal carcinoma in situ)
60
Q

When do angiosarcomas arise?

A

Post radiotherapy

61
Q

What tumours can metastasise to the breast?

A
  • carcinoma; bronchial, ovarian serous or clear cell of the kidney
  • malignant melanoma
  • soft tissue tumours; leiomyosarcoma
62
Q

Where does breast carcinoma arise?

A

In the glandular epithelium of the terminal duct lobular unit (TDLU)

63
Q

Name precursor lesions of breast carcinoma

A 
Ductal; 
- epithelial hyperplasia of usual type 
- columnar cell change (+/- atypia) 
- atypical ductal hyperplasia (ADH) 
- ductal carcinoma in situ (DCIS) 
Lobular; 
- lobular in situ neoplasia 
- atypical lobular hyperplasia (ALH) 
- lobular carcinoma in situ (LCIS)
64
Q

Describe in situ carcinoma

A
  • confined within basement membrane of acini and ducts
  • cytologically malignant but non-invasive
  • non-obligate precursor of invasive carcinoma
  • classification; lobular, ductal
65
Q

What are the two forms of lobular in situ neoplasia?

A
  • atypical lobular hyperplasia, <50% of lobule involved

- lobular carcinoma in situ (LCIS), >50% of lobule involved

66
Q

Describe the pathology of lobular in situ neoplasia

A
  • intra lobular proliferation of characteristic cells
  • small intermediate sized nuclei
  • solid proliferation
  • intra-cytoplasmic lumens / vacuoles
  • ER positive
  • E-cadherin negative (deletion and mutation of CDH1 gene on Chr 16q22.1)
67
Q

Describe the clinical features of lobular in situ neoplasia

A
  • frequently multifocal and bilateral
  • incidence 0.5-4% in benign biopsies
  • incidence decreases after menopause
  • not palpable, not visible grossly
  • may calcify; mammography
  • usually an incidental finding
68
Q

Describe the management of lobular in situ neoplasia

A
  • L(is)N discovered on core biopsy; proceed to excision or vacuum biopsy to exclude higher grade lesion
  • L(is)N discovered on vacuum or excision biopsy; follow up, clinical trials
69
Q

What are the forms of intraductal proliferation?

A
  • epithelial hyperplasia of usual type
  • columnar cell change (lesion)
  • columnar cell change with atypia
  • atypical ductal hyperplasia
  • ductal carcinoma in situ
70
Q

Describe the clinical features of ductal carcinoma in situ

A
  • 15-20% of breast malignancies are DCIS
  • arises in TDLU
  • characteristically unicentric (single duct system)
71
Q

Describe the pathology of ductal carcinoma in situ

A
  • cytologically malignant epithelial cells
  • confined within basement membrane of duct
  • may involve lobules (cancerisation)
  • may involve nipple skin (pagets)
72
Q

Describe pagets disease of the nipple

A
  • high grade DCIS extending along ducts to reach the epidermis of the nipple
  • still in situ carcinoma (i.e. non-invasive)
73
Q

Describe management of ductal carcinoma in situ

A
  • diagnosis
  • surgery; trials of mammographic follow up in low risk DCIS
  • adjuvant radiotherapy
  • chemoprevention; endocrine therapy
74
Q

Describe microinvasive carcinoma

A
  • rare
  • DCIS (high grade) with invasion <1mm
  • treat as high grade DCIS
75
Q

What is invasive breast carcinoma?

A
  • malignant epithelial cells which have breached the BM
  • infiltration of normal tissues
  • risk of metastasis and death
76
Q

Name risk factors for breast carcinoma

A
  • age
  • age at menarche
  • age at first birth
  • parity
  • breastfeeding
  • age at menopause
  • hormones; endogenous, exogenous (OCP, HRT)
  • previous breast disease
  • high BMI
  • alcohol consumption
  • high fat intake
  • smoking
  • genetics
77
Q

Name cancer syndromes associated with breast cancer

A
  • BRCA1
  • BRCA2
  • li fraumeni syndrome (TP53)
  • PTEN cowdens syndrome
  • peutx-jeghers syndrome
  • ataxia telangiectasia
78
Q

Describe the histopathological classification of invasive breast carcinoma

A
  • ductal 70%
  • lobular 10%
  • mucinous 2%
  • medullary 3%
  • tubular 2%
  • cribiform 1%
  • papillary <1%
  • mixed 10%
79
Q

What are the hormone receptors associated with invasive breast carcinoma?

A
  • 80% ER positive
  • 67% PgR positive
  • 14% HER2 positive
80
Q

HER2 overexpression and amplification predicts the response to which drug?

