Breast Lectures Flashcards
Describe the location and relations of breasts
- 2nd/3rd rib to 6th rib
- Sternal edge to midaxillary line
- Lies on the deep pectoral fascia
- A small part (axillary tail) may extend towards the axillary fossa
- Retromammary space - helps some degree of movement
Describe the structure of the breast
- Nipple
- Areola
- 15-20 lobules of glandular tissue (parenchyma)
- Each lobule is drained by a lactiferous duct
- Each duct has a dilated portion (lactiferous sinus)
Describe the structure of the nipple
- No fat or hair
- Contains collagenous dense connective tissue, elastic fibres and bands of smooth muscle
- The tips of the nipples are fissured with lactiferous ducts opening into them
- Position: 4th intercostal space (roughly)
Describe the structure of the areola
- Skin covering the nipple and areola contains numerous sweat and sebaceous glands
- Oily secretion lubricates the nipple and areola
Name the four quadrants of the breast
- Superolateral
- Superomedial
- Interolateral
- Inferomedial
Describe the development of the breast
- Mammary crests or ridges appear during the 4th week
- These crests extend from the axillary region to inguinal region
- The crests usually disappear (except in the pectoral region)
- Primary mammary buds > secondary mammary buds > lactiferous ducts and their branches
What is the blood supply to the breasts?
- Branches of axillary, internal thoracic and some intercostal arteries
- Thoraco acromial a.
- Lateral thoracic a.
- Internal mammary a.
What is the innervation of the breasts?
- Anterior and lateral cutaneous branches of 4-6th intercostal nerves
- Sensory fibres and sumpathetic fibres to the blood vessels and smooth muscle
Which lymph nodes drain lymph from the breasts?
-Axillary lymph nodes
-Supraclavicular nodes
-Inferior cervical nodes
-Parasternal
(can drain to the opposite breast)
What is the function of the terminal duct lobular unit?
Milk secretory component of the breast
Describe the features of breast tissue prepuberty
- Neonatal breast contains lactiferous ducts but no alveoli
- Until puberty, little branching of the ducts occurs
- Slight breast enlargement reflects the growth of fibrous stroma and fat
Describe the features of breast tissue at puberty
- Branching of lactiferous ducts
- Solid, spheroidal masses of granular polyhedral cells
- Accumulation of lipids in the adipocytes
Describe the features of breast tissue post menopausal
- Progressive atrophy of lobules and ducts
- Fatty replacement of glandular tissue
Name the signs of breast cancer
- Skin dimpling
- Abnormal contours
- Oedema of the skin
- Nipple retraction or deviation
Name some of the benign breast tumours
- Fibroadenoma
- Duct papillomas
- Adenomas
- Corrective tissue tumours
What is cytology and how can samples be obtained?
- Miscroscopic examination of a thin layer of cells on a slide
- FNA
- Direct smear from nipple discharge
- Scrape of nipple with scalpel
Which groups of patients should get cytology?
- Symptomatic patients (discrete mass, diffuse thickening and nipple lesion)
- Breast screening
What would you see on a benign cytology?
- Low/moderate cellularity
- Cohesive groups of cells
- Flat sheets of cells
- Bipolar nuclei in the background
- Cells of uniform size
- Uniform chromatin pattern
What would be seen on a malignant cytology?
- High cellularity
- Loss of cohesion
- Crowding/ overlapping of cells
- Nuclear pleomorphism
- Hyperchromasia
- Absence of bipolar nuclei
Which features on a cytology would suggest a specific type of cancer?
- Cytoplasmic vacuoles: lobular carcinoma
- Cells arranged in tubes: tubular carcinoma
Describe the cytology scoring system
- C1: unsatisfactory
- C2: benign
- C3: atypia (probably benign)
- C4: suspicious
- C5: malignant
What is the treatment for cysts?
Aspiration: fluid is then discarded unless blood stained or there is residual mass
What are the advantages of cytology?
- Simple procedure
- Well tolerated
- Inexpensive
- Immediate results
What are the limitations of cytology?
- Accuracy not 100%
- False positives and false negatives
- Invasion cannot be assessed
- Grading cannot be done
- Sampling: lesion can be missed
- Suboptimal smears
- Interpretation: features are similar
What are the complications of FNA?
- Pain
- Haematoma
- Fainting
- Infection
- Pneumothorax (rare)
Which nipple lesions can be diagnosed from cytology of nipple discharge?
- Duct ectasia: macrophages only
- Intraduct papilloma: benign cells in papillary groups
- Intraduct carcinoma: malignant cells
What can cytology of a nipple scrape determine?
Whether there is Paget’s disease or eczema
What is an axillary lymph node FNA used for?
Pre-operative planning
When is a core biopsy performed?
- All cases with clinical/ radiological/ cytological suspicion
- Breast screening
- Pre-operative classification
What can a core biopsy do?
