Breast Flashcards
What muscles do the breasts lie upon
pectoralis major
serratus anterior
external oblique
Breast nerve supply
intercostal nerves from T4-T6
Breast arterial supply
internal mammary (thoracic) artery
external mammary artery (laterally)
anterior intercostal arteries
thoraco-acromial artery
Breast venous drainage
superficial venous plexus to subclavian, axillary and intercostal veins
lymphatic drainage of breasts
70% axillary nodes
internal mammary chain
other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease)
Preparation for lactation involves
Oestrogen: promotes duct development in high concentrations
progesterone: high levels stimulate formation of lobules
human placental lactogen: prepares mammary glands for lactation
Two hormones involved in stimulating lactation
prolactin: causes milk stimulation
oxytocin: causes contraction of the my-epithelial cells surrounding the mammary alveoli to result in milk ejection from the breast
What is the most common type of breast cancer
invasive ductal carcinoma
Typical changes seen in conjunction with invasive breast cancer
- Nuclear pleomorphism
- Coarse chromatin
- Angiogenesis
- Invasion of the basement membrane
- Dystrophic calcification (may be seen on mammography)
- Abnormal mitoses
- Vascular invasion
- Lymph node metastasis
What breast tumour is most commonly associated with a risk of metastasis to the contralateral breast
invasive lobular carcinoma
How does invasive lobular carcinoma of the breast present
mass is typically more diffuse than in ductal carcinoma
Less obvious on U/S and mammogram
Safest to perform an MRI (so there isn’t a risk of under-staging the lesion)
More likely to be multifocal and metastasise to the other breast
Most common causes of cancer in the UK
- Breast
- Lung
- Colorectal
- Prostate
- Bladder
- Non-Hodgkin’s lymphoma
- Melanoma
- Stomach
- Oesophagus
- Pancreas
Most common causes of death from cancer in the UK
- Lung
- Colorectal
- Breast
- Prostate
- Pancreas
- Oesophagus
- Stomach
- Bladder
- Non-Hodgkin’s lymphoma
- Ovarian
Classical demographic and presentation of primary hyperparathyroidism
elderly female with unquenchable thirst and inappropriately normal or raised parathyroid hormone level
Causes of hyperparathyroidism
80% solitary adenoma
15% hyperplasia
4% multiple adenoma
1% carcinoma
Symptomatic features of primary hyperparathyroidism
bones, stones, abdominal moans, and psychic groans
polydipsia, polyuria
depression
anorexia, nausea, constipation
peptic ulceration
pancreatitis
bone pain/fracture
renal stones
hypertension
primary hyperparathyroidism associations
hypertension
multiple endocrine neoplasia: MEN I and II
Investigations for primary hyperparathyroidism
raised calcium, low phosphate
PTH may be raised or (inappropriately, given the raised calcium) normal
technetium-MIBI subtraction scan
pepperpot skull is a characteristic X-ray finding of hyperparathyroidism
Treatment for primary hyperparathyroidism
the definitive management is total parathyroidectomy
conservative management may be offered if the calcium level is less than 0.25 mmol/L above the upper limit of normal AND the patient is > 50 years AND there is no evidence of end-organ damage
patients not suitable for surgery may be treated with cinacalcet, a calcimimetic
a calcimimetic ‘mimics’ the action of calcium on tissues by allosteric activation of the calcium-sensing receptor
Selective oEstrogen Receptor Modulators (SERM)
Example
What is it
Adverse effects
Tamoxifen
acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor-positive breast cancer.
Adverse effects
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
Aromatase inhibitors
example
what is it
adverse effects
Anastrozole and letrozole
reduces peripheral oestrogen synthesis. This is important as aromatisation accounts for the majority of oestrogen production in postmenopausal women and therefore anastrozole is used for ER +ve breast cancer in this group.
Adverse effects
osteoporosis
NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer
hot flushes
arthralgia, myalgia
insomnia
