Breast Disorders Flashcards
What is the functional unit of the breast called and what does it consist of?
it is called the terminal duct lobular unit and it is composed of a lobule filled with glands, which drain into a common terminal duct
What happens to breast tissue as a woman ages?
the glands involute and are replaced by fat
In which layer of tissue is the breast located?
within the superficial fascia of the chest wall
Most glandular or lobular breast tissue is located where within the breast?
the upper outer quadrant
Describe the ductal epithelium within the breast.
- there is the luminal cell layer, the inner layer which is responsible for milk production
- and there is the myoepithelial layer, which has contractile ability and propels milk towards the nipple
What are “milk lines”?
an imaginary line between the axilla and groin, along which breast tissue can sometimes be found
Define polymastia and polythelia.
- polymastia: true accessory breasts
- polythelia: extra nipples
To what lymph nodes does breast cancer most often spread?
the ipsilateral lymph node and the internal mammary nodes
The breasts receive blood supply from which arteries?
- perforating branches of the internal mammary artery
- lateral thoracic artery
- thoracodorsal artery
- thoracoacrimal artery
- intercostal perforating arteries
What is the effect of estrogen and progesterone on breast tissue?
- estrogen is responsible for growth of adipose tissue and lactiferous ducts
- progesterone leads to lobular growth and alveolar budding
What risk factors exist for breast cancer?
- age
- personal history of breast cancer or atypical hyperplasia
- BRCA mutations
- high breast density
- estrogen exposure
How much earlier is mammography typically able to detect breast lesions than palpation? What is the size threshold for detection with each method?
- mammography is able to detect 1 mm lesions, meaning it typically detects lesions 2 years before they become palpable
- palpation is typically only able to detect lesions 1 cm or larger
What is the BI-RADS system? What are the levels?
a standardized system to help communicate the final assessment and recommendations related to mammography findings
- class 0: need additional imaging
- class 1: negative
- class 2: benign
- class 3: probably benign
- class 4 (A, B, C): low, intermediate, or moderate suspicion of malignancy
- class 5: highly suggestive of malignancy
- class 6: biopsy-proven malignancy
What role does ultrasonography play in evaluating breast lesions?
it is useful in evaluating inconclusive mammography findings, in evaluating breasts of young women and others with dense tissue, allowing better differentiation between solid and cystic masses, and in guiding tissue core-needle biopsy
What does an anechoic defect found on breast ultrasound suggest?
it is suggestive of a simple cyst which can be drained for symptomatic relief
What imaging modality should be used to screen women younger than 30 for breast cancer?
ultrasonography
What role does MRI play in evaluating breast lesions?
it is used as an adjunct for early detection of breast cancer in women at very high risk
If fine-needle aspiration biopsy of a breast lesions drains clear fluid what is the next step? What if it is bloody?
- clear fluid does not require pathologic evaluation
- bloody fluid should be sent for cytologic evaluation ad the patient should undergo diagnostic mammography and ultrasonography
In what circumstances are fine-needle aspiration and core-needle biopsies used to evaluation breast lesions?
- fine-needle is used to obtain a fluid sample from a cystic lesions
- core-needle is used to obtain samples from a larger, solid mass
Contrast cyclic and noncyclic mastalgia.
- cyclic begins during the luteal phase of the menstrual cycle and resolves after the onset of menses with bilateral pain, usually in the upper outer quadrants of the breast
- noncyclic is not associated with the menstrual cycle and includes various etiologies including tumor, mastitis, cysts, or history of trauma
What is the likely diagnosis for someone with cyclic breast pain, beginning in the luteal phase and resolving after the onset of menses, localized to the upper outer quadrant?
cyclic mastalgia
What are the side effects of tamoxifen?
- increased risk of endometrial hyperplasia
- increased risk of DVT
- hot flashes and vaginal bleeding
How does raloxifen compare to tamoxifen with regards to the treatment of mastalgia?
- both are SERMs used off-label for cases of refractory mastalgia
- both are accompanied by a risk for DVT and menopausal symptoms like hot flashes and vaginal bleeding
- however, raloxifen does not carry the same risk for endometrial hyperplasia as tamoxifen
Name three medical therapies for mastalgia.
- danazol
- tamoxifen
- raloxifen
Mammary Duct Ectasia
- chronic inflammation with dilation of the subareolar ducts
- classically arises in multiparous postmenopausal women
- presents as a periareolar mass with a green-brown nipple discharge composed of inflammatory debris
Fibrocystic Change
- development of fibrosis and cysts in the breast; thought to be hormone driven
- lobules dilate and form cysts; the cyst walls are lined by flattened atrophic epithelium or may be modified through apocrine metaplasia; if the cysts rupture, the resulting scarring and inflammation may lead to fibrotic changes
- the most common change in the premenopausal breast
- presents as vague irregularity of the breast tissue bilaterally, usually in the upper outer quadrant, and cysts have a blue-dome appearance on gross exam
- benign but associated with an increased risk for invasive carcinoma IN BOTH BREASTS
Intraductal Papilloma
- a papillary growth into a large duct
- characterized by fibrovascular projections lined by luminal and myoepithelial cells
- classically presents as a bloody nipple discharge in premenopausal women
- must be distinguished from papillary carcinoma, which also presents with a bloody nipple discharge; this is done on the basis that papillary carcinoma has fibrovascular projections lined with luminal but not myoepithelial cells
List possible characteristics of breast masses that suggest malignancy rather than benign processes.
