Breast Cancer/ Breast Disease (4 breast lectures) Flashcards
where is the anatomical location of the breasts?
vertical 2nd rib - 6th rib, transverse: sternal edge to midauxillary line, lying on deep pectoral fascia of the pectoralis major and a third of the breast covers the serrratus anterior
what part of the breast extends towards the axillary fossa?
Axillary tail of spence
what is the breast attatched to the dermis by?
suspensory ligament of Cooper - this helps to support the lobules of the gland
What is the succession of drainage from the 20 lobules of glandular tissue?
> lactiferous duct > lactiferous sinus
what glands does the areola contain
sebaceous and sweat - this oily materioal provides a protective lubricant for the nipple and areola
what kind of tissue does the nipple contain?
collagenous dense connective tissue, elastic fibres and bands of smooth muscle - located on the 4th intercostal space
outline the development of the breast
mammary crests w4, extend from the axillary region to the inguinal region, crests usually disappear except in the pectoral region > primary mammary buds, secodary mammary buds >lactiferous ducts ad their branches.
what braches off the axillary, interal thoracic and intercostal a. supply the breast?
Thoraco acromial artery, Lateral thoracic artery, Internal mammary (thoracic) artery
what are the nerves of the breast?
Anterior and lateral cutaneous branches of 4-6th intercostal nerves, They convey sensory fibers to the skin of the breast, They also carry sympathetic fibres to the blood vessels and to the smooth muscle around the nipple
where does lymph from the lateral and medial breast drain?
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
how is the sentinel lymph node labelled?
A radiolabelled colloid is used to locate the sentinel node, At the time of surgery, a vital blue dye is injected, Combination of rodioisotope and dye provides most accurate means of localizing the node
describe the soft tissue of the breast
Made up of lobes which contains a network of glandular tissue consisting of branching ducts and secretory lobules in a connective tissue stroma. The terminal duct lobular unit is the functional milk secretory component of the breast, The connective tissue stroma that surrounds the lobules is dense and fibrocollagenous, whereas intralobular tissue has a loose texture.
describe the histology of normal breast tissue
duct system, surrounded by dense fibrous interlobular tissue and adipose tissue. The ducts and acini are lined by 2 layers of cells - luminal epithelial cells and myoepithelial cells.
Age – Related Changes, 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
Puberty
Branching of lactiferous ducts, Solid, spheroidal masses of granular polyhedral cells (alveoli), Accumulation of lipids in the adipocytes
Post menopausal
Progressive atrophy of lobules and ducts, Fatty replacement of glandular tissue
the breast during pregnancy on histology -
Enlarged lobules, Acini are dilated, Epithelium vary from cuboidal, to low columnar (Colostrum – Protein rich fluid, available few days after birth – rich in maternal antibodies)
the lactating breast on histology -
Acini distended with milk, Thin septa (S) between the lobules, At higher magnification (b) – Acini with eosinophilic material containing, clear vacuoles, Milk production – Suckling -Neurohormonal reflex –Prolactin & Oxytocin
diagonstic methods of breast cancer
mammography and US, fnac, core biopsy
epidemiology of breast cancer
20% of all cancers in women, Commonest cause of death in women in 35-55 age group, In UK, any woman has a 1in 9 chance of developing breast cancer
sy/sx of breast cancer specificslly seen on the breasts…
skin dimpling (peau d’orange skin), abnormal contours, oedema of the skin, nipple retraction
name some beinign breast tumours
fibroadeonmas, duct papillomas, adenomas, conntective tissue tumours, pagets disease of the nipple (Erosion of the nipple resembling eczema Associated with ductal or invasive carcinoma)
when is mammography offered?
over 40, under 40 if cancer suspected or fhx risk greater than 40%, radiation dose is 1mSv
how is ca seen on mammography?
mass, asymmetry, architectural distortion, calfcifications, skin changes, dense, irregular, spiculated,
how Is a benign mass seen?
smooth or lobulated, normal density, halo
what does an us provide?
Diferentiates solid from cystic, benign from malignant, First line imaging under 40 age, No radiation, Improves specificity of imaging
what does a malignnant tumour look like on us>
Malignant - irregular outline, interrupting breast architecture, acoustic shadowing, anterior halo
what is the triple assessment for breast ca?