A

trastuxamab (herceptin), human mouse monoclonal antibody

81
Q

Name imaging techniques used in breast radiology

A

Standard techniques;
-mammography, ultrasound
Advanced techniques;
- mammographic; tomosynthesis, contrast enhanced spectral mammography
- ultrasound; elastrography, contrast enhanced US, automated breast ultrasound
- MRI

82
Q

Name different forms of benign micro-calcification

A
  • vascular calcification
  • oil cyst ‘eggshell’ calcification
  • plasma cell mastitis; long, bilateral, pointing to nipple, rod shaped coarse
  • dystrophic calcification in scar
83
Q

Describe the radiological appearance of ductal carcinoma in situ

A
  • shape; linear or branching
  • distribution; cluster or segmental
  • pleomorphic (varying) size and density
84
Q

Name indications for mammography

A
  • screening (50-70yrs)
  • higher risk screening >40 years
  • symptomatic assessment >40 years
  • monitoring response to systemic treatment; NACT
  • follow up after cancer treatment
  • image guided (stereotactic) techniques, biopsy / VAE, localisation
85
Q

Describe the appearance of benign masses on ultrasound

A
  • ‘wide’
  • well defined
  • anechoic (black)
  • hyperechoic
86
Q

Describe the appearance of malignant masses on ultrasound

A
  • ‘tall’
  • ill defined
  • hyperechoic and heterogeneous (dark/ mixed)
87
Q

What is tomosynthesis?

A
  • ‘3D’ technique
  • images taken at different angles in an arc
  • reconstruction into multiple slices; removes overlap, shows margins better
88
Q

Name indications for tomosynthesis

A
  • assessment of mammographic abnormalities

- screening; may increase sensitivity in denser breasts (not very dense)

89
Q

What is contrast enhanced spectral mammography?

A
  • mammogram technique
  • IV contrast agent (same as for CT)
  • two clinical images for each breast view
  • low energy image; equivalent to a standard mammogram
  • subtracted image; enhancing lesions only, cancer have increased vascularity so enhance
90
Q

What is elastography?

A
  • a measure of tissue ‘stiffness’

- cancer tends to be stiffer than normal breast tissue / benign lesion

91
Q

Describe strain elastography

A
  • produced by palpation with ultrasound probe
  • colour map of stiffness superimposed on grey scale image
  • area of stiffness often bigger than greyscale abnormality
92
Q

Describe shear wave elastography

A
  • strain produced by the ultrasound probe (shear wave)

- ultrafast sequence catches in real time the propagation of shear waves

93
Q

Name indications for shear wave elastography

A
  • adjuvant to grey scale ultrasound
  • diagnosis of fibroadenomas (24-40 years)
  • monitoring of treatment response
94
Q

Describe malignant features on contrast-enhanced ultrasound

A
  • hyper-enhancement with enlarged range / irregular margin
  • hyper centri-petal enhancement with persfusion defect
  • rapid / iso-enhancement with penetrating vessels
95
Q

Name red flag symptoms for breast cancer

A
  • solitary breast lump
  • altered shape or contour or skin change
  • breast lumpiness or nodularity
  • breast pain
  • non blood stained nipple discharge
96
Q

Describe the neoadjuvant treatment that can be used to achieve breast conservation

A
  • chemotherapy (standard FEC and taxane) +/- herceptin
  • endocrine; aromatase inhibitors more effective than tamoxifen, so usually reserved for postmenopausal women
  • both methods shown to reduce mastectomy rates
97
Q

What are the types of breast surgery?

A
  • breast conservation; wide local excision, image guided local excision, oncoplastic breast conservation including therapeutic mammopladty
  • mastectomy; traditional transverse, skin sparing with immediate reconstruction
98
Q

Describe the reconstruction options for mastectomy

A
  • external prosthesis
  • implant only (+/- autologous cellular matrix)
  • latissimus dorsi pedicled flap +/- implant
  • deep inferior epigastric artery perforator free flap
  • inferior gluteal artery perforator free flap
  • superior gluteal artery perforator
  • transverse upper gracilis free flap
  • profunda artery perforator free flap
99
Q

Name genomic tests used for staging cancer

A
  • mammaprint test; analyses the activity of certain genes in early bc
  • breast cancer index test; used to predict risk of node negative, hormone receptor positive breast cancer combing back in 5-10 years
  • endopredict test; used to predict risk of distant recurrence
  • mammostrat; predict risk of recurrence
  • oncotype DX; how likely the benefit of chemo / radio
100
Q

Name acute side effects of chemotherapy

A
  • fatigue
  • myelosuppression and risk of infection, anaemia, thrombocytopenia
  • nausea / vomiting
  • alopecia
  • mucositis
  • diarrhoea
  • constipation
  • renal probloems
  • neurotoxicity
  • infertility
101
Q

Name late side effects of chemotherapy

A
  • cardiac
  • infertility; premature menopause
  • neuropathy
  • renal impairment
  • osteoporosis
  • carcinogenesis
102
Q

Describe the neo-adjuvant endocrine therapies

A

Pre or perimenopausal
- tamoxifen 20mg daily for up to 12 months +/- goserelin 3.6 mg by monthly subcutaneous implant
- letrozole 2.5mg daily for up to 12 months + goserelin 3.6mg by monthly s/c injectio
Post menopausal
- letrozole 2.5mg daily for up to 12 months

103
Q

Adjuvant bisphosphonates are used whe?

A
  • for women with a diagnosis of early invasive breast cancer who are;
  • post menopausal and considered of sufficient clinical risk for treatment with an adjuvant AI or HER2 positive or ER low /negative or
  • pre menopausal with ovarian suppression

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