Breast Flashcards
Breast location?
Vertical = 2nd or 3rd rib to the 6th rib
Transverse = Sternal edge to midaxillary line
Which fascia does the breast sit on?
2/3rd of the breast rests on the pectoral fascia covering pectoralis major
1/3rd of the breast rests on the fascia covering serratus anterior
Firmly attached to the dermis by suspensory ligament of cooper – help support the lobules of the gland
What is the nipple?
Nipple – Prominence of the breast
What is the areola?
Areola – Pigmented area around the nipple
How many lobules of glandular tissue (parenchyma) does each breast contain?
15-20 lobules of parenchyma
Each lobule of the breast is drained by what?
A lactiferous duct - opens independently on the nipple
What is the name of the dilated portion of the lactiferous duct?
Lactiferous sinus
Nipple is made of?
Contains collagenous dense connective tissue, elastic fibres and bands of smooth muscle
Nipple lactation?
Variable on size of breast or 4th intercostal space
When may the areola change in size physiologically?
During pregnancy
What can be found in the supernatural quadrant of the breast?
The axillary tail, an extension of the breast tissue.
How and why do we have quadrants for the breast?
1) Superolateral
2) Superomedial
3) Inferomedial
4) Inferolateral
For anatomical location and description of pathology (cysts and tumours) the breast is divided into 4 quadrants.
Difference between male versus female breast?
Although male does contain lactiferous ducts the male breast usually lacks lobules or alveoli like a female breast
During the development of the breast what appears during the 4th week?
Mammary crests
What is gynecomastia?
Postnatal development of rudimentary lactiferous ducts in males
What is polymastia?
An extra breast
What is polythelia?
An extra nipple
What is athelia?
Absence of a nipple
What is amastia?
Absence of a breast
What is significant about the breast lymphatic drainage clinically?
Great clinical significance because metastatic dissemination occurs primarily by the lymphatic routes
Lymphatic drainage of the breast?
Most lymph (more than 75%) from lateral quadrants – axillary lymph nodes
Some lymph may drain directly to supraclavicular or inferior cervical nodes
Lymph from medial quadrants – parasternal or to opposite breast
What is a sentinel lymph node within breast cancer?
The first draining node
What is used to located the sentinel lymph node within breast cancer?
A radiolabelled colloid is usd to locate the sentinel node
What is the most accurate method at localising the sentinel lymph node?
A combination of radioisotope and dye
What is the functional secretory component of the breast?
The terminal duct lobular unit
What is the difference between the connective tissue stroma that surrounds the lobules and the interlobular tissue itself?
The connective tissue stroma that surrounds the lobules is dense and fibrocollagenous, whereas intralobular tissue has a loose texture
Age related changes of the breast - prepuberty?
Neonatal breast contain lactiferous ducts but no alveoli
Until puberty, little branching of the ducts occurs
Slight breast enlargement reflects the growth of fibrous stroma and fat
Age related changes of the breast - puberty?
Branching of lactiferous ducts
Solid, spheroidal masses of granular polyhedral cells (alveoli)
Accumulation of lipids in the adipocytes
Age related changes of the breast - Post menopausal?
Progressive atrophy of lobules and ducts
Fatty replacement of glandular tissue
Diagnostic methods within breast pathologies?
1) Imaging = Mammography/ Ultrasound
2) Fine needle aspiration cytology
3) Core biopsy
How would cancer appear on a mammogram?
Bright often circular mass
How common is breast cancer?
1) 20% of all cancers in women
2) In UK, any woman has a 1 in 9 chance of developing breast cancer
What is the most common cause of death in women in the 35-55 age group?
Breast cancer
Signs of carcinoma of the breast?
1) Skin dimpling
2) Abnormal contours
3) Oedema of the skin (Peau d’orange sign)
4) Nipple retraction and deviation
5) Paget disease (Nipple ulceration and erythema)
6) Palpable mass
Benign breast tumours?
1) Firboadenomas
2) Intraductal papillomas
3) Adenomas
4) Connective tissue tumours
What is cytology?
Microscopic examination of a thin layer of cells on a slide obtained via:
- Fine needle aspiration
- Direct smear from nipple discharge
- Scrape of nipple with scalpel
How is a patient who is symptomatic assessed - breast carcinoma?
