Breast Flashcards
A 2-day-old baby presents with unilateral breast discharge. On examination, milky thin fluid can be expressed from the right nipple. What is the appropriate management?
A check oestrogen level, prolactin level, progesterone level
B pelvic ultrasound
C breast ultrasound
D reassurance and observation
E trauma workup
D
By birth neonatal mammary tissue may be functional and may secrete colostrum for the first week of life. The fluid, termed ‘witch’s milk’, consists of cellular debris. This is not a pathological finding. Parents should be advised that this condition is self-limiting.
SPSE 1
Which of the following is not true regarding the anatomy and embryology of the breast?
A The internal mammary artery and lateral thoracic artery supply the majority of blood to the breast.
B Breast tissue is derived from ectoderm.
C The tail of Spence is the portion of the breast that projects towards the clavicle.
D Breasts begin to form at 5–7 weeks’ fetal development from the base of the forelimbs to the hind limbs.
E Sensory innervation of the anterolateral and anteromedial breast is from T3 to T5 nerve roots.
C
The tail of Spence is the part of the breast that extends towards the axilla. Careful palpation of this part is essential for a complete breast exam.
SPSE 1
Which of the following statements is not true regarding the anatomy of the breast?
A Cooper’s ligaments support the nipple–areola complex.
B Breast tissue is composed of skin, subcutaneous tissue, parenchyma and stroma.
C Collecting ducts of breast drain each segment, converging into lactiferous sinuses that drain into milk ducts.
D Breast parenchyma overlies the deep pectoral fascia and is enveloped by superficial pectoral fascia.
E Lymphatic drainage is to the axillary nodes and the mammary nodes.
A
Cooper’s ligaments are bands of fibrous tissue that span the superficial and deep pectoral fascia, supporting the whole breast.
Alveoli make up lobules, and 20–40 lobules make up a lobe. lobes are grouped into segments.
Segments are located radially around the nipple with 15–20 segments present in each breast.
There are up to 10 milk ducts per breast.
SPSE 1
All of the following statements are true regarding congenital breast deformities except:
A Ectopic breast tissue may be subject to the same pathology as normally located breast.
B Patients with polythelia should have a renal ultrasound.
C Athelia is always bilateral.
D Athelia is highly associated with a syndrome or cluster of other abnormalities.
E Amastia may or may not be associated with athelia.
C
Deficiency in parathyroid-related hormone is thought to lead to lack of proliferation of the mesenchyme that forms the nipple–areola complex.
Polythelia, the presence of supernumerary nipple(s) should prompt a workup for renal abnormalities such as duplication, obstruction and agenesis. Polythelia is treated by excision of the supernumerary nipple in a healthy child.
Athelia, the absence of nipple–areola complex, is not addressed until puberty.
Athelia may be unilateral or bilateral and is almost always associated with syndromes such as Poland’s syndrome, ectodermal dysplasia, choanal atresia and athelia syndrome.
Polymastia is the presence of ectopic breast tissue within the breast line. Complete resection is recommended for patients with polymastia for reasons of cosmesis and symptoms. Risks and outcomes of supernumerary mastectomies have not been analysed.
Amastia may or may not be associated with athelia.
SPSE 1
A 2-month-old baby girl presents with a tender, inflamed left breast abscess. The following are true regarding the treatment course of the disease except:
A Treatment may include IV or oral antibiotics.
B Drainage of the infected fluid may be performed by needle aspiration.
C If surgical drainage is necessary, care must be exercised in order to avoid damage to the breast bud.
D All breast abscesses should be drained surgically since the infection would damage the developing breast tissue.
E Staphylococcus and streptococcus are the most common organisms that have been implicated in breast abscesses in infants.
D
Breast infection usually presents as a tender, fluctuant mass. Antibiotic administration is the initial course of therapy.
The most common organisms causing breast infections include Staphylococcus aureus, beta haemolytic streptococcus, Escherichia coli and Pseudomonas aeruginosa.