- size greater than 2 cm
- immobility
- poorly defined margins
- firmness
- skin dimpling or color changes
- retraction or change in the nipple
- bloody nipple discharge
- ipsilateral lymphadenopathy
What is the estimated time it takes for a breast tumor to become palpable?
5 years
Describe the pathogenesis of fibrocystic changes of the breast.
- lobules may dilate and form cysts
- these cysts are lined by flattened, atrophic epithelium or epithelium modified through apocrine metaplasia
- if the cysts rupture, the resulting scarring and inflammation may lead to fibrotic changes
Define adenosis.
an increase in the number of glands with associated lobular growth in the breast without a change in the architecture of the lobule
Fibroadenoma of the Breast
- a tumor of fibrous tissue and glands
- the most common benign neoplasm of the breast
- presents in premenopausal women as a well-circumscribed, mobile, marble-like mass
- estrogen sensitive so it grows during pregnancy and may be painful during the menstrual cycle
- carries no risk for carcinoma
Define epithelial hyperplasia and sclerosing adenosis of the breast.
- epithelial hyperplasia is when more than the typical two cell layers in the epithelium
- sclerosing adenosis is when there is increased fibrosis within the expanded lobule which distorts and compresses of the epithelium
What is a radial scar of the breast?
also known as a complex sclerosing lesion, it is a proliferative lesion without atypia defined as a nidus of tubules entrapped in a densely hyalinized stroma surrounded by radiating arms of epithelium
Lobular Carcinoma In Situ
- a malignant proliferation of cells in lobules with no invasion of the basement membrane
- does not produce a mass or calcifications and is usually discovered incidentally on biopsy
- characterized by dyscohesive cells lacking the E-cadherin adhesion protein
- often multifocal and bilateral
- it has a low risk of progressing to invasive carcinoma but treat with tamoxifen and close follow up
- managed with excision biopsy
Ductal Carcinoma In Situ
- a malignant proliferation of cells in ducts without invasion of the BM
- often detected as calcification on mammography, but does not usually produce a mass
- histologic subtypes are based on architecture, and the most important one is comedo type
- comedo type is characterized by high-grade cells with necrosis and dystrophic calcification in the center of ducts
- Paget disease of the breast is another form of DCIS
- patients are at increased risk for invasive cancer or a recurrence of the DCIS lesion
- diagnosed with core-needle biopsy, which is followed with surgical biopsy or excision and finally with tamoxifen
What is the most significant risk factor for developing breast cancer?
advancing age
What risks do BRCA1 and BRCA2 mutations carry?
- BRCA1 has a high risk for both breast and ovarian cancer
- BRCA2 has a high risk for breast cancer but does not carry as much risk for ovarian cancer compared to BRCA1
Describe some risk factors for breast cancer.
- advancing age is the most important
- family history, especially of BRCA mutations
- greater estrogen exposure
- radiation exposure
- dense breast tissue or history of typical hyperplasia or LCIS
Describe the Gail model.
- used to estimate a woman’s risk of developing invasive breast cancer over the next 5 years and in their lifetime
- uses history of LCIS/DCIS, age, age at onset of menstruation, age at the time of the first live birth, number of first-degree relatives with breast cancer, history of breast biopsy, and race
- the strongest predictive factor in this assessment is family history
What aspect of the Gail model is the strongest predictive factor for breast cancer?
a family history of breast cancer
Compare LCIS and DCIS.
- LCIS is often bilateral, multi centric, and increases the risk for invasive cancer in both breasts
- DCIS is unilateral, unicentric, and increases the risk for invasive cancer in the ipsilateral breast
What does a mastectomy involve?
removal of all breast tissue and the nipple areolar complex with preservation of the pectoralis
Lumpectomy should always be supplemented with what other form of therapy?
radiation, when this is used in conjunction with lumpectomy, it has outcomes equal to those of radical mastectomy
What is the mechanism of action of trastuzumab?
it acts on membrane-bound proteins produced by Her2/neu
Most breast cancer recurrences occur within what time period?
five years
What forms of primary prevention are recommended for BRCA mutation carriers?
- monthly breast-self exams beginning at age 18
- annual CBEs
- screening mammograms beginning at age 25 or 5-10 years before the age of diagnosis in the affected relative
