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ESA 4 - Reproductive System > Breast Disease > Flashcards

Breast Disease Flashcards

1
Q

What do the breasts start off as embryologically?

A

Sweat glands

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2
Q

How are the breasts unusual amongst glands?

A

They are non-functional except during lactation

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3
Q

What are the histological features of the breast?

A

Lobules with acini and intralobular stroma

Double layer of cells - myoepithelial and epithelila

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4
Q

When do physiological breast changes occur?

A 
Menarche
Menstrual cycle
Pregnancy
Cessation of lactation
Increasing age
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5
Q

Describe the histological features of the breast before puberty?

A

Few lobules - mainly just terminal ducts

Before puberty, male and female breasts are identical

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6
Q

What happens to the histology of the breast at puberty?

A

Increase in number of lobules, increased volume of interlobular stroma

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7
Q

How do the breasts change with the menstrual cycle?

A

Follicular phase lobules quiescent
After ovulation cell proliferation and stromal oedema
With menstruation see decrease in the size of lobules

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8
Q

What is the result of the decrease in size of lobules before mensturation?

A

Some women get pain or discomfort shortly before mensturation

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9
Q

What happens to the breasts in pregnancy?

A

Increase in size and number of lobules, decrease in stroma, secretory changes

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10
Q

What happens to the breast histology when there is cessation of lactation?

A

There is atrophy of lobules, but not to former levels

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11
Q

What happens to breast histology with increasing age?

A

Terminal duct lobular units (TLDUs) decrease in number and size
Interlobular stroma replaced by adipose tissue

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12
Q

What is the result of the interlobular tissue being replaced by adipose tissue in the ageing breast?

A

Mammograms are easier to interpret- when younger, very dense, so not much use

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13
Q

What are the clinical presentations of breast conditions?

A 
Pain
Palpable mass
Nipple discharge
Skin changes
Lumpiness
Mammographic abnormalities
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14
Q

When may mammographic abnormalities be the presenting complaint in breast conditions?

A

Screening

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15
Q

What kind of pain indicates physiological changes?

A

Cyclical - with menstrual cycle

Diffuse - through most of both breastt

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16
Q

What kind of breast pain can indicate pathological change?

A

Non-cyclical

Focal

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17
Q

What can cause breast pain?

A

Ruptured cyst
Injury
Inflammation
Occasionally presenting complaint in breast cancer

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18
Q

What does a palpable mass in the breast indicate?

A

May represent normal nodularity

May be pathology

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19
Q

When are palpable breast masses most concerning?

A

When hard, craggy, fixed

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20
Q

What can cause a palpable breast mass?

A

Invasive carcinomas
Fibroadenomas
Cysts

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21
Q

What is true of all women when they have a palpable breast mass?

A

No woman should be allowed to have a lump in the breast without a firm diagnosis

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22
Q

When is nipple discharge most concerning?

A

If spontaneous (rather than occuring when nipple squeezed) and unilateral

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23
Q

What could cause a milky nipple discharge?

A

Endocrine disorders

Side effect of medication

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24
Q

Give an example of an endocrine disorder that might produce nipple discharge?

A

Pituitary adenoma

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25
Q

What medication could have nipple discharge as a side effect?

A

Oral contraceptive

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26
Q

What could cause a bloody or serous nipple discharge?

A

Benign lesions

Occasionally malignant lesions

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27
Q

What benign lesions could cause nipple discharge?

A

Papilloma

Duct ectasia

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28
Q

What is duct ectasia?

A

Enlargement or inflammation of duct

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29
Q

When are mammographic abnormalities found?

A

During mammographic screening

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30
Q

Who are mammographic abnormalities easier to detect in?

A

Older women

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31
Q

When are women screened with a mammograph?

A

When they are 47-73, every 3 years

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32
Q

Why are women 47-73 invited for mammographic screening?

A

More useful in older women

Malignancies more common

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33
Q

What are the worrying findings on mammographic screening?