Because of the widespread distribution of the methicillin-resistant S. aureus, this organism should be covered pending definitive identification of the causative organism.
Aspiration or incision and drainage may be required. Care must be exercised in procedures performed to the prepubertal breast as damage to the breast bud may occur with injudicious procedures.
SPSE 1
An 11-year-old female presents with Tanner stage II breast development on the right side and Tanner stage I development on the left side. What is the most appropriate course of action?
A Advise the child and her parents that asymmetric development is common and that most asymmetry will not have discernible size discrepancy at adulthood.
B Check follicle-stimulating hormone and luteinising hormone levels.
C Perform a careful family history evaluation, paying close attention to a history of early breast carcinoma and male breast carcinoma.
D Obtain serum oestrogen, progesterone and prolactin levels.
E Ultrasonography of the breast.
A Thelarche marks the onset of puberty and is the first sign of puberty. It should occur by age 13. In the early stages, it is very common for the breast development to be asymmetrical. A careful examination in the office is necessary to rule out masses or infections. Thereafter, the child and the family should be reassured that asymmetrical development is common in the early stages of puberty.
There are five Tanner stages of breast development.
I Elevation of breast papilla only.
II Elevation of breast bud and papilla as a small round enlargement of the areola diameter. Areola becomes pinker.
III Further enlargement of the breast and areola show no separation of their contours. Appearance of montgomery’s tubercles.
IV Further enlargement with projection of the areola and papilla to form a secondary mound above the level of the breast.
V Projection of the papilla only resulting from the recession of the areola to the general contour of the breast.
SPSE 1
A 14-year-old female with Tanner V breast development presents with a 2 cm well-rounded mass in the upper inner quadrant of the right breast. There is no nipple discharge or erythema around the breast. She states that the mass becomes slightly larger and more tender a few days before her menstrual period. On exam, the mass is easily palpable with regular edges and is freely moveable. There is no adenopathy in the bilateral axillae, supraclavicular or infraclavicular areas. Each of the following is a reasonable course of action except:
A ultrasound of the mass
B excisional biopsy of the mass
C bilateral mammography
D observation
E serial examination.
C
A fibroadenoma is the most commonly encountered breast mass in the female adolescent population. on examination, these are discrete, rubbery, moveable and nontender.
They may be bilateral (10% of the time) and multiple (10%–15% of the time).
The average size of a lesion is 2–3 cm. on ultrasound fibroadenomas are hypoechoic and well circumscribed.
Two histological types of fibroadenomas have been described: simple and complex.
Simple fibroadenomas have both epithelial and connective elements. There is no increased risk of breast carcinoma in these patients with any family history of breast carcinoma or proliferative breast disease.
Complex fibroadenomas show foci of cysts, sclerosing adenomas, epithelial calcifications and papillary apocrine metaplasia. The future risk of breast cancer in patients with complex fibroadenomas is higher. overall, malignant transformations of fibroadenomas are considered to be rare, in the order of 0.002%–0.00125%.
Complete resolution of fibroadenomas is reported in 16%–59% of longitudinal studies. of those that did not regress, half become smaller and the other half enlarged.
Solitary discrete fibroadenomas may be excised or observed.
observation requires serial examinations and ultrasound every 6 months to a year to monitor size.
operative indications include rapid size, enlargement, symptoms, desire by the patient and her family or radiological findings that differ from a typical fibroadenoma.
Excision does not require a margin of normal breast.
SPSE 1
A 14-year-old female presents with a 7 cm rapidly growing mass of the left breast. On examination, there is significant left breast distortion, overlying warmth with dilatation of superficial breast veins. Differential diagnoses include all of the following except:
A breast cancer
B giant fibroadenoma
C infection
D cystosarcoma phyllodes
E prolactinoma.
