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Year 3 - Reproduction > Breast > Flashcards

Breast Flashcards

1
Q

Breast location?

A

Vertical = 2nd or 3rd rib to the 6th rib

Transverse = Sternal edge to midaxillary line

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2
Q

Which fascia does the breast sit on?

A

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

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3
Q

What is the nipple?

A

Nipple – Prominence of the breast

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4
Q

What is the areola?

A

Areola – Pigmented area around the nipple

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5
Q

How many lobules of glandular tissue (parenchyma) does each breast contain?

A

15-20 lobules of parenchyma

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6
Q

Each lobule of the breast is drained by what?

A

A lactiferous duct - opens independently on the nipple

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7
Q

What is the name of the dilated portion of the lactiferous duct?

A

Lactiferous sinus

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8
Q

Nipple is made of?

A

Contains collagenous dense connective tissue, elastic fibres and bands of smooth muscle

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9
Q

Nipple lactation?

A

Variable on size of breast or 4th intercostal space

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10
Q

When may the areola change in size physiologically?

A

During pregnancy

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11
Q

What can be found in the supernatural quadrant of the breast?

A

The axillary tail, an extension of the breast tissue.

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12
Q

How and why do we have quadrants for the breast?

A

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.

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13
Q

Difference between male versus female breast?

A

Although male does contain lactiferous ducts the male breast usually lacks lobules or alveoli like a female breast

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14
Q

During the development of the breast what appears during the 4th week?

A

Mammary crests

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15
Q

What is gynecomastia?

A

Postnatal development of rudimentary lactiferous ducts in males

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16
Q

What is polymastia?

A

An extra breast

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17
Q

What is polythelia?

A

An extra nipple

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18
Q

What is athelia?

A

Absence of a nipple

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19
Q

What is amastia?

A

Absence of a breast

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20
Q

What is significant about the breast lymphatic drainage clinically?

A

Great clinical significance because metastatic dissemination occurs primarily by the lymphatic routes

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21
Q

Lymphatic drainage of the breast?

A

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

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22
Q

What is a sentinel lymph node within breast cancer?

A

The first draining node

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23
Q

What is used to located the sentinel lymph node within breast cancer?

A

A radiolabelled colloid is usd to locate the sentinel node

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24
Q

What is the most accurate method at localising the sentinel lymph node?

A

A combination of radioisotope and dye

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25
Q

What is the functional secretory component of the breast?

A

The terminal duct lobular unit

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26
Q

What is the difference between the connective tissue stroma that surrounds the lobules and the interlobular tissue itself?

A

The connective tissue stroma that surrounds the lobules is dense and fibrocollagenous, whereas intralobular tissue has a loose texture

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27
Q

Age related changes of the breast - prepuberty?

A

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

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28
Q

Age related changes of the breast - puberty?

A

Branching of lactiferous ducts

Solid, spheroidal masses of granular polyhedral cells (alveoli)

Accumulation of lipids in the adipocytes

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29
Q

Age related changes of the breast - Post menopausal?

A

Progressive atrophy of lobules and ducts

Fatty replacement of glandular tissue

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30
Q

Diagnostic methods within breast pathologies?

A

1) Imaging = Mammography/ Ultrasound
2) Fine needle aspiration cytology
3) Core biopsy

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31
Q

How would cancer appear on a mammogram?

A

Bright often circular mass

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32
Q

How common is breast cancer?

A

1) 20% of all cancers in women

2) In UK, any woman has a 1 in 9 chance of developing breast cancer

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33
Q

What is the most common cause of death in women in the 35-55 age group?

A

Breast cancer

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34
Q

Signs of carcinoma of the breast?

A

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

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35
Q

Benign breast tumours?

A

1) Firboadenomas
2) Intraductal papillomas
3) Adenomas
4) Connective tissue tumours

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36
Q

What is cytology?

A

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
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37
Q

How is a patient who is symptomatic assessed - breast carcinoma?

A

Triple assessment:

1) Surgeon
2) Radiologist
3) Cytopathologist

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38
Q

How is a patient who is asymptomatic assessed - breast carcinoma?

A

Asymptomatic women invited for mammographic examination – mostly get core biopsy - FNA of axillary nodes/ satellite lesions

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39
Q

Symptoms of breast cancer?

A

1) Discrete mass
- Solid
- Cystic

2) Diffuse thickening

3) Nipple lesion:
- Discharge
- Eczematous skin

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40
Q

How is fine needle aspiration carried out?

A

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

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41
Q

When would ultrasound guided FNA be used?

A

When an impalpable area has been seen on ultrasound

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42
Q

Benign cytology of breast cancer?