A

Densities

Calcifications

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34
Q

What could cause a density on mammographic screening?

A

Invasive carcinomas
Fibroadenomas
Cysts

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35
Q

What could cause calcifications on mammographic screening?

A

Ductal carcinoma in situ (DCIS)

Benign changes

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36
Q

Are breast symptoms and signs common?

A

Yes

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37
Q

What is true of most breast symptoms and signs?

A

They will be benign

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38
Q

What is the most common benign breast tumour?

A

Fibroadenoma

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39
Q

How does breast cancer compare to other forms of cancer in terms of incidence?

A

It is the most common non-skin malignancy in women

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40
Q

What is the advantage of mammographic screening?

A

It increases detection of small invasive tumours and in situ carcinomas

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41
Q

At what age can fibroadenomas occur?

A

At any age during the reproductive period, often <30 years

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42
Q

At what age do most Phyllodes tumours present?

A

In the 6th decade

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43
Q

At what age is breast cancer rare?

A

Before 25 years (except for in some familial cases)

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44
Q

What happens to the incidence of breast cancer with age?

A

It rises

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45
Q

What % of breast cancers occur in women >50 years?

A

77%

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46
Q

What is the average age of breast cancer diagnosis?

A

64

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47
Q

Give 6 pathological conditions of the breast

A 
Disorders of development
Inflammatory conditions
Benign epithelial lesions
Stromal tumours
Gynaecomastia
Breast carcinoma
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48
Q

Give an example of a disorder of breast development?

A

Milk line remnants

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49
Q

What conditions can arise from milk line remnants?

A

Polythelia - third nipple

Accessory axillary breast tissue

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50
Q

Where on the body can polythelia occur?

A

Anywhere along the milk line - from axilla to vulva

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51
Q

Give two inflammatory conditions of the breast

A

Acute mastitis

Fat necrosis

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52
Q

What is acute mastitis?

A

Acute inflammation of the breast

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53
Q

When does acute mastitis occur?

A

Almost always during lactation or pregnancy

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54
Q

What causes acute mastitis?

A

Usually S. Aureus infection from nipple cracks and fissues

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55
Q

What are nipple cracks and fissures usually secondary to?

A

Breastfeeding

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56
Q

What are the symptoms of acute mastitis?

A

Erythematous painful breast

Pyrexia

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57
Q

What complications can arise from acute mastitis?

A

Breast abscesses

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58
Q

How is acute mastitis treated?

A

Expressing milk

Antibiotics

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59
Q

How does fat necrosis present?

A

Mass
Skin changes
Mammographic abnormality

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60
Q

How does the mass feel in fat necrosis of the breast?

A

Craggy, fixed feeling - similar to malignancy

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61
Q

What is there often a history of in fat necrosis of the breast?

A

Trauma

Surgery

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62
Q

What can fat necrosis mimic clinically and mammographically?

A

Carcinoma

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63
Q

Give a benign epithelial lesion of the breast

A

Fibrocystic change

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64
Q

How common is fibrocystic change

A

In autopsy, virtually all women have fibrocystic change

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65
Q

How may fibrocystic change present?

A

Mass or mammographic abnormality

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66
Q

What often happens to the mass on investigations?

A

Mass often disappears after fine needle aspiration

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67
Q

How does fibrocystic change appear histologically?

A

Cyst formation
Fibrosis
Apocrine metaplasia

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68
Q

What can fibrocystic change mimic clinically and mammographically?

A

Carcinoma

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69
Q

Give 5 examples of stromal tumours of the breast

A 
Fibroadenoma
Phyllodes tumours
Lipoma
Leiomyoma
Hamartoma
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70
Q

How do fibroadenomas present?

A

Mass - usually mobile

Mammographic abnormality

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71
Q

What is the mass termed in fibroadenomas?

