Breast disease Flashcards
What is the surface anatomy of the breast?
2/3rd rib - 6th rib
Sternal edge to midaxillary line
What is the axillary tail?
Small part of breast extends towards axillary fossa
What muscles does the breast lie on?
2/3 Pectoral fascia covering pectoralis major
1/3 Serratus anterior
How is the breast attached to the dermis?
Suspensory ligament of cooper
What does the suspensory ligament of cooper do?
Attaches breast to dermis
Helps support the lobules of the gland
How many lobules does each breast contain?
15-20 lobules of glandular tissue
What is the glandular tissue of the breast called?
Parenchyma
What is the dilated portion of each lactiferous duct called?
Lactiferous sinus
What type of tissue is the nipple made from?
Collagenous dense connective tissue, elastic fibre and bands of smooth muscle
What are the tips of the nipples fissured with?
Lactiferous ducts
Where are the nipples typically located?
4th intercostal space
What does the areola contain?
Sweat and sebaceous glands
What is the areola?
Skin covering the nipple
What happens to the areola during pregnancy?
Enlarge
How many quadrants of the breast are there?
4
What are the 4 quadrants of the breast?
Superolateral
Superomedial
Inferolateral
Inferomedial
Which quadrant does the axillary tail extend into?
Superolateral
What is the male breast formed by?
Small ducts without lobules or alveoli
In the development of breast, when do mammary crests or ridges appear?
During 4th week
What is gynecomastia?
Postnatal development of rudimentary lacteriferous ducts in males
What is polymastia?
Extra breast
What is polythelia?
Extra nipple
What is aphelia or amastia?
Absence of nipple or breast
What is breast’s blood supply?
Branches of the axillary a., internal thoracic a. and some intercostal a.
Thoraco-acromial a.
Lateral thoracic a.
Internal mammary (thoracic) a.
What veins drain the breasts?
Axillary and internal thoracic veins
What nerves supply the breast?
Anterior and lateral cutaneous branches of 4-6th intercostal nerves
What is important about breast lymphatics that is of clinical significance?
Branch extensively and do not contain valves
Where does most lymph from the breast drain?
Axillary lymph nodes
Apart from the axillary nodes, where else does lymph drain from the breasts?
Supraclavicular nodes
Inferior cervical nodes
Parasternal nodes
What is the sentinel node?
First few lymph nodes into which tumour drains
What is used to locate the sentinel node?
Radiolabelled colloid
What lobe is the functional milk secretory component of the breast?
Terminal duct lobular unit
What is the histology of normal breast tissue?
Surrounded by dense fibrous interlobular tissue & adipose tissue
What are the ducts and acini of breast tissue lined by?
Luminal epithelial cells
Myoepithelial cells
What are changes that happen to breast tissue during puberty?
Branching of lactiferous ducts
Accumulation of lipids in adipocytes
What are changes that happen to breast tissue post-menopause?
Progressive atrophy of lobules and ducts
Fatty replacement of glandular tissue
What happens to breast tissue during pregnancy?
Enlarged lobules
Acini dilated
Epithelium vary from cuboidal to low columnar
Colostrum producted
What is colostrum?
Protein rich fluid, available few days after birth, rich in maternal antibodies
What happens to breast tissue during lactation?
Acini distended with milk
What are diagnostic methods used on breasts?
Mammography US FNA cytology Core biopsy MRI Nuclear medicine Breast screening programme
What are signs of breast cancer?
Skin dimpling
Abnormal contours
Edema of skin
Nipple retraction/deviation
What are types of benign breast tumours?
Fibroadenomeas Duct papillomas Adenomas Connect tissue tumours Paget's disease of nipple
How can cytology samples be gained for breast tissue?
FNA
Smear nipple discharge
Scrape of nipple with scalpel
What is the FNA of usually?
Axillary nodes
Satellite lesions
What are palpable symptoms of breast disease?
Discrete mass: solid or cystic Diffuse thickening Nipple lesion Discharge Eczematous skin
How can an area that is unpalatable have FNA?
US-guided FNA
What are important considerations when doing FNA?
Patient: informed, comfortable, chaperone
Safety: PPA, dispose needle, care handle of material
What are signs 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
What are signs of malignant cytology?
High cellularity Loss of cohesion Crowding/overlapping of cells Nuclear pleomorphism Hyperchromasia Absence of bipolar nuclei
What is the cytology scoring system?
C1-C5 C1: unsatisfactory C2: benign C3: atypic C4: suspicious C5: malignant
How are cysts managed?
Aspiration is curative
What are the advantages of FNA?
Simple - can be done at clinic
Well tolerated
Inexpensive
Immediate results
What are the limitations of FNA?
Accuracy not 100% - false negatives/positives Invasion cannot be assessed Grading cannot be done Lesions missed Technical - suboptimal smears Interpretation
What are the complications of FNA?
Pain
Haematoma
Fainting
Infection
What are the contraindications of FNA?
None
What is an indication of a nipple lesion?
Bloody discharge from single duct
What could a nipple scrape determine between?
Paget’s disease (squamous cells + malignant cells)
Eczema (squamous cells only)
What could a nipple discharge cytology sample tell the different between?
