BREAST Flashcards
DESRIBE THE ANATOMY OF THE BREAST
Breast tissue is a modified sweat gland found in the superficial fascia of the anterior chest wall derived from
ectoderm, as branching epithelial cords
Vertically extends from 2nd to 6th rib in mid clavicular line and lies over pectoralis major, serratus anterior
and external oblique muscles
Horizontally from the sternum to mid axillary line. Lower medial quadrant gland
rests on external oblique aponeurosis, which separates it from rectus abdominis.
2
/3 lie on Pectoralis major, 1/3 on Serratus anterior
Outer part has prolongation into the the axilla called Axillary tail of Spence
It gets into the axilla though an opening in deep fascia = Foramen of Langer
Retromammary bursa/space is between deep layer of superficial fascia and
pectoral (deep) fascia allowing free mobility of breast.
Nipple is at level of 4th ICS just below centre/summit of breast, has circular and longitudinal muscles to
make nipple stiff or flat and is pierced by 15–20 lactiferous ducts. It’s supplied by 4
th intercostal nerve
Breast is anchored to overlying skin and to underlying pectoral fascia by bands of connective tissue called
ligament of Cooper (when these are affected by Ca they cause breast skin dimpling or growth attachment to
the skin or fix the breast to the pectoralis major by binding the breast to the pectoral fascia)
DESCRIBE THE HISTOLOGY OF THE BREAST
Bulk of breast is adipose tissue and ducts only contribute 10%
Breast parenchyma contains 15–20 lobes.
Each lobe has alveoli, lactiferous sinus and lactiferous duct (2–4
mm in diameter).
Alveolus is lined by cuboidal (in rest) and columnar (in lactation)
epithelium; smaller duct is by single layer of columnar epithelium;
larger ducts by many layered columnar; lactiferous duct is by
stratified squamous epithelium.
Alveoli →Lobules →Lobes
Three types of tissue: glandular epithelium, fibrous stroma with supporting structures and fat
Myoepithelial cells lie between epithelium and basement membrane from alveoli to duct
Areola skin is thin stratified squamous with sebaceous glands of Montgomery
Areola is circular pigmented area around nipple, rich in modified sebaceous glands, enlarge during preg
and lactation as Montgomery tubercles and secrete oily lubricant.
Contains more melanin and has sensory nerve ending
OUTLINE THE INNERVATION OF THE BREAST
Nerves-related (During MRM)
Long thoracic nerve - Bell supplies serratus anterior.
Thoracodorsal nerve supplies latissimus dorsi.
Medial pectoral nerve (from medial cord of brachial plexus) which
lies lateral, runs & winds from lateral margin of pectoralis minor.
Lateral pectoral nerve arises from lateral cord passes through pectori either middle or medial part
Nerve supply of breast is by anterior and lateral cutaneous branches of 4th to 6th intercostal nerves
OUTLINE THE BLOOD SUPPLY OF THE BREAST
Lateral thoracic artery (external mammary
artery) a branch of the 2nd part of the axillary
artery- 30%
Perforating cutaneous branches of the Internal
thoracic (mammary) artery to the 2nd 3rd and
4th costal spaces- 60%
Pectoral branch of the thoracoacromial artery
Lateral branch to the 2nd, 3rd and 4th intercostal arteries
Superior thoracic artery.
OULINE THE VENOUS DRAINAGE OF THE BREAST
external mammary vein a tributary of axillary vein
internal thoracic vein a tributary of the brachicephalic vein
intercostal veins which drain into the azygous vein
Forms a plexus around the nipple= Sappey’ s plexus
Also there is communication with the vertebral plexus of Batson through posterior intercostal veins
OUTLINE THE LYMPHATIC DRAINAGE OF THE BREAST
80% by the axillary group of lymph nodes (40-50 nodes)
Clinically :apical, lateral, anterior, posterior and medial
Apical nodes aka subclavicular or Halsted nodes
Anatomically : anterior(pectoral), lateral (humeral), posterior (subscapular),
apical, central (medial) and interpectoral node (Rotter’ s)
Interpectoral node (Rotter’s node)-signifies retrograde spread of tumour. It
lies betwn pectoralis major and minor
Minimal drainage to the internal mammary chain ( parasternal)
DESCRIBE THE LEVELS OF BREAST LYMPH NODES
There are three levels of Lymph nodes: level I below Pect. Minor, II behind and III above
Levels of the axillary nodes (Berg’s levels)
1. Level I: Below and lateral to the pectoralis
minor muscle—anterior, lateral, posterior
2. Level II: Behind the pectoralis minor muscle-
central, interpectoral
3. Level III: Above and medial to pectoralis -
minor muscle-apical or infraclavicular
HOW DO YOU TAKE HX FOR A BREAST LUMP?