A

Breast mouse

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72
Q

Why is the mass termed a ‘breast mouse’ in fibroadenomas?

A

Mobile and elusive

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73
Q

How many fibroadenomas is a person likely to have?

A

May be multiple and bilateral

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74
Q

How do fibroadenomas appear macroscopically?

A

Well circumscribed
Rubbery
Greyish/white

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75
Q

How do fibroadenomas present histologically?

A

Composed of a mixture of stromal and epithelial elements

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76
Q

What can fibroadenomas mimic clinically and mammographically?

A

Carcinoma

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77
Q

Are fibroadenomas true neoplasms?

A

No, they are localised hyperplasia

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78
Q

How do Phyllodes tumours present?

A

Masses

Mammographic abnormalities

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79
Q

What are the different types of Phyllodes tumours?

A

Benign
Borderline
Malignant

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80
Q

What is meant by a borderline Phyllodes tumour?

A

Grows quicker than benign, and can metastasise

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81
Q

How big are Phyllodes tumours?

A

Can be very large and involve entire breast

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82
Q

What are the histological features of Phyllodes tumours?

A

Nodules of proliferating stroma covered by epithelium

Stroma more cellular and atypical than in fibroadenomas

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83
Q

How are Phyllodes tumours?

A

Need to be excised with wide margin

84
Q

Why do Phyllodes tumours need to be excised with wide margin?

A

Otherwise they reoccur, and come back further along the line towards malignancy

85
Q

What is gynaecomastia?

A

Enlargement of the male breast

86
Q

Is gynaecomastia unilateral or bilateral?

A

Can be either

87
Q

Is gynaecomastia more concerning when it is unilateral or bilateral?

A

Unilateral (because breast cancers are unilateral)

88
Q

When is gynaecomastia often seen?

A

Puberty

Elderly

89
Q

What causes gynaecomastia?

A

Relative decrease in the androgen effect

Increase in oestrogen effect

90
Q

What can gynaecomastia mimic?

A

Male breast cancer, especially if unilateral

91
Q

Does gynaecomastia cause an increase risk of cancer?

A

No

92
Q

Why does gynaecomastia occur in most neonates?

A

Secondary to circulating maternal and placental oestrogens and progesterone

93
Q

How common is transient gyanecomatia in puberty?

A

Affects more than half of boys

94
Q

What causes transient gynaecomastia in puberty?

A

Oestrogen production peaks earlier than testosterone

95
Q

What are the pathological causes of gynaecomastia?

A

Klinefelter’s syndrome
Oestrogen excess
Gonadotrophin excess
Drug related

96
Q

What are the pathological causes of oestrogen excess?

A

Cirrhosis of the liver

97
Q

Why does cirrhosis of the liver cause oestrogen excess?

A

Oestrogen is not metabolised effectively

98
Q

What can cause gonadotrophin excess?

A

Functioning testicular tumours, e.g. Leydig and Sertoli cell tumours
Testicular germ cell tumours

99
Q

What drugs can cause gynaecomastia?

A 
Spironolactone
Chlorpromazine
Digitalis
Cimetidine
Alcohol
Marijuana
Heroin 
Anabolic steroid
100
Q

What % of malignancies in women are accounted for by breast cancer?

A

About 30%

101
Q

What proportion of women develop breast cancer at some point in their life?

A

1 in 12

102
Q

What % of breast cancer cases are in males?

A

1%

103
Q

What is the problem with male breast cancer?

A

It tends to present later

104
Q

Why does male breast cancer tend to present later?

A

Don’t think they can get it

Embarassed

105
Q

What increases the risk of male breast cancer?

A

Klinefelter’s syndrome
Male to female transexuals
Men treated with oestrogen for prostate cancer

106
Q

What % of breast cancers are adenomcarcinomas?

A

95%

107
Q

Give an example of a rare malignant tumour of the breast

A

Primary sarcomas such as angiosarcoma

108
Q

Where are breast cancers most common?