E
Giant fibroadenoma (also known as juvenile cellular fibroadenoma) is an uncommon variant of fibroadenoma characterised by rapid growth. The lesions are generally over 5 cm, encapsulated, benign and may have dilated veins on the overlying skin.
Cystosarcoma tumours present as bulky breast masses, which may reach up to 20 cm in size. These masses are firm and mobile. The overlying skin may be thin and shiny with increased vascularity. Typically, skin dimpling, nipple retraction or nipple discharge is not seen. Patients usually present with a rapidly growing, non-tender breast mass or with accelerated growth of a previously stable mass. ultrasonography and mRI cannot distinguish between a fibroadenoma and a phyllodes tumour. microscopically, benign phyllodes tumours have a hyperplastic and cellular stromal component. Cellular atypia and increased mitotic figures are seen more commonly in the malignant variant. Not fully encapsulated, the abnormal phyllodes tissue often extends projections into the surrounding normal breast tissue.
Breast abscess and cellulitis present with a rapidly growing isolated tender mass. Although uncommon in this age group, inflammatory breast lesions have a similar presentation to the one described. Prolactin-secreting tumours typically present with galactorrhoea and not a unilateral mass.
SPSE 1
The following agents have been implicated in problems associated with nipple piercing except:
A platinum
B Mycobacterium fortuitum
C S. aureus
D nickel
E anaerobic bacteria.
A
M. fortuitum and Prevotella melaninogenica (anaerobic organism) have been implicated in breast abscesses. other organisms that have been reported to be associated with nipple piercing include coagulase-negative staphylococcus, streptococcus and gordonea.
Nickel allergies have also been well described as the cause of post-piercing inflammation. Platinum has not been implicated in piercing-associated inflammation.
SPSE 1
To investigate nipple discharge in a 16-year-old female the following may be useful except:
A complete history and physical examination
B list of current medications including illicit drugs
C cytology of discharge fluid
D thyroid function tests
E serum prolactin level.
C
Brown episodic discharge may occur from montgomery’s tubercles, areolar tubercles involved in lactation.
Causes of milky discharge or galactorrhoea include prolactin-seeding tumours, pregnancy, hypothyroidism, hyperthyroidism, papillary duct ectasia, papillary duct hyperplasia and the postpartum state.
Hyperprolactinaemia has been associated with thoracotomy, nipple irritation and chest trauma.
Nipple discharge may be associated with primary or secondary amenorrhoea, interrupted puberty and medication such as oral contraceptives, tricyclic antidepressants, H2 antagonists, cannabis, phenothiazines and hypertensive agents.
Exfoliative cytological examination of nipple discharge and scrape smears has a low sensitivity for diagnosis.
SPSE 1
Which one of the following statements about juvenile papillomatosis is not true?
A It occurs as a localised mass.
B Microscopically it is characterised by cysts in combination with epithelial hyperplasia, marked papillomatosis, papillary apocrine metaplasia and mild cytologic atypia.
C Treatment is simple mastectomy.
D Ultrasound features include poor mass definition with internal echoes of variable strength and one or more small, rounded, echo-free areas at the border of the lesion.
E It is a marker for families with a high frequency of breast carcinoma.
C
Juvenile papillomatosis is a distinct entity seen at a young age. It presents as a localised mass. It occurs in women <30 years of age, but has been described in men.
Treatment is total resection with preservation of normal breast.
There is an increased risk of breast cancer in patients with juvenile papillomatosis and therefore close follow-up is needed.
SPSE 1
Which of the following is not true regarding the clinical course of phyllodes tumours of the breast?
A Phyllodes tumours may metastasise or locally recur.
B The lymphatic route is the primary means of spread for malignant cystosarcoma phyllodes.
C Clinically positive nodes are present about 20% of the time.
D If local recurrence is present, re-excision or mastectomy may be necessary.
E Phylloides tumours in children and adolescents have a more favourable prognosis than their adult counterparts.
B
Cystosarcoma phyllodes or phyllodes tumours are stromal tumours. They are histologically classified as benign, intermediate or malignant.