Clinical examination, imaging, FNA cytology
outlne use of MRI
Sensitivity 94-98% for all breast density, Specificity is poor, Claustrophobic, noisy, lengthy, IV contrast, Expensive, Great problem solving tool
outlne use of Sentinel node sampling
Peritumoral injection of 99m Tc sulphur colloid ± isosulphan blue dye, Lymphoscintigraphy, Intraoperative Gamma probe, Single Lymph node removal, 97% accurate in identifying sentinel node
outline the BREAST SCREENING PROGRAMME
Women 50-70 invited every 3 years for mammography, Mammograms detect 5 cancers/1000 screened, Uptake is 84% (2018), Recall for further investigations is 5-10%, Static centres in urban areas, mobile vans for rural areas, Assessments in static centre with breast team-radiologist, radiographer, breast clinician, nurse, cytologist and surgeon, Additional views, clinical exam, ultrasound, FNAC or core biopsy, Aim to detect cancers at DCIS stage or less than 15mm in size ie impalpable
what is cytology?
Microscopic examination of a thin layer of cells on a slide obtained by - Fine Needle Aspiration , Direct smear from nipple discharge, Scrape off nipple with scalpel.
microscopic feature of benign cytology
low/ moderate cellularity, cohesive groups of cells, flat sheets of cells, bipolar nuclei in background, cells of uniform size, uniform chromatin pattern
microscopic feature of malignant cytology
high cellularity, loss of cohesion, crowding/overlapping of cells, nuclear pleomorphism, hyperchromasia, absence of bipolar nuclei
outlie the cytology scoring system
C1Unsatisfactory, C2Benign, C3Atypia (probably benign), C4Suspicious (probably malignant), C5Malignant
adv and disadv of cytology
simple, well tolerated, cheap, immediate/ not 100% accurate, false positives and negatives, invasion cannot be assessed, grading cannot be done, lesions may be missed, technincal and interpretation difficulties.
complcations of fnac
pain, haematoma, fainting, infection, pneumothorax (rare)
structure of the inside of the breast.
Each breast has 8 to 10 sections (lobes) arranged like the petals of a daisy Inside each lobe are many smaller structures called lobules, At the end of each lobule are tiny sacs (bulbs) LOBES -LOBULES-BULBS.
name some benign breast conditions
fibrocystic change, fibroadennoma, intraduct papilloma, fat necrosis, duct ectasia
fibroadenoma
proliferation of epithelial and stromal elements, most common breast tumour in adolescet and youg adult women, well circumscribed, freely mobile and nnonpainful mass. Ducts distorted elongated, slit like structures, intracanalicular patternn.
inntraduct papilloma
middle ages women, nippple discharge, epithelial hyperplasia which might be atypical
fat necrosis
simulate necrosis, hx of trauma, foamy cytoplasm, lipid filled cysts, calcifications
Phyllodes tumour
leaf like pattern and cysts of cut surface, circumscribed, hematogenous metastases
BREAST CA sy/sx
hard lump, fixed mass, tethering to skin, (peau d’orange) skin dimpling, abnormal contours, oedema of the skin, nipple retraction
rf’s
women, older, menstrual hx, age at first pregnancy, radiation, fhx, personal hx, hormonal tx, genetic factors, obesity, alcohol , early mearche, late menopause, HRT
5-10% of breast ca are attributed to inherited factors which genes cause this?
BRCA1, BRCA2, TP53, PTEN, OTHER…
histological classification of non-innvasive breast cancer
ductal carcioma in situ, lobular carcinoma in situ (palpable tumour not formed, nnot clinically detected only via xray, on metastatic spread, multicetricity annd bilaterality).
histological classification of innvasive breast cancer
invasive ductal, invasive lobular
special histologicla types
tubular, mucinous, medullary features, metaplastic
diagonstic procedures
cliical examination, mammogram, us, mri, fnac, needle core biopsy, wide local excision.
screening is done eevery…
3 years inn women 50-70, providing a 30% reduction in mortality
what are 2 of the most important inndicators of breast ca on a mammogram?
masses, microcalcifications (tiny flecks of calcium like grais of salt - this cann sometimes indicate ann early cancer)
what do you need to say on a histology report?
invasive vs non, type (ductal vs lobular), grade, size, margins, lymph nodes, HER-2, oestrogen and progesterone receptors.
what type of spread occurs in breast ca and where does it spread to?