Duct ectasia
Intraduct papilloma
Intraduct carcinoma
When is a core biopsy done?
All cases with clinical or radiological or cytological suspicion
What can a core biopsy do?
Confirm invasion
Tumour typing and grading
Immunohistochemistry
What is the main view on mammography?
ML oblique view and craniocaudal view
When is mammography offered?
Over age 40
When is mammography offered for <40yrs?
Strong suspicion cancer
FHx risk greater than 40%
What is the radiation dose of mammography?
1mSv
What are signs of malignant disease on mammography?
Irregular, illdefined
Spiculated
Dense
Distortion of architecture
What are signs of benign disease on mammography?
Smooth or lobulated
Normal density
Halo
What can an US differentiate between?
Solid from cystic mass
Solid benign from malignant
What is first line of investigation of breast disease in <40yrs?
US
What does a solid benign tumour look like on US?
Smooth outline
Oval shape
Acoustic enhancement
What does a malignant tumour look like on US?
Irregular outline
Interrupting breast architecture
Acoustic shadowing and anterior halo
What is the triple assessment in breast disease management?
Clinical examination
Imaging
FNA cytology
What are the 2 types of image guided needle biopsy in breast disease?
FNA
Core biopsy
What are the indications for MRI of the breast?
Recurrent disease
Implants
Indeterminate lesion following triple assessment
Screening high risk women
What age is the breast screening programme aimed at?
50-70yrs
What is duct ectasia?
A milk duct beneath the nipple widens, the duct walls thicken and the duct fills with fluid. This is the most common cause of greenish discharge.
What is fibroadenoma?
Proliferation of epithelial and stromal elements
What is the most common breast tumour in adolescent and young adult women?
Fibroadenoma
How does fibroadenoma present?
Well-circumscribed
Freely mobile
Nonpainful mass
May regress with age if untreated
What are other adenomas apart from fibroadenoma?
Tubular adenoma
Lactating adenoma
What group of women usually get introducet papilloma?
Middle aged women
How does introduction papilloma present?
Nipple discharge
What can simulate carcinoma clinically and mammographically?
Fat necrosis
What are causes of fat necrosis in breast tissue?
History of antecedent trauma
Prior surgical intervention
What type of tumour is Phyllodes tumour: benign or malignant?
Can be either
How is Phyllodes tumour described?
Fleshy
Leaf-like patterns
Cysts on cut surface
Circumscribed
What is the metastatic route of Phyllodes tumour?
Hematogenous
What is the commonest cause of female cancer death?
Breast Ca
What are risk factors for breast cancer?
Gender Age Menstrual Hx Age at first pregnancy Radiation FHx Hormonal treatment Genetics Others: obesity, alcohol, lack activity
What % of breast cancers attributed to inherited factors?
5-10%
What are the most prominent genes that causes breast ca?
BRCA 1
BRCA 2
What are the histological classifications of breast ca?
Non-invasive:
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
Invasive:
- Invasive ductal carcinoma
- Invasive lobular carcinoma and variants
- Special types
What are 2 types of non-invasive breast ca?
- Ductal carcinoma in situ (DCIS)
- Lobular carcinoma in situ (LCIS)
What are the features of in situ breast carcinoma?
Does not form palpable tumour
Not detected clinically - imaging needed
No metastatic spread
Risk invasion depending on grade
Which type of non-invasive breast ca has a higher risk of progression?
DCIS
What are the special types of breast ca?
Tubular carcinoma
Mucinous carcinoma
Carcinoma with medullary features
Metaplastic carcinoma
How often is mammography screening?
Every 3yrs
What are microcalcifications?
Tiny deposits of calcium can appear in breast and show on mammogram
Majority are harmless
Some precancerous/cancerous
What are two of most important mammography indicators of breast ca?
Masses
Microcalcifications
What is in a histology report from breast tissue sample?
Invasive or non-invasive Type: ductal or lobular Grade Size Margins Lymph nodes Estrogen/progesterone receptor
Where is the usual spread of breast ca?
Local - skin, pectoral muscles
Lymphatic - axillary, internal mammary nodes
Blood - bone, lungs, liver, brain
What is the prognosis tool for breast ca?
Nottingham Prognostic Index (NPI)
Which tumours don’t respond to hormonal therapies?
ER/PR negative tumours
What does HER-2 status predict?
Response to trastuzumab (Herceptin)
20-30% are positive Her-2
What are the 5 molecular subtypes of breast ca?
Normal Basal Luminal A Luminal B Her-2
What is the management of breast ca?
Staging Surgery Radiotherapy Antihormonal therapy Chemotherapy
What is the antihormonal therapy for breast ca?
Tamoxifen
What are the surgery options for breast ca?
Mastectomy
Breast conserving surgery +/- lymph nodes
What is Paget’s disease of the nipple a result of?
Intraepithelial spread of intraductal carcinoma
What are signs of Paget’s disease of the nippled?
Pain/itching Scaling/redness Mistaken for eczema Ulceration Crusting Serous/bloody discharge
What is gynecomastia associated with?
Hyperthyroidism Cirrhosis of liver Chronic renal failure Chronic pulmonary disease Hypogonadism Use of hormones