They occur more commonly on the left breast. Benign tumours should be surgically excised with at least a 1 cm margin.
Benign phylloides tumours are often difficult to differentiate from fibroadenomas on ultrasonography and MRI.
On cytopathology, several properties are seen in phyllodes tumours that are not seen in fibroadenoma, such as fibromyxoid stromal fragments with spindle nuclei, fibroblastic pavements, and appreciable numbers of spindle cells of fibroblastic nature among dispersed cell population.
malignant tumours should be treated with simple mastectomy.
Recurrent tumours may be treated by re-excision or mastectomy.
The haematogenous route is the primary route of spread and metastases to lung, pleura, soft tissue, bone, pancreas and CNS has been described.
Radiation therapy should be considered if an adequate margin cannot be achieved on the chest wall.
Prognosis for phylloides tumours in adolescents is more favourable than in adults.
SPSE 1
Which of the following is not true regarding primary breast tumours in adolescents?
A Chest wall radiation for Hodgkin’s disease has been implicated as a risk factor in primary breast cancer.
B The usual presentation is an enlarging, non-tender, firm, immobile lesion in the lateral breast quadrants.
C Nipple discharge and nipple retraction are less common in adolescents with primary breast cancer than in adults with primary breast cancer.
D Secretory carcinoma is a type of invasive ductal carcinoma with favourable prognosis that may spread beyond the breast to regional lymph nodes or may metastasise by the haematological route.
E Secretory carcinoma almost always requires adjuvant chemotherapy and radiation therapy.
E
Primary breast cancer has been reported in 39 children as of the year 2000.
The average age is 11 (range 3–19). Histological subtypes of breast carcinoma seen in adolescents include the secretory subtype which has a thick- walled capsule.
For the secretory subtype, surgical excision is the primary treatment and adjuvant therapy is rarely needed.
Other subtypes described in children and adolescents include inflammatory breast cancer and medullary carcinoma.
Surgical options for infiltrating lobular or intraductal carcinoma in adolescents include breast-sparing surgery (lumpectomy with axillary node dissection and irradiation) or modified radical mastectomy.
Younger women tend to have more aggressive disease.
Systemic adjuvant chemotherapy is strongly advised in all young women with breast carcinoma.
SPSE 1
Regarding the inherited predisposition to breast cancer, the following are true except:
A BRCA1 is located on chromosome 17 and BRCA2 is located on chromosome 13.
B Recommendations for girls with predisposition to breast cancer include monthly breast examination between 18 and 21 years of age and mammography at age 23–35 years.
C Annual bilateral breast MRI is recommended beginning at age 16.
D BRCA1 and BRCA2 are felt to be responsible for 7%–9% of breast cancers.
E Not all women with the BRCA genes will develop breast cancer.
C
There are two genes responsible for 5%–9% of all breast cancers, BRCA1 located on chromosome 17 and BRCA2, located on chromosome 13.
Studies imply that carriers for BRCA1 have a 65%–80% lifetime risk of breast cancer and BRCA2 carriers have a 45%–85% lifetime risk of breast cancer.
Adolescent genetic testing has been deemed ethically unacceptable by most professional organisations because of the current absence of beneficial medical interventions in children that would affect the course of disease.
In adults, surveillance of BRCA carriers includes monthly breast examinations, clinical breast examinations once or twice yearly, yearly mammograms, and mRI of breast starting at age 25–30.
SPSE 1
The most common malignant breast tumour in the adolescent female is:
A a metastasis
B secretory breast carcinoma
C malignant cystosarcoma phyllodes
D infiltrating ductal carcinoma
E rhabdomyosarcoma.
A
metastatic lesions are more common than primary lesions in children and adolescents.
Hodgkin’s and non- Hodgkin’s lymphoma, rhabdomyosarcoma, melanoma and neuroblastoma have been described to metastasise in the breast.
SPSE 1