A

Upper outer quadrant, towards axilla

109
Q

What % of breast cancers occur in the upper outer quadrant?

A

Approx 50%

110
Q

What are the major risk factors for breast cancer related to?

A

Hormone exposure

111
Q

What are the risk factors for breast cancer?

A 
Gender
Uninterrupted menses
Early menarche
Late menopause
Reproductive history
Breast-feeding
Obesity and high fat diet 
Exogenous androgens 
Geographic influence
Atypical changes on previous biopsy
Previous breast cancer
Radiation
Genes
112
Q

When will a woman have uninterrupted menses?

A

Very few or no pregnancies

Didn’t breast feed

113
Q

Why does uninterrupted menses increase in risk of breast cancer?

A

During menstrual cycle, turnover of cels - more mitoses and mutations

114
Q

What age of menarche increases risk of breast cancer?

A

<11 years

115
Q

What aspects of reproductive history are related to risk of breast cancer?

A

Parity

Age at first full term pregnancy

116
Q

Why does obesity and a high fat diet increase risk of breast cancer?

A

Androgens are converted to oestrogens in peripheral adipose tissue

117
Q

Where may exogenous oestrogens come from?

A

HRT slightly increases risk

Long term users of OCP possibly have an increased risk

118
Q

By how much is risk of breast cancer increased with HRT?

A

1.2-1.7 times

119
Q

What countries have a higher incidence of breast cancer?

A

US and Europe

120
Q

What are the possible explantations for the geographical influence of breast cancer?

A

Diet
Physical activity
Breast-feeding
Environmental factors

121
Q

By how much does atypical changes in previous biopsy increase the risk of breast cancer?

A

4-5 times

122
Q

By how much does previous breast cancer increase the risk of breast cancer?

A

10x

123
Q

How is radiation related to breast cancer risk?

A

Increased risk with previous exposure to therapeutic radiation, especially in childhood and adolesence

124
Q

Give an example of when radiation may increase risk of breast cancer?

A

Mantle radiation for Hodgkin’s lymphoma

125
Q

What % of breast cancers are hereditary?

A

10%

126
Q

What % of breast cancers are attributed to BRCA1 and BRCA1 genes?

A

3% of all, 25% of familial

127
Q

What do BRCA1 and BRCA2 do?

A

Tumour suppressor genes - their proteins repair damaged DNA

128
Q

What % of the population have BRCA1 germline mutations?

A

0.1%

129
Q

What is the lifetime risk of breast cancer of female carriers of BRCA1 or 2 genes?

A

85%

130
Q

What happens to the median age of diagnosis when a woman has a mutation in BRCA1 or 2?

A

It decreases by 20 years

131
Q

What may carriers of the BRCA1 or 2 gene choose to do?

A

Undergo prophylatic bilateral mastectomies

132
Q

Other than BRCA genes, what other gene is involved in hereditary breast cancer?

A

P53 (Li-Fraumeni syndrome)

133
Q

What are breast carcinomas classified into?

A

In situ

Invasive

134
Q

Where can breast carcinomas involve?

A

Ducts

Lobules

135
Q

What happens in an in situ carcinoma?

A

Neoplastic population of cells limited to ducts and lobules by basement membrane, and so myoepithelial cells are preserved

136
Q

What is the result of the limitation of neoplastic cells in in situ breast carcinoma?

A

It does not invade into vessels, and therefore cannot metastasise and kill

137
Q

How does ductal carcinoma in situ most often present?

A

As mammographic calcifications, but can present as mass

138
Q

How to the mammographic calcifications appear with DCIS?

A

Clusters or linear and branching

139
Q

How extensive is DCIS?

A

Can spread through ducts and lobules, and be very extensive

140
Q

How does DCIS appear histologically?

A

Often shows central (comedo) necrosis with calcification

141
Q

What % of DCIS become invasive cancer?

A

50%

142
Q

What is Paget’s disease?

