Breast Flashcards
The breast is a ______ gland
subcutaneous
Basic structure of the breast?
- Tubuloacinar glands make up lobules, many lobules make up lobes, lobes drain milk to the nipple
- Lobules are also known as terminal duct lobular units
- Lobules/ TDLUs are the basic functional secretory unit of the breast
- Lots of small ducts connect to bigger ducts, the ducts that lead directly to the nipple are called lactiferous ducts
- Lactiferous ducts lead to the nipple passing through an expanded duct region near the nipple termed the lactiferous sinus
What do suspensory ligaments do?
these extend from the dermis of the skin to the deep fascia overlying the muscle of the anterior chest wall and support the breast tissue
Describe the blood supply to the breast?
- The medial side of the breast is supplied by medial mammary arteries which are branches of the internal thoracic artery (a branch of the subclavian)
- The lateral side of the breast is supplied by lateral mammary arteries which are branches of the lateral thoracic artery (a branch of the axillary artery)
- Venous drainage corresponds to the arteries
Describe lymph drainage of the breast?
- Most lymph drains to axillary nodes (> 75%)
- The rest drains to parasternal and some to abdominal nodes
How does fibrocystic change usually present?
This presents as a lump or lumpiness of the breast in pre-menopausal women, can be painful
Microscopically and macroscopically fibrocystic change appears as ____
cysts with intervening fibrosis
Management of fibrocystic change
exclude malignancy
reassure
only excise if necessary and causing symptoms
What is the commonest benign tumour of the breast?
fibroadenoma
How does fibroadenoma usually present?
single lump that is small, firm and mobile and usually painless
It generally occurs in young women
Management of fibroadenoma?
Managed conservatively if asymptomatic, advice to regularly perform self exam, may excise if causing symptoms
How does fibroadenoma appear on ultrasound?
solid
Fibroadenoma vs fibrocystic change?
fibrocystic change is painful vs fibroadenoma which is painless, fibrocystic change is more of an irregular lumpiness but fibroadenoma is a single solid lump
What is a radial scar?
- Small (up to 1cm) firm lesion with dense fibrous core with radiating fingers of fibrosis entrapping and distorting glandular elements
- Benign but can be confused with carcinoma (even when examined histologically can be confusing!)
- in situ or invasive carcinoma may occur in these lesions
- generally dont get symptoms
Management of radial scar?
these are excised or vacuumed
What can cause fat necrosis?
local trauma e.g. seatbelt or surgery
or warfarin therapy
Fat necrosis can present as a mass _______
that mimics carcinoma
Management of fat necrosis?
- Management involves excluding malignancy and reassurance, lumps generally go away, if they become big or uncomfortable, surgery can be done
What is duct ectasia and what is it associated with?
- This is a chronic inflammatory condition associated with ectasia of ducts/ cystic dilation
- It’s associated with ageing (often women going through menopause) and smoking
Presentation of duct ectasia?
affects sub areolar ducts most often, pain, acute episodic inflammatory changes, bloody and/or purulent discharge, fistulation, nipple retraction and distortion
Management of duct ectasia?
treat acute infections, exclude malignancy, smoking cessation, if bad can do surgery to excise the ducts
2 aetiologies of acute mastitis and breast abscess?
- Duct ectasia > involves mixed organisms and anaerobes
- Lactation > staph A, strep pyogenes
Presentation of mastitis/ breast abscess ?
presents with signs of infection and a painful swollen breast
Management of mastitis/ breast abscess?
- Mastitis in women breastfeeding is generally caused by a build up of milk so should check breastfeeding technique and encourage them to keep feeding and express between feeds to reduce build up
- May give antibiotics
- If an abscess is present this needs drainage
Presentation of duct papilloma?
either picked up on breast screening or discharge from the nipple which may be blood stained
Management of duct papilloma?
- Papillomas should be surgically removed and histology examined as small risk of cancer developing
Breast cancers arise in the glandular epithelium so are ______
adenocarcinomas
Describe phyllodes tumour of the breast?
- These tumours are rare
- There is stromal overgrowth
- The cut surface look like leaves (phyllodes is Greek for leaf like)
- Occasionally the stromal component can turn sarcomatous and then this is a malignant phyllodes tumour hence they should always be exicsed
Define DCIS?
- Cells lining the ducts show cytological features of malignancy but have not yet invaded the stroma
Presentation of DCIS?
- Focal calcification allows it to be detected by mammographic screening or it may present as a palpable mass
What is LCIS (sometimes called lobular in situ neoplasia) ?
a lobular carcinoma in situ, cells not yet invaded but can progress to infiltrative carcinoma, these lesions are often multifocal and bilateral
Is LCIS pre cancer?
- It is less clear with LCIS vs DCIS whether it is pre-cancer, as some women it never progresses to cancer, however it increases your risk of breast cancer overall i.e. you have more chance of getting cancer even in the opposite breast or ductal carcinoma
What is Paget’s disease of the nipple and what is its significance?
- Paget’s disease of the nipple is characterised by inflammatory eczema like changes of the nipple that may involve the areola
- It is caused by high grade DCIS extending along ducts to reach the epidermis of the nipple
- Hence if someone presents with inflammatory changes around the nipple there could be underlying DCIS
What is the commonest form of breast cancer and how does it present?
infiltrating ductal carcinoma - presents as a firm hard lump
Only ____ % of breast cancer is Infiltrating lobular carcinoma of the breast
10
Microscopically the tumour infiltrates as a single line of malignant cells?
infiltrating lobular carcinoma
In infiltrating lobular carcinoma there is more of a chance of the _____
cancer being multifocal or bilateral
Describe metastatic spread of breast cancer?
