Breast Anatomy & Pathology

Question 1

On which surface and muscle do the breasts lie?

Answer 1

2/3rds lies on the Deep pectoral fascia which covers the pectoralis major muscle

1/3rd of the breast lies on the fascia covering the serratus anterior

Question 2

How are the breasts attached to the skin?

Answer 2

By the Suspensory Ligament of Cooper

Question 3

What is the basic structure of the breast?

Answer 3

Nipple - prominence of the breast

Areola - pigmented area around the nipple

Lobules - each breast contains around 15-20 lobules of glandular tissue (parenchyma)

Lactiferous duct - drains each lobule

Lactiferous sinus - the dilated portion of the lactiferous ducts

Question 4

What is the blood supply to the breast?

Answer 4

1 - Internal Thoracic artery (subclavian artery)

2 - Lateral thoracic artery (axillary artery)

3 - Intercostal arteries

Question 5

From which artery are the internal thoracic and lateral thoracic arteries branches of?

Answer 5

Internal thoracic Artery - Subclavian artery

Lateral thoracic Artery - Axillary artery

Question 6

What is the nerve supply to the breast?

Answer 6

Anterior & lateral cutaneous bracnhes of 4th-6th intercostal nerves - sensory and sympathetic fibres

Question 7

What is the lymphatic drainage of the breasts and how does the lymphatic fluid travel away from the breast?

Answer 7

Lateral quadrants - Axillary lymph nodes

Medial quadrants - parasternal lymph nodes

Question 8

What does the breast soft tissue consist of?

Answer 8

Mammary glands - consist of a series of ducts and lobules (15-20 each breast)

Lobules - drained by lactiferous ducts which converge on the nipple

Connective tissue Stroma - surrounds the mammary glands and form suspensory ligament of Cooper

Question 9

What are the 2 layers of cells which line the ducts and acini?

Answer 9

Luminal epithelial cells

Myoepithelial cells

Question 10

What are the pathological types of breast cancer?

Answer 10

1) In-situ carcinoma
2) Invasive carcinoma

Question 11

How are in-situ carcinoma’s classified?

Answer 11

• Ductal carcinoma in-situ
• Lobular carcinoma in-situ

Question 12

How are invasive carcinomas of the breast classified?

Answer 12

• Ductal
• Lobular
• Tubular
• Cribriform
• Medullary

Question 13

Which ways can someone be diagnosed with breast cancer?

Answer 13

1 - Present with a symptom

2 - NHS breast screening programme (woman 50-70 invited through GP for a 3 yearly mammogram)

Question 14

What are the principles for management of a patient with breast cancer?

Answer 14

1 - Establish diagnosis

2 - Assess severity (‘staging’)

3 - Treat underlying cause

4 - General measures

5 - Specific measures

Question 15

How is a diagnosis of breast cancer made?

Answer 15

Triple assessment:

1 - Clinical examination

2 - Mammography or Ultrasound

3 - Biopsy

Question 16

What are the risk factors associated with breast cancer in order of risk (highest to lowest)?

Answer 16

Female

Older age

Age at menarche & menopause (early and late respectively = longer exposure to oestrogen)

Older age at first pregnancy

+ve Family history

HRT & OCP

BRCA1 & BRCA2

Obesity

Alcohol

Question 17

What are the signs and symptoms to look out for in breast cancer?

Answer 17

1 - Lump or thickening in breast (usually painless)

2 - Discharge or bleeding from nipple

3 - Change in size or contours of breast

4 - Change in colour or appearance of areola

5 - Orange peel skin of the breast

Question 18

How is the cancer severity assessed?

Answer 18

1 - FBC, U&E’s, LFT’s

2 - Chext X-ray

3 - Isotope bone scan (if spread to lymph nodes)

4 - Biopsy

* No reliable tumour markers

Question 19

How are patients with breast cancer staged?

Answer 19

TNM

T - size of tumour (T4 = fixed to skin)

N - Nodes involved or not

M - Metastases

Question 20

What are the surgical options for treating breast cancer?

Answer 20

1 - Breast conservation (remove lump & 1mm of surrounding healthy tissue)

2 - Mastectomy (remove entire breast)

Question 21

What is meant by the term sentinel lymph node biopsy?

Answer 21

A biopsy of the 1st lymph node to receive lymphatic drainage from the breast

The sentinel lymph node is usually the 1st node to which the tumour spreads

If the sentinel lymph node is -ve for cancer then the rest of nodes in the lymphatic ‘basin’ must also be negative

Question 22

What happens if malignant cells are found from a FNAC from a patient with breast cancer?

Answer 22

• All nodes are removed from the axilla

Question 23

What are some of the complications associated with treatment to the axilla?

Answer 23

Lymphoedema

Numbness on inner side of arm

Decreased range of movement of shoulder joint

Nerve damage (brachial plexus)

Question 24

Which factors indicate a poor prognosis for breast cancer?

Answer 24

1 - Those with lymph node involvement

2 - Those with a high grade tumour

3 - Those with a large tumour

4 - Those with absent oestrogen receptors, and Her2 receptors present

Question 25

How are patients with micrometastases treated?

Answer 25

1) Hormone Therapy
2) Chemotherapy
3) Targeted therapies

Question 26

What are the specifics of hormone therapy in patients with breast cancer micrometastases?

Answer 26

Pre-menopausal woman - Tamoxifen (oestrogen receptor modulator) for 5 years

Post-menopausal woman - Anastrazole (aromatase inhibitor) for 5-10 years

Question 27

What are the specifics of chemotherapy treatment of breast cancer micrometastases?

Answer 27

For the following patients:

• +ve for node involvement
• Cancer grade 3 or >

Question 28

What medication is used to treat micrometastases that are Her-2 +ve?

Answer 28

Herceptin

Question 29

What is the screening programme for brest cancer in the UK?

Answer 29

Woman aged 50-70 screened every 3 years