A

Condition related to DCIS, where cells can extend to the nipple skin without crossing the BM

143
Q

What are the symptoms of Paget’s disease?

A

Unilateral red and crusting nipple

144
Q

What should be done when a patient presents with eczematous or inflammatory conditions of the nipple?

A

Should be regarded as suspicious and a biopsy performed to exclude Paget’s disease

145
Q

What is the difference between DCIS and an invasive carcinoma?

A

Invasive has invaded beyond BM into stroma, and can invade into vessels

146
Q

What is the result of invasive carcinoma being able to invade into vessels?

A

Can metastasise to lymph nodes and other sides

147
Q

How does invasive breast carcinoma usually present?

A

Mammographic abnormality or mass

148
Q

What is the problem with detection of invasive breast carcinoma with a mass?

A

By the time a cancer is palpable, more than half of patients will have axillary lymph node mets

149
Q

What is peau d’orange?

A

The involvement of the lymphatic drainage of the skin in invasive carcinoma

150
Q

What happens in peau d’orange?

A

There is disruption of lymphatic drainage, and so the skin becomes oedematous, so swells, but the hair follicles are tethered and pulled down into the breast

151
Q

What causes a retracted nipple in invasive carcinoma?

A

The tumour causes tethering

152
Q

What are the types of invasive breast carcinoma?

A

Invasive ductal carcinoma, no special type (IDC NST)
Invasive lobular carcinoma
Tubular
Mucinous

153
Q

What % of invasive breast carcinomas are IDC NST?

A

70-80%

154
Q

What are the different types of IDC NST?

A

Well-differentiated type

Poorly differentiated type

155
Q

What is the histological appearance of the well differentiated type of IDC NST?

A

Tubules lined by atypical cells

156
Q

What is the histological appearance of the poorly differentiated type of IDC NST?

A

Sheets of pleomorphic cels

157
Q

What is the 10 year survival of IDC NST?

A

35-50%

158
Q

What % of invasive carcinomas are invasive lobular carcinoma?

A

5-15%

159
Q

What is the histological appearance of invasive lobular carcinoma?

A

Infiltrating cells in a single file, cells lack cohesion

160
Q

Why do cells lack cohesion in invasive lobular carcinoma?

A

No longer have E-cadherin, so have lost links

161
Q

What is the 10 year survival of invasive lobular carcinoma?

A

Similar to IDC NST

162
Q

What % of invasive breast carcinomas are tubular?

A

1-2%

163
Q

What is the prognosis of tubular invasive carcinoma?

A

Excellent

164
Q

What % of invasive breast carcinomas are mucinous?

A

1-6%

165
Q

What is the prognosis of mucinous breast carcinoma?

A

Excellent

166
Q

Who is often affected by mucinous breast carcinoma?

A

Older women

167
Q

Where may breast cancer metastasise to?

A

Lymph nodes via lymphatics
Distant metastases via blood vessels
Invasive lobular carcinoma can spread to odd sites

168
Q

Where does breast cancer usually spread by lymphatics?

A

To the ipsilateral (same side) axilla

169
Q

Where does breast cancer metastasise by blood vessels?

A

Bones (most frequent site)
Lungs
Liver
Brain

170
Q

What sites can invasive lobular carcinoma spread to>

A 
Peritoneum
Retroperitoneum
Leptomeninges
Gastrointestinal tract
Ovaries
Uterus
171
Q

What factors determine prognosis in breast cancer?

A 
In situ disease of invasive carcinoma
Histological subtype
Tumour grade
Tumour stage
Gene expression profile
172
Q

What histological subtype of breast cancer has the poorest prognosis?

A

IDC NST

173
Q

What factors are considered in tumour stage?

A

Size
Locally advanced disease
Lymph node metastases
Distant mets

174
Q

What is meant by locally advanced disease in cancer?

A

Invading into skin or skeletal muscle

175
Q

How are gene expression patterns useful in breast cancer?