A

> Low/ moderate cellularity

> Cohesive groups of cells

> Flat sheets of cells

> Bipolar nuclei in background

> Cells of uniform size

> Uniform chromatin pattern

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43
Q

Malignant cytology of breast cancer?

A

> High cellularity

> Loss of cohesion

> Crowding/overlapping of cells

> Nuclear pleomorphism

> Hyperchromasia

> Absence of bipolar nuclei

44
Q

Lobular versus tubular carcinoma characteristics?

A

Tubular = Well differentiated tubules that lack myoepithelial cells; relatively good prognosis

Lobular = Dsycohesive cells lacking E-cadherin adhesion proteins

45
Q

Cytology scoring system?

A 
C1 = Unsatisfactory
C2 = Benign
C3 = Atypia (probably benign)
C4 = Suspicious (probably malignant)
C5 = Malignant
46
Q

How can breast cysts be cured?

A

Aspiration

47
Q

When aspirating a cyst what may lead to a follow up investigation?

A

1) Fluid is bloodstained
2) There is a residual mass

Follow up with cytology/histology

48
Q

Advantages of FNA/cytology?

A

Simple procedure - can be done at clinic

Well tolerated by patients

Inexpensive

Immediate results

49
Q

Limitation of of FNA/cytology?

A

> 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)

50
Q

Complications of FNA?

A

> Pain
Haematoma
Fainting
Infection, Pneumothorax –rare

51
Q

Contraindications of FNA?

A

None

52
Q

If nipple discharge only contained macrophage what would this suggest?

A

Duct ectasia

53
Q

If nipple discharge only contained benign cells in papillary groups what would this suggest?

A

Intraductal papilloma

54
Q

If nipple discharge only contained malignant cells what would this suggest?

A

Intraductal carcinoma (DCIS = Ductal carcinoma in situ)

55
Q

If a nipple was erythematous and a nipple scraping was performed what would you expect to see in Paget’s disease?

A

Squamous cells and malignant cells

56
Q

If a nipple was erythematous and a nipple scraping was performed what would you expect to see in eczema?

A

Squamous cells from epidermis only

57
Q

Why is axillary lymph node FNA performed in breast cancer?

A

Aids with pre surgical planning

58
Q

When is a core biopsy performed in breast cancer?

A

> All cases with clinical OR radiological OR cytological suspicion

> Breast screening – especially architectural distortion and microcalcification

> Pre-operative classification

> Rarely open biopsy

59
Q

Core biopsy versus FNA size needle?

A

Core - 14G needle

FNA - 21G needle

60
Q

Why is a core biopsy performed in breast cancer?

A

1) Confirm invasion
2) Tumour typing and grading
3) Immunohistochemistry – receptor status (Oestrogen receptor)

61
Q

Benign breast condition - Fibrocystic changes?

A

FIBROCYSTIC CHANGE - fibrosis , adenosis, cysts , apocrine metaplasia, ductal epithelial hyperplasia ( usual type , atypical )

62
Q

Benign breast condition - fibroadenoma?

A

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
63
Q

Benign breast condition - Intraduct papilloma?

A

INTRADUCT PAPILLOMA
- Lactiferous ducts, nipple discharge

  • Can show epithelial hyperplasia, which might be atypical
  • Usually middle aged women
64
Q

Benign breast condition - fat necrosis?

A

FAT NECROSIS
- Traumatic

  • Histiocytes with foamy cytoplasm
  • Lipid–filled cysts
  • Fibrosis, calcifications, egg shell on mammography
  • Can simulate carcinoma clinically and
    mammographically
65
Q

Benign breast condition - Duct ectasia?

A

DUCT ECTASIA – nipple discharge

66
Q

Benign breast condition - Tubular adenoma?

A

Tubular adenoma
• far less common than fibroadenomas
• young women, discrete, freely movable masses
• uniform sized ducts

67
Q

Benign breast condition - Lactating adenoma?

A

Lactating Adenoma
• enlarging masses during lactation or pregnancy
• prominent secretory change

68
Q

Phyllodes tumour?

A
  • 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
69
Q

Mammogram sign in breast carcinoma?

A

Mammogram- soft tissue opacity, microcalcification

70
Q

Signs of breast carcinoma?

A

Macroscopic- hard lump, fixed mass, tethering to skin, peau d’orange dimpling of skin

71
Q

Risk factors for breast cancer?

A 
 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
72
Q

Breast lesions and risk of breast cancer?

A

 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

73
Q

Genes associated with breast cancer?