Local - skin, pectoral muscles, Lymphatic - axillary and internal mammary nodes, Blood - bone, lunngs, liver, brain.
prognosis of breast ca
look at histological report
mx
staging, surgery, radiotherapy, antihormonal therapy, chemotherapy.
what is pagets disease of the nipple?
intraepithelial spread of intraductal carcinoma, large plae-staining, cells within the epidermis of the nipple, pain, itching, scaling, redness, mistaken for eczema, ulceration, crusting ad serous or bloody discharge
pathology of the male breast…
gynecomastia - increase in subareolar tissue, assiciated with hyperthyroidism, liver cirrhosis hypogonadism, copd, use of hormones. Carcinnoma of the male breast (very uncommon)
presentation
Lump: Mastalgia (persistent unilateral pain), Nipple discharge (blood-stained), Nipple changes (Paget’s disease, retraction), Change in the size or shape of the breast, Lymphoedema (Swelling of the arm), Dimpling of the breast skin.
sy/sx
lump, disacharge, contour change, redness and pitting (peau d’orange), colour/shape of areola.
pathological types of breast cancer
Innvasive = 80% Ductal, 10% lobular (mucinous, tubular, papillary, medullary, sarcoma, lymphoma), noninvasive = DCIS, LCIS
how is it staged?
FBC, EANDE, LFT, ca2+, cxray, TNM CLASSIFICATION
what is T
Tx Primary tumour cannot be assessed, T0 Primary tumour not palpable, T1 Clinically palpable tumour -size < 2 cm , T2 Tumour size 2-5 cm, T3 Tumour size > 5 cm, T4a Tumour invading skin, T4b Tumour invading chest wall, T4c Tumour invading both, T4d Inflammatory breast cancer
N
N0, N1 mobile palpable, N2 fixed palpable.
M
distant mets
Tx
SURGERY, RADIO, CHEMO, HORMONAL
2 types of surgery
breast conservation (breast/tumour size ratio, suitable for radiotherapy, patients wish), mestectomy, surgery to the axilla for SLN biopsy
surgery to axilla/ sentinal lymph node biopsy…
first node to receive lymphatic drainage, first node the tumour spreads to, if negative, rest of nodes in lymphatic basin are negative, Only performed when preoperative axillary USS normal/benign
SLN -ve thhen
no further tx
SLN +ve then
remove tumour surgically or give radiotherapy to all the axillary nodes
complications of axillary node tx
Lymphoedema (10-17%), sensory disturbance (intercostobrachial n.), decrease ROM of the shoulder joint, nerve damage (long thoracic, thoracodorsal, brachial plexus), vascular damage, radiation-induced sarcoma
factors associated with increased risk of disease recurrence
lymph node involvement, grade, size, steroid receptor status (ER/RR negativity), HER2 status, lymphovascular invasion.
adjuvant therapy is…
radiotherapy, hormone, chemo
radiotherapy and its complicaitons
(All) patients after WLE as adjuvant treatment, 40 Gy –50 Gy over 3 weeks, Boosts reduce local recurrence, After Mx if there is local involv./signif LN involv. Complications: immediate - longterm, Skin reaction- Skin telangiectasis, Radiation pneumonitis, Cutaneous Radionecrosis/ Osteonecrosis, Angiosarcoma.
Hormone therapy (what does it do and what is specifically used)?
it is oestrogen receptor +ve and blocks the stimulation of cell growth by oestrogen. Tamoxifen (comp- thromboembolotic evennts), Aromatase inhibitors (LETROZOLE, ARIMIDEX - comp - osteoporosis), Zoladex (blocks gonadotrophins - FSH AND LH)
Chemotherapy combinations
CMF Combinations (1st generation), Anthracycline Combinations (Doxorubicin or Epirubicin- 2nd generation), Taxane based Combinations (eg. Docetaxel- 3rd generation)
HER2 positivity and Anti-HER2 therapy…
Trastuzumab (Monoclonal antibody against Her-2 receptor, Given to patients with over-expression of Her2 and chemotherapy)