Triple assessment:
1) Surgeon
2) Radiologist
3) Cytopathologist
How is a patient who is asymptomatic assessed - breast carcinoma?
Asymptomatic women invited for mammographic examination – mostly get core biopsy - FNA of axillary nodes/ satellite lesions
Symptoms of breast cancer?
1) Discrete mass
- Solid
- Cystic
2) Diffuse thickening
3) Nipple lesion:
- Discharge
- Eczematous skin
How is fine needle aspiration carried out?
1) Ensure patient comfortable
2) Examine to locate lump
3) Swab area
4) Localise lump between fingers
5) Insert needle (45o)
6) Aspirate using in and out action, applying negative pressure on syringe.
7) Release pressure and remove needle.
8) Apply cotton wool to ensure haemostasis
9) Spread material onto glass slides - fix, air dry
When would ultrasound guided FNA be used?
When an impalpable area has been seen on ultrasound
Benign cytology of breast cancer?
> Low/ moderate cellularity
> Cohesive groups of cells
> Flat sheets of cells
> Bipolar nuclei in background
> Cells of uniform size
> Uniform chromatin pattern
Malignant cytology of breast cancer?
> High cellularity
> Loss of cohesion
> Crowding/overlapping of cells
> Nuclear pleomorphism
> Hyperchromasia
> Absence of bipolar nuclei
Lobular versus tubular carcinoma characteristics?
Tubular = Well differentiated tubules that lack myoepithelial cells; relatively good prognosis
Lobular = Dsycohesive cells lacking E-cadherin adhesion proteins
Cytology scoring system?
C1 = Unsatisfactory C2 = Benign C3 = Atypia (probably benign) C4 = Suspicious (probably malignant) C5 = Malignant
How can breast cysts be cured?
Aspiration
When aspirating a cyst what may lead to a follow up investigation?
1) Fluid is bloodstained
2) There is a residual mass
Follow up with cytology/histology
Advantages of FNA/cytology?
Simple procedure - can be done at clinic
Well tolerated by patients
Inexpensive
Immediate results
Limitation of of FNA/cytology?
> False Negatives
> False Positives
> Invasion cannot be assessed
> Grading cannot be done
> Sampling (lesion missed)
- small lesions
- small tumour in larger area of thickening
> Technical (difficult to examine cells)
- suboptimal smears (blood, thick, cells smeared)
> Interpretation (features similar)
Complications of FNA?
> Pain
Haematoma
Fainting
Infection, Pneumothorax –rare
Contraindications of FNA?
None
If nipple discharge only contained macrophage what would this suggest?
Duct ectasia
If nipple discharge only contained benign cells in papillary groups what would this suggest?
Intraductal papilloma
If nipple discharge only contained malignant cells what would this suggest?
Intraductal carcinoma (DCIS = Ductal carcinoma in situ)
If a nipple was erythematous and a nipple scraping was performed what would you expect to see in Paget’s disease?
Squamous cells and malignant cells
If a nipple was erythematous and a nipple scraping was performed what would you expect to see in eczema?
Squamous cells from epidermis only
Why is axillary lymph node FNA performed in breast cancer?
Aids with pre surgical planning
When is a core biopsy performed in breast cancer?
> All cases with clinical OR radiological OR cytological suspicion
> Breast screening – especially architectural distortion and microcalcification
> Pre-operative classification
> Rarely open biopsy
Core biopsy versus FNA size needle?
Core - 14G needle
FNA - 21G needle
Why is a core biopsy performed in breast cancer?
1) Confirm invasion
2) Tumour typing and grading
3) Immunohistochemistry – receptor status (Oestrogen receptor)
Benign breast condition - Fibrocystic changes?
FIBROCYSTIC CHANGE - fibrosis , adenosis, cysts , apocrine metaplasia, ductal epithelial hyperplasia ( usual type , atypical )
Benign breast condition - fibroadenoma?
FIBROADENOMA
- Circumscribed, non-painful, mobile nodule in reproductive age
- Proliferation of epithelial and stromal elements
- Most common breast tumour in adolescent and young adult women (peak age = third decade)
- Ducts distorted elongated slit-like structures intracanalicular pattern, ducts not compressed
pericanalicular growth pattern
Benign breast condition - Intraduct papilloma?