Hx taking
(a) Demographic Hx
(b) PC
(c) Hx of PC of a lump/ ulcer
- When it was 1st noticed?
- What brought it to the patient’s notice?
- What symptoms does it cause e.g. pain, nipple discharge? - Has it
changed? How much has it changed since it was 1st noticed?
- Has it ever disappeared or healed
- Does the patient have any other lumps/ulcers?
- What does the patient think caused it?
LIST THE PRESDISPOSING FACTORS FOR THE APPEARANCE OF A BREAST LUMP
Predisposing factors
1) Age of the patient
2) Parity- Nulliparity is a risk
3) Did she breast feed all children and for how long?
4) When was the last time to breast feed?
5) At what age did she have her 1st pregnancy or 1st child?
6) Age at menarche? Early menarche is a risk
7) Pre or post menopause- late menopause is a risk
8) If premenopausal- what is the menstrual pattern (regularity,
duration, quantity).
9) What breast symptoms after the menstrual cycle
10) Medication i.e. HRT (Hormonal replacement therapy), Radiation, Combined oral contraceptive
11) Hx of alcohol or smoking
12) Family Hx- in 1st degree relative
13) Diet- obesity/ increased BMI
(d) Medical Hx- BRCA1/BRCA2 gene mutation
-Hx breast ca- in contralateral breast
-Hx ca colon
-Hx ca ovary
-Hx radiation exposure
WHAT ARE THE METASTATIC SYMPTOMS OF A BREAST LUMP
-Back pain (bone metastasis esp. to lumbar spine)
-Dyspnea (lung metastasis)
-Jaundice or Abdominal distension (liver metastasis)
-Hard nodules on skin (MSS metastasis)
-Swelling of arm (s) (axillary lymphadenopathy)
OUTLINE THE EXAMINATION THE BREAST
Inspection
-Symmetry
-Site- position of lump
-Skin – color discoloration
-Puckering
-Peau de orange
-Ulceration
-Nipple discharge and appearance
-Edgar- Montgomery tubercle
-Calor
-Oedema
Ask patient to hold the waist
-Gross lumps
-Phyllodes
-Distended veins
Ask pt. to raise hands
-Look for skin tethering and nipple retraction
Palpation
-Flat of finger
-Begin with normal side
-Palpate for
i. Tenderness
ii. Temperature
If there is a lump or mass; check
-Site
-Size
-Shape
-Consistence
-Is it fixed or free mobile
-Palpate axillary lymph nodes and or supraclavicular
Ask if they have a lump anywhere also
General examination
-Arms for swelling
-P/A – -Hepatomegaly
-Ascites
-Nodules in pouch of Douglas
-Lumbar spine- hit back for tenderness and restricted movement
WHAT ARE THE Ds TO KEEP IN MIND WHEN INSPECTING THE NIPPLE?
Nipple (7 D‘s)
-Depression
-Discharge
-Discoloration
-Duplication
-Destroyed
-Deviated
-DisplacemenT
WHAT EXAMINATION FINDINGS SUGGEST BREAST CA?
-Hard, non-tender, irregular lump in LOQ
-Tethering/fixation of the lump
-Palpable axillary LN‘s
OUTLINE HOW BREAST DISEASE PRESENTS
a) Painless lump
b) Carcinoma
c) Cyst
d) Fat necrosis
e) Fibroadenoma
f) An area of Fibroadenosis
g) Lipoma of breast (intra-ductal papilloma)
h) Phylloides tumor (Brodie tumor) -
WHAT IS A PHYLLOIDES TUMOR?
Phylloides tumor (Brodie tumor) - Phyllodes tumors (from Greek:
phullon leaf), also cystosarcoma phylloides and phylloides tumor, are
typically large, fast-growing masses that form from the periductal stromal
cells of the breast. They account for less than 1% of all breast neoplasms.