- Initially cancers spread via lymphatics to axillary nodes
- Spread via bloodstream is most common to the bone marrow and lung
- Secondaries are common to the liver, lung and bones
Risk factors for development of breast cancer?
- Increasing Age
- Genetics: BRCA1 and 2
- Smoking
- Lack of physical activity
- Alcohol
Risk factors to do with oestrogen (anything that prolongs cyclical exposure to sex hormones increases risk):
- Early menarche and late menopause increases risk
- Breast feeding reduces risk (because it inhibits menstruation)
- Obesity increases risk as increased adipose tissue results in increased oestrogen
- Nulliparity increases risk (when you are pregnant you aren’t being exposed to cyclical oestrogen as you are not menstruating)
Presentation of breast cancer?
- 50% of women are asymptomatic and picked up on screening
- 50% are symptomatic and of the 50% that are symptomatic 50% of them have a lump
- Symptoms of breast cancer include: dimpled or depressed skin, visible lump, nipple change, bloody discharge, texture change, colour change
One stop clinic involves?
clinical exam/ assessment, imaging and pathology
Only ____ of people attending one stop clinic will have a cancer?
10%
Describe prognosis of different receptor status in breast cancer?
- ER and/or PR+, HER2- have the best prognosis
- HER2+ but ER- and PR- have a poorer prognosis
- Triple negative cancers have the worst prognosis
What 3 breast cancer pathologies are treated? What is only sometimes treated?
- Ductal carcinoma, lobular carcinoma and DCIS are treated
- In LCIS no treatment is often need
- However, if the LCIS is pleomorphic it may be treated like DCIS and removed
Overview of breast cancer treatment?
surgery - WLE or mastectomy
radiotherapy usually given as adjuvant
hormanal therapy
targeted her2
chemo for triple negative or high tumour burden
Describe use of anti-oestrogen therapy in breast cancer?
- In those with ER+ cancers this can reduce the risk of recurrence
- Pre-menopausal women should be given tamoxifen (ER receptor antagonist) for 5 years at least
- Post-menopausal women should get tamoxifen or an aromatase inhibitor e.g. letrozole for at least 5 years
- Aromatase inhibitors are thought to be better in post-menopausal women vs tamoxifen
Describe use of targeted her2 therapy in breast cancer?
- HER2 receptor blockers can be used in HER2+ cancers
- They are a type of monoclonal antibody
- E.g. trastuzumab/ Herceptin
Breast screening in scotland is done?
age 50-70 every 3 years
mammography is a form of ______
low energy xr (high energy xr would not show breast)
What two views do you get from mammography?
craniocaudal and mediolateral oblique
Women with _____ breasts are more difficult to detect abnormalities on mammogram?
denser
Mammogram has a high sensitivity for ____
detecting DCIS and invasive cancer and is only screening modality known to reduce population mortality
Why is mammography not as good in younger patients?
breast tissue tends to be denser
Indications for breast ultrasound?
- Indications for breast US include: palpable mass, work up of mammographically detected lesion, image guided biopsy, breast inflammation, breast problems in pregnancy
Pros and cons of breast ultrasound?
- This has good specificity and sensitivity for detecting invasive cancer
- Can differentiate solid from cystic
- However, has low sensitivity for DCIS
- Low specificity if used for screening
- Good for looking at particular area but to look at the whole breast tissue is time consuming
Describe MRI pros and cons?
- Most accurate method for sizing and focality assessment of breast cancer
- However, using MRI can increase mastectomy rates but not positive margins as it picks up such small tumour foci that radiotherapy would have got
Describe breast biopsy?
- FNA is not used anymore as only shows you cells so not very good
- Core biopsy is used when there is a mass
- Vacuum biopsy is used when there is no lump or calcifications are present as this allows a better chance of diagnosis
What is gynaecomastia?
- Benign enlargement of male breast tissue resulting from a relative decrease in androgen effect or increase in oestrogen effect
Causes of gynaecomastia?
- Medications
- Liver, kidney or thyroid disease
- Testicular and adrenal gland tumours
- Physiologic gynaecomastia (benign growth)
Investigations for gynaecomastia?
- In tayside first line is an ultrasound scan
- Should only image the scrotum if palpable mass present
- Should do hormone testing
- Test for liver, renal and thyroid function
- Check medications
Management of gynaecomastia?
- Change medications if the cause
- Treat any underlying disorder
- Severe acute gynaecomastia with no underlying cause should be treated with tamoxifen
When is best to do breast self exam?
menstruating women - 5-7 days after start of period
menopausal and pregnant - same day every month
Different nipple discharges and likely conditions?
yellowish/ pus > breast abscess
serous/ greenish > fibrocystic change, duct ectasia
bloody > duct papilloma
milky > galactocele
Fibroadenoma is sometimes known as a __________
breast mouse
COCP_____ breast cancer risk?
increases
Axillary node clearance for breast cancer surgery risk?
risk of lymphoedema causing functional arm impairment
Bilateral small volumes of pale or colourless discharge in adolescent most likely?
associated with hormonal changes of puberty
What is an antifungal associated with gynaecomastia?
ketoconazole
Do aromatase inhibitors increase risk of endometrial cancer?
no - only tamoxifen does
they do however cause osteoporosis