A

1) BRCA1 = 20-40%
2) BRCA2 = 10-30%
3) TP53 = <1%
4) PTEN = <1%
5) Other genes = 30-70%

74
Q

Non-invasive carcinoma?

A

 Ductal carcinoma in situ (DCIS)

 Lobular carcinoma in situ (LCIS/ LISN)

75
Q

Invasive carcinoma?

A

 Invasive ductal carcinoma, NST ( ~75%)
 Invasive lobular carcinoma and itsvariants (5- 15%)
 Special types (rest)

76
Q

In situ cancer - risk of progression?

A

 Low grade DCIS - 30% in 15 years
 High grade DCIS - 50% in 8 years
 LCIS - 19% in 25 years and bilaterality

77
Q

Diagnostic procedure in breast carcinoma?

A

 Clinical examination
 Radiology (Mammogram, ultrasound, MRI)  Fine needle aspiration cytology FNA
 Needle core biopsy
 Wide local excision with adequate margins

78
Q

Important mammography indicators of breast cancer?

A

◦ Masses

◦ Microcalcifications: Tiny flecks of calcium – like grains of salt – in the soft tissue of the breast that can sometimes indicate an early cancer.

79
Q

Spread of breast cancer?

A

 Local-skin, pectoral muscles

 Lymphatic- axillary and internal mammary nodes 

 Blood- bone, lungs, liver, brain

80
Q

Spread of breast cancer - local?

A

Local-skin

Pectoral muscles

81
Q

Spread of breast cancer - Lymphatic?

A

Axillary

Internal mammary nodes

82
Q

Spread of breast cancer - blood?

A

Bone
Lungs
Liver
Brain

83
Q

Prognosis of breast cancer?

A

 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 )

84
Q

Which drug may be used to target HER2 positive breast cancer?

A

Trastuzumab (Herceptin)

85
Q

Molecular classification of breast cancer?

A

5 subtypes : ER + luminal A, luminal B, Basal,

Her 2+ and normal breast-like

86
Q

Management of breast cancer?

A

 Staging

 Surgery (mastectomy, breast conserving surgery

 Radiotherapy

 Antihormonal therapy (Tamoxifen)

 Trastuzumab (Herceptin) for HER2 positive

 Chemotherapy

87
Q

Paget’s disease of the nipple?

A

 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

88
Q

Medical condition associated with gynecomastia?

A

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)

89
Q

Invasive breast carcinoma?

A 
ductal
 lobular
 tubular
 cribriform
 medullary
90
Q

NHS breast screening programme ?

A

Women aged 50-70 invited, through GP practice, to attend for a 3 yearly mammogram

91
Q

5 Principles for the management of a patient with breast cancer?

A

Establish the diagnosis

Assess the severity (“staging”)

Treat the underlying cause

General measures

Specific measures

92
Q

Diagnostic techniques in breast cancer?

A

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

93
Q

From highest risk to lowest what risk factors are there for breast cancer?

A

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)

94
Q

Signs of breast cancer?

A

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

95
Q

Assessing the severity of breast cancer?

A

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

96
Q

Staging of breast cancer (T)?

A 
Tumour (T)
T1 – 0-2cm
T2 - 2-5cm
T3 - >5cm
T4 – fixed to skin or muscle
97
Q

Staging of breast cancer (N)?

A

Nodes (N)
N0 – none
N1 – nodes in axilla
N2 – large or fixed nodes in the axilla

98
Q

Staging of breast cancer (M)?

A

Metastases (M)
M0 – none
M1 - metastases

99
Q

Specific measures within breast cancer?

A

Primary breast cancer (local control, eradicate disease)

Regional tumour-draining nodes (regional control, staging, eradicate disease)

Micrometastases (eradicate disease)

100
Q

Types of surgery to the breast within cancer?

A

1) Breast conservation surgery (Wide local excision, quadrantectomy or segmentectomy)
2) Mastectomy

101
Q

When to use breast conservation surgery for breast cancer?

A

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!!

102
Q

Risk of other invasive

or in situ cancer in terms of size?

A

1 cm = 60%
2 cm = 40%
3 cm = 20%
4 cm = 10%

103
Q

Why is Sentinel lymph node biopsy performed in breast cancer?

A

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

104
Q

Complications of treatment to the axilla within breast cancer?

A
  • Lymphoedema
  • Sensory disturbance (intercostobrachial n.)
  • Decrease ROM of the shoulder joint
  • Nerve damage (long thoracic, thoracodorsal, brachial plexus)
  • Vascular damage
  • Radiation-induced sarcoma
105
Q

Treatment of micro- metastases?

A

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

106
Q

Follow up within breast cancer?

A

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

Year 3 - Reproduction (25 decks)

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