They show a wide spectrum of activity, varying from almost a benign condition (85%) to a locally
aggressive and sometimes metastatic tumour. Depending on mitotic index and degree of pleomorphism they
are graded as low grade to high grade tumours (15%)
BREAST PAINFUL LUMP DDX
a) An area of Fibroadenosiso Cyst
b) Periductal mastitis
c) Abscess (usually postpartum or Lactational)
d) Carcinoma (sometimes)
DDX OF PAINFUL AND TENDER BREAST BUT NO LUMP
a) Cyclic breast pain
b) Non-cyclical breast pain
c) Carcinoma (very rare)
WHAT IS THE DDX OF NIPPLE DISCHARGE?
a) Duct ectasia- mammary duct ectasia is a condition which occurs when lactiferous duct beneath the nipple
dilates, with thickening of its walls & become filled up with fluid. Most common cause of greenish discharge
b) Intraductal papilloma
c) Ductal cis
d) Associated with a cyst
CHANGES IN THE NIPPLE OR AREOLAR DDX
a) Ductal ectasia
b) Carcinoma
c) Paget‘s disease
d) Eczema
WHAT IS THE DDX OF CHANGES IN BREAST SIZE OR SHAPE?
a) Pregnancy
b) Carcinoma
c) Benign hypertrophy
d) Rare large tumours
BRIEFLY DESCRIBE THE PATHOLOGY OF BREAST CA
Pathology
a) Breast carcinoma arising from lactiferous ducts is called as ductal
carcinoma.
b) Those arising from lobules is called as lobular carcinoma. It is 10%
common
DDX OF BREAST CA
It may be:
a) Ductal in situ carcinoma (Ductal Carcinoma in Situ, DCIS) or
b) Lobular in situ carcinoma (Lobular Carcinoma in Situ, LCIS).
COMPARE AND CONTRAST INVASIVE AND NON-INVASIVE CA
Non invasive
- Ductal Carcinoma in situ
* Commoner than LCIS
* Has not breached the basement membrane
* Premalignant lesion
* >50 years
* Types: solid, cribriform, papillary, comedo (worse)
- Lobular carcinoma in situ
* Not premalignant
* Can be bilateral
* Can be missed on mammography
Invasive
-Ductal
1. Non specific type (80%)
2. Medullary (soft, younger age, favourable prog) 3-5%
3. Papillary
4. Mucinous/colloid (1-2%)
5. Scirrhotic (worst prog)
Lobular (5-10%)
* 30-40% bilateral
* Signet ring cells-pattern of adenocarcinoma in which cells are filled with mucin vacuoles that push nucleus to one side,
DESCRIBE PAGET’S DISEASE OF THE NIPPLE
1) Paget’s disease of the nipple
- Accounts for 1-3% of all breast malignancy
- Usually associated with DCIS or invasion
- Initially presents with erythema or mild eczema
- Rapid or lethal malignancy
- Treat with mastectomy
DESCRIBE INFLAMMATORY CA OF THE BREAST
2) Inflammatory ca of the breast/ inflammatory carcinoma/Lactating carcinoma/Mastitis carcinomatosis:
- Accounts for 1-4% of all breast malignancies
- Can affect pregnant and lactating women
- Associated with erythema, peau d’ orange
- Most rapid and lethal- Most aggressive type of carcinoma breast.
- Clinically, it is a rapidly progressive tumour of short duration, diffuse, painful, warm often involving
whole of breast tissue with occurrence of peau d’ orange, often extending to the skin of chest wall also.
- Axillary spread always present
- Metastasis in 17-30% at time of presentation
- Mimics acute mastitis because of its short
duration, pain, warmth and tenderness
DESCRIBE THE PRESENTATIONS OF BREAST CA
Presentation of breast cancer
1. Lump
- Commonest presentation
- Usually painless
- 50% in upper outer quadrant
- +/- involvement of axillary nodes
- Skin changes
- Skin dimpling
- Peau d’ orange
- Eczema (Pagets)
- Cancer-en-cuirasse: Skin over the chest wall and breast is
studded with cancer nodules appearing like an armour coat - Nipple Nipple discharge is second common feature
-Ulceration and fungation
- Inversion
- Destruction
- Discharge - Metastatic features
- SOB, bone pain
- Axillary lymph node enlargement; supraclavicular lymph node enlargement
-Chest pain and haemoptysis
-Bone pain, tenderness, and pathological #
-Pleural effusion, ascites
-Liver secondaries (yellowing of eyes), secondary ovarian tumour
-Pain in the lump in 10% cases
- Pathological fractures
- Abdominal pains, / weight loss
- Seizures
HOW IS BREAST CA STAGED?