INTRADUCT PAPILLOMA
- Lactiferous ducts, nipple discharge
- Can show epithelial hyperplasia, which might be atypical
- Usually middle aged women
Benign breast condition - fat necrosis?
FAT NECROSIS
- Traumatic
- Histiocytes with foamy cytoplasm
- Lipid–filled cysts
- Fibrosis, calcifications, egg shell on mammography
- Can simulate carcinoma clinically and
mammographically
Benign breast condition - Duct ectasia?
DUCT ECTASIA – nipple discharge
Benign breast condition - Tubular adenoma?
Tubular adenoma
• far less common than fibroadenomas
• young women, discrete, freely movable masses
• uniform sized ducts
Benign breast condition - Lactating adenoma?
Lactating Adenoma
• enlarging masses during lactation or pregnancy
• prominent secretory change
Phyllodes tumour?
- Fleshy tumor, leaf-like pattern and cysts on cut surface
- Circumscribed, connective tissue and epithelial elements, 1-15 cm
- Less than 1 % of breast tumours
- Benign, borderline, malignant
- Metastases are hematogenous
Mammogram sign in breast carcinoma?
Mammogram- soft tissue opacity, microcalcification
Signs of breast carcinoma?
Macroscopic- hard lump, fixed mass, tethering to skin, peau d’orange dimpling of skin
Risk factors for breast cancer?
Gender Age Menstrual history Age at first pregnancy Radiation Family history Personal history Hormonal treatment Genetic factors Other factors: obesity, lack of physical activity, alcohol
Breast lesions and risk of breast cancer?
Epithelial proliferation without atypia – RR 1.5-2x
With atypia ductal or lobular – RR 4-5x
Lobular carcinoma in situ – RR 8-10x
Ductal carcinoma in situ – RR 8-10x
Genes associated with breast cancer?
1) BRCA1 = 20-40%
2) BRCA2 = 10-30%
3) TP53 = <1%
4) PTEN = <1%
5) Other genes = 30-70%
Non-invasive carcinoma?
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS/ LISN)
Invasive carcinoma?
Invasive ductal carcinoma, NST ( ~75%)
Invasive lobular carcinoma and itsvariants (5- 15%)
Special types (rest)
In situ cancer - risk of progression?
Low grade DCIS - 30% in 15 years
High grade DCIS - 50% in 8 years
LCIS - 19% in 25 years and bilaterality
Diagnostic procedure in breast carcinoma?
Clinical examination
Radiology (Mammogram, ultrasound, MRI) Fine needle aspiration cytology FNA
Needle core biopsy
Wide local excision with adequate margins
Important mammography indicators of breast cancer?
◦ Masses
◦ Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer.
Spread of breast cancer?
Local-skin, pectoral muscles
Lymphatic- axillary and internal mammary nodes
Blood- bone, lungs, liver, brain
Spread of breast cancer - local?
Local-skin
Pectoral muscles
Spread of breast cancer - Lymphatic?
Axillary
Internal mammary nodes
Spread of breast cancer - blood?
Bone
Lungs
Liver
Brain
Prognosis of breast cancer?
Patient related and tumour related
Node status (best prognostic indicator) Tumour size ( < 2cm )
Type
Grade (1,2,3 )
Age
Lymphovascular space invasion
Proliferative rate of tumour
Gene expression profiling
Nottingham Prognostic Index ( NPI ) based on tumour size, grade and nodal status
Overall 64 % five year survival
Oestrogen receptor (OR)/ Progesterone receptor (PR) strong predictors of response to hormonal therapies
ER/PR negative tumours do not respond
HER-2 : about 20-30% positive- predicts response to trastuzumab ( Herceptin )
Which drug may be used to target HER2 positive breast cancer?
Trastuzumab (Herceptin)
Molecular classification of breast cancer?
5 subtypes : ER + luminal A, luminal B, Basal,
Her 2+ and normal breast-like
Management of breast cancer?
Staging
Surgery (mastectomy, breast conserving surgery
Radiotherapy
Antihormonal therapy (Tamoxifen)
Trastuzumab (Herceptin) for HER2 positive
Chemotherapy
Paget’s disease of the nipple?