A

Microarrays have been used to examine the expression patterns of some 25,000 genes in tissues from breast cancer patients.
Computer cluster analysis of the patterns led to the identification of about 17 marker genes that can correctly identify about 90% of women who would eventually develop mets, and therefore guides what treatment they should get

176
Q

How is breast cancer investigated?

A

Clinically
Radiographic imaging
Pathology

177
Q

How is breast cancer investigated clinically?

A

History
Family history
Examination

178
Q

How is breast cancer investigated radiographically?

A

Mammogram

Ultrasound scan

179
Q

How is breast cancer investigated by pathology?

A

Fine needle aspiration cytology

Core biopsy

180
Q

When was mammographic screening started in the UK?

A

Late 1980s

181
Q

What happens in the mammographic screening programme in the UK?

A

Women 47-73 have 2 view mammograms every 3 years

182
Q

What is the aim of mammographic screening?

A

Detect small impalpable cancers and pre-invasive cancer

183
Q

How has mammographic screening changed the incidence of DCIS?

A

Increased from 5% of breast cancers to 25% in screened populations

184
Q

What is looked for on mammographic screening?

A

Asymmetrical densities
Parenchymal deformities
Calcifications

185
Q

What happens when an abnormality is found on breast cancer screening?

A

Assessed with further imaging - FNAC and core biopsy

186
Q

What are the therapeutical approaches in breast cancer?

A

Local and regional control

Systemic control

187
Q

How is breast cancer controlled locally and regionally?

A

Breast surgery
Axillary surgery
Post-operative radiotherapy

188
Q

What are the types of breast surgery in control of cancer?

A

Mastectomy

Breast conserving therapy

189
Q

What does the decision regarding mastectomy or breast conserving surgery depend on?

A

Patient choice
Size and site of tumour
Number of tumours
Size of breast

190
Q

What does the extent of axillary surgery depend on in breast cancer?

A

Whether there are involved nodes

191
Q

What are the types of axillary surgery in the control of breast cancer?

A

Sentinel node sampling

Axillary dissection

192
Q

What is the advantage of sentinel lymph node biopsy?

A

Reduces risk of postoperative morbidity

193
Q

What happens in a sentinel lymph node biopsy?

A

Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or ‘sentinel’ lymph node(s) - the one most likely to contain breast cancer mets/
If sentinel node is negative, axillary dissection can be avoided

194
Q

How is systemic control of breast cancer achieved?

A

Chemotherapy
Hormonal treatment
Herceptin treatment

195
Q

When is chemotherapy given as a neoadjuvant (before surgery)

A

If the benefits outweigh the risks

196
Q

Give an example of a hormonal treatment for breast cancer?

A

Tamoxifen

197
Q

What does hormonal treatment for breast cancer depend on?

A

Oestrogen receptor status

198
Q

What % of breast cancers are ER positive, and so can have endocrine therapy?

A

80%

199
Q

What does herceptin treatment depend on?

A

Her2 receptor status

200
Q

What % of cancers are Her2 positive?

A

20%

201
Q

What is Her2?

A

A member of the human epidermal growth factor receptor family that encodes a transmembrane tyrosine kinase receptor

202
Q

What is herceptin?

A

Humanised monoclonal antibodies against the Her2 protein

203
Q

How can survival from breast cancer be improved?

A 
Early detection
Neoadjuvant chemotherapy
Use of newer therapies e.g. Herceptin
Gene expression profiles
Prevention of familial cases
204
Q

How can early detection of breast cancer be achieved?

A

Awareness of disease
Importance of family history
Self-examination
Mammographic screening

205
Q

What is the purpose of neoadjuvant chemotherapy?

A

Early treatment of metastatic disease

206
Q

How can familial cases of breast cancer be prevented?

A

Genetic screening

Prophylactic mastectomies

ESA 4 - Reproductive System (31 decks)

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