Manchester staging (outdated)
International TNM staging
OUTLINE THE MANCHESTER STAGING OF BREAST CA
Manchester staging (outdated)
Stage1: A mobile lump in the breast
-No palpable axillary nodes
-No tethering or fixation
Stage 2: A mobile lump in the breast
-Palpable mobile axillary nodes
-Tethering & fixation
Stages 3: A fixed lump in the breast
-Palpable axillary LN
-Fixed & tethering
Stage 4: Distant metastases
-Fixed axillary nodes
-Palpable supraclavicular node
-Skin and chest wall fixation of lump
-Involvement of contralateral lymph nodes
OUTLINE THE INTERNATIONAL TNM STAGING OF BREAST CA
Tumor
T0:- No palpable tumor
Tis: - Tumor in situ
T1:- Tumor 2cm, not fixed /tethering
T2:- Tumor, 2 - 5 cm, nipple retraction or tethering
T3:- 5cm (5-10cm) infiltration or ulceration
T4:- Any size invading skin or chest wall (10cm),
Ulceration greater than the distance of the lump
NODE
- No: - No palpable ALN‘s
- N1:- Mobile palpable ALN‘s
- N2:- Fixed palpable ALN
- N3:- Palpable supraclavicular LNs
Distant Metastasis
Mo: - No distant metastasis
M1:- Metastasis present
HOW DOES WHO CLASSIFY BREAST CA?
1) Epithelial
2) Invasive or Non-invasive
3) Ductal or Lobular
4) Mixed
WHAT IS THE NOTTINGHAM PROGNOSTIC INDEX?
Predicts survival and risk of relapse
* Guides appropriate adjuvant systemic therapy
* (0.2 x tumour size) + histo grade + nodal status
Nodal status ( single most prognostic factor)
* N1: no nodes involved
* N2: 1-3 nodes; N3: 4 and above nodes
Histo grade: Bloom-Richardson system (1-3)
Based on nuclear pleomorphism; tubule formation; mitotic rate
* Grade 1: well differentiated (better prognosis)
* Grade 2: Moderately differentiated
* Grade 3: Poorly differentiated (worse prognosis)
LIST AND EXPLAIN THE MODES OF BREAST CANCER METASTASIS
- Direct spread - Surrounding structures- pectoralis major muscle, latissimus
dorsi muscle, serratus anterior and into the chest wall - Lymphatic – via Subareolar Sappey’s lymphatic plexus, cutaneous and
intramammary lymphatics. Lymph nodes- lungs,
From axillary lymph nodes spread occurs to supraclavicular lymph nodes
by lymphatic embolization
Through dermal lymphatics, it may spread to opposite breast or to
opposite axillary lymph nodes.
Spread may occur into internal mammary lymph nodes of same side and then to mediastinal lymph nodes.
Contralateral internal mammary lymph nodes can also get involved by retrograde spread.
Fixed enlarged axillary nodes can cause lymphoedema due to lymphatic block; venous thrombosis & venous
oedema due to venous block; and severe excruciating pain along distribution of median and ulnar nerves - Hematogenous - Valveles nalves of Batson to the spine and brain. Bone (most common) (70%)
Lumbar vertebrae, femur, ends of long bones, thoracic vertebrae, ribs, skull, in order.
They are osteolytic lesion often with pathological fracture.
Presents with painful, tender, hard, nonmobile swelling,
with disability.
OUTLINE THE TRIPLE ASSESSMENT OF THE BREAST
a. Clinical – Hx + exam
b. Diagnostic imaging by Mammogram (>35) or U/S <35, bone scan, X-Ray for metastasis –brain, chest, bones
Solid + cysts
Mammography finding in Malignancy
Irregularly marginated stellate or spiculated
Architectural distortion with retraction and speculation
Asymmetrical localized fibrosis
Fine pleomorphic microcalcifications
Increased vascularity
Altered subareolar duct pattern
Unclear border with the rest of breast tissue- -Soft tissue shadow is irregular
c. Histology/Cytology
- FNA for cytology
- Core needle biopsy for histology is standard
- Incisional biopsy
- Excisional biopsy
WHAT ARE THE INDICATIONS FOR BREAST CONSERVING SURGERY?
INDICATION FOR BREAST
CONSERVING SURGERY
a) Single clinical and mammographic lesion
b) Tumour 4 cm in diameter
c) No sign of local advancement (T1, T2 4 cm),
extensive nodal involvement (N0, N1), or metastases (M0)
d) Tumour 4 cm in large breast
WHAT ARE THE COMPLICATIONS OF BREAST SURGERY?
COMPLICATIONS OF SURGERY
a) Axillary vein thrombosis—sudden, early postoperative swelling; rare
b) Lymphedema—slow swelling of upper extremity or breast/chest over 18 months
c) Lymphangiosarcoma (Stewart–Treves syndrome)—dark purple bruiselike discoloration on arm about 10 to
20 years after surgery
d) Intercostal brachiocutaneous nerve—most commonly injured nerve