Result of intraepithelial spread of intraductal carcinoma
Large pale-staining cells within the epidermis of the nipple
Limited to the nipple or extend to the areola
Pain or itching, scaling and redness, mistaken for
eczema
Ulceration, crusting, and serous or bloody discharge
Medical condition associated with 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)
Invasive breast carcinoma?
ductal lobular tubular cribriform medullary
NHS breast screening programme ?
Women aged 50-70 invited, through GP practice, to attend for a 3 yearly mammogram
5 Principles for the management of a patient with breast cancer?
Establish the diagnosis
Assess the severity (“staging”)
Treat the underlying cause
General measures
Specific measures
Diagnostic techniques in breast cancer?
History and Clinical examination (88% sensitivity)
Mammography (93% sensitivity)
Ultrasonography (88% sensitivity)
Magnetic resonance mammography
Cytology (FNAC) (94% sensitivity)
Core biopsy
Image guided cytology or core biopsy
Open (surgical) biopsy
From highest risk to lowest what risk factors are there for breast cancer?
Age
Geographical variation
Age at menarche and menopause
Age at first pregnancy
Family history
Previous benign breast disease
Cancer in other breast
Radiation
Lifestyle (obesity, alcohol)
Oral contraceptive
Hormone replacement (HRT)
Signs of breast cancer?
1) Most common: lump or thickening in breast. Often painless
2) Discharge or bleeding from nipple
3) Crusting of the areola
4) Inversion of the areola
5) Change in the colour or appearance of the areola
6) Change in size or contours of breast
7) Redness or pitting of skin over the breast, like the skin of an orange
Assessing the severity of breast cancer?
Hb FBC, U&Es, LFTs
Chest x ray
Isotope bone scan (if has spread to lymph nodes)
Others as clinically indicated
No reliable tumour markers
Staging of breast cancer (T)?
Tumour (T) T1 – 0-2cm T2 - 2-5cm T3 - >5cm T4 – fixed to skin or muscle
Staging of breast cancer (N)?
Nodes (N)
N0 – none
N1 – nodes in axilla
N2 – large or fixed nodes in the axilla
Staging of breast cancer (M)?
Metastases (M)
M0 – none
M1 - metastases
Specific measures within breast cancer?
Primary breast cancer (local control, eradicate disease)
Regional tumour-draining nodes (regional control, staging, eradicate disease)
Micrometastases (eradicate disease)
Types of surgery to the breast within cancer?
1) Breast conservation surgery (Wide local excision, quadrantectomy or segmentectomy)
2) Mastectomy
When to use breast conservation surgery for breast cancer?
Tumour size <4cm (clinically)
Breast/Tumour size ratio
Suitable for radiotherapy
Single tumours – but now we do sometimes offer multiple tumours
Patient’s wish – most important!!
Risk of other invasive
or in situ cancer in terms of size?
1 cm = 60%
2 cm = 40%
3 cm = 20%
4 cm = 10%
Why is Sentinel lymph node biopsy performed in breast cancer?
1) First node to receive lymphatic drainage
2) First node to which tumour spreads
3) If negative, rest of nodes in lymphatic basin are negative
4) “skip” metastases do not occur
If SLN is clear of tumour – no further treatment required
If SLN contains tumour – either remove them all surgically (clearance) or give radiotherapy to all the nodes in the axilla
Complications of treatment to the axilla within breast cancer?
- Lymphoedema
- Sensory disturbance (intercostobrachial n.)
- Decrease ROM of the shoulder joint
- Nerve damage (long thoracic, thoracodorsal, brachial plexus)
- Vascular damage
- Radiation-induced sarcoma
Treatment of micro- metastases?
1) Hormone therapy
- Zoladex (FSH + LH)
- Tamoxifen (Oestrogen)
- Aromatase inhibitors (Anastrazole or letrozole)
2) Chemotherapy
- Better effect if <50
- Node positive or grade 3
- Oncotype DX = 21 gene assay to determine whether chemotherapy going to be of benefit
3) Targeted therapies:
- HER2 receptor therapy = Trastuzumab (Herceptin),, a monoclonal antibody against HER2
Follow up within breast cancer?
Many different protocols – poor evidence base
Clinical examination 6 monthly for 3- 5 years
Discharge after 3- 5 years, or even sooner!
Mammogram of breast(s) at yearly intervals for 10 years