- Confirms invasion
- Tumour typing and grading
- Immuno histochemistry - receptor status
Which imaging techniques can be used for imaging breast tissue?
- Mammography
- USS
- MRI
- Nuclear medicine
- Image guided techniques
- CT
When should a mammography be used?
- Over age 40
- Under 40: if strong suspicion of cancer or FH risk > 40%
When should an USS be used?
- To differentiate solid from cystic and benign from malignant
- First line for under 40yrs
What is involved in a triple assessment?
- Clinical examination
- Imaging
- FNA cytology
What are the indications for an MRI of the breast?
- Recurrent disease
- Implants
- Indeterminate lesion following triple assessment
- Screening for high risk women
Describe how the breast screening programme works
- Women aged 50-70 invited every 3 yrs for a mammography
- Detects 5 cancers for every 100 screened
- Aims to detects cancers at DCIS stage or less than 15mm in size
- Additional views: clinical exam, USS, FNA or core biopsy
Give examples of benign breast conditions
- Fibrocystic change: fibrosis, adenosis, cysts, apocrine metaplasia, ductal epithelial hyperplasia
- Fibroadenoma: circumscribed mobile nodule
- Intraduct papilloma: lactiferous ducts and nipple discharge
- Fat necrosis: traumatic
- Duct ectasia: nipple discharge
Describe the features of a fibroadenoma
- Proliferation of epithelial and stromal elements
- Most common breast tumour in adolescent and young adult women
- Well circumscribed, freely mobile and non painful mass
- May regress with age if left untreated
Describe the features of a tubular adenoma
- Far less common
- Young women
- Discrete, freely movable masses
- Uniform sized ducts
Describe the features of a lactating adenoma
- Enlarging masses during lactation or pregnancy
- Prominent secretory changes
Describe the features of a phyllodes tumour
- Fleshy tumour: leaf like pattern and cysts on cut surface
- Benign, borderline or malignant
- Metastases are haematogenous
Describe the features of breast carcinoma
- Hard, fixed mass which is tethered to the skin
- Peau d’ orange dimpling of the skin
- Soft tissue opacity and microcalcification on a mammogram
What are the risk factors for breast cancer?
- Gender
- Age
- Menstrual history
- Age at first pregnancy
- Radiation
- FH
- Hormonal treatment
- Genetic factors (BRCA1 and 2)
- Obesity and lack of physical activity
- Alcohol
Name the histological classification of breast cancer
- Non Invasive: ductal carcinoma in situ and lobular carcinoma in situ
- Invasive: invasive ductal carcinoma and invasive lobular carcinoma
Describe the features of in situ carcinoma
- Preinvasive (not a palpable tumour)
- Not detected clinically
- Multicentricity and bilaterality
- No metastatic spread
- Risk of invasion depends on the grade
How can breast cancer be diagnosed?
- Clinical examination
- Radiology: mammogram, USS and MRI
- FNA cytology
- Needle core biopsy
- Wide local excision
What are microcalcifications and what is their significance?
- Tiny deposits of calcium
- Majority are harmless
- Minority may be in precancerous or cancerous tissue
What is included in the histology report?
- Invasive vs non invasive
- Histological type
- Grade
- Size
- Margins
- Lymph nodes
- Oestrogen/progesterone receptor
- HER-2
How does breast cancer spread?
- Local: skin and pectoral muscles
- Lymphatic: axillary and internal mammary nodes
- Blood: bone, lungs, liver and brain
Which factors affect the prognosis of breast cancer/
- Node status
- Tumour size
- Type and grade
- Age
- Lymphovascular space invasion
- Oestrogen and progesterone receptors
- HER-2
- Proliferation rate of tumour
- Gene expression profiling
- Nottingham prognostic index
What do ER ad PR receptors show?
Presence is strong predictor of response to hormonal therapies
How is breast cancer managed?
- Staging
- Surgery
- Radiotherapy
- Antihormonal therapy (Tamoxifen)
- Chemotherapy
Describe the features of Paget’s disease of the nipple
- Result of intraepithelial spread of intraductal carcinoma
- Large pale staining cells within the epidermis of the nipple
- Limited to the nipple or extend to the areola
- Pain or itching, scaling and redness
- Ulceration, crusting and serous or bloody discharge
Which investigations are used to assess the severity of the breast cancer?
- FBC, U&Es, LFTs, calcium and PO2
- CXR
What are the two main types of surgery to the breast?
- Breast conservation surgery
- Mastectomy
Which patients are suitable for breast conservation surgery?
- Breast/tumour size ratio
- Suitable for radiotherapy
- Single tumours < 4cm (in olden days)
What are the complications of axillary treatment?
- Lymphoedema
- Sensory disturbance
- Decreased ROM of the shoulder joint
- Nerve damage
- Vascular damage
- Radiation induced sarcoma
