BREAST PATHOLOGY

Question 1

What is the position of the breast ?

Answer 1

• extend from 2nd to 6th rib
• transversely extend from lateral border of sternum to midaxillary line
• lies over the pectoralis major

Question 2

Blood supply of the breast

Answer 2

Arterial (PAI)
1. Posterior Intercostal artery
2. Axillary artery
3. Internal Thoracic artery

Venous
1. Intercostal vein
2. Axillary vein
3. Internal thoracic vein

Question 3

Nerve supply of the breast

Answer 3

anteromedial and anterolateral branches of thoracic intercostal nerves T3-T5

Question 3

Lymphatic drainage of the breast

Answer 3

drain into axillary lymph node

Question 4

lady presented with breast lump . Differential diagnosis ?

Answer 4

Fibroadenoma
Fibrocystic breast tissue
Phyllodes tumour

Question 5

What is triple assessment ?

Answer 5

1. Clinical examination
2. Imaging (BI-RADS)
3. Pathology

Question 6

Clinical examination consist of what

Answer 6

History taking
Physical examination

Question 7

Imaging consists of what

Answer 7

1. Ultrasound of the breast
   *useful in young woman ( < 35yo)
2. Mammography
   *Sensitive increases with age (breast is less dense = more fat, less
   glandular tissue)
   * Taken in two views (craniocaudal view, mediolateral oblique view)

Question 8

Malignant findings in ultrasound

Answer 8

• hypoechoic (dark) lesion,
• poorly defined margin,
• taller than wide,
• microlobulation,
• internal calcification

Question 9

Malignant findings in mammography

Answer 9

• irregular border and shape,
• clustered microcalcifications,
• spiculated mass,
• localized architectural distortion

Question 10

For pathology ( triple assessment ) what do we do ?

Answer 10

1. Fine needle aspiration cytology
   * Pros: least invasive; rapid and very accurate, less painful, does not
   require analgesia

• Cons: false negatives can occur; cannot distinguish between invasive
  cancer and in situ disease

2. Trucut biopsy
   *Definitive pre-operative diagnosis
   * Pros: able to differentiate between DCIS and invasive disease; can
   identify cell type and the grading; allows specimen to be stained for
   ER, PR status and HER-2 status

Question 11

Risk factors of breast carcinoma

Answer 11

➢ Early menarche <12 years old
➢ Late menopause >55 years old
➢ First full-term pregnancy at late age (>30 years old)
➢ Nulliparity
➢ Oral contraceptive pill
➢ Hormonal replacement therapy (>10 yrs)
➢ High alcohol consumption
➢ Exposure to ionizing radiation (previous breast disease)
➢ Family history of cancer (breast, ovary, colon, prostate, gastric, pancreatic)
➢ Obesity
➢ Age > 50 yo
➢ No breast-feeding

Breastfeeding - protective factor

Question 12

Clinical features of locally advanced breast carcinoma

Answer 12

➢ Peau d’ orange
➢ Ulceration and fungating
➢ Fixed axillary lymph node
➢ Tethering, skin dimpling and puckering
➢ Cancer-en-cuirasse

Question 13

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Criteria for Breast Conserving Surgery

Answer 13

✓ Criteria of BCS:
* Tumour size less than 5cm
* No skin or chest wall involvement
* No metastatic disease
* Appropriate tumour size-to-breast ratio
* Only 1 tumour, not multi-centric, unless within same quadrant
* Patient must agree to have post-operative radiotherapy

Question 14

Complication od mastectomy and axillary clearance

Answer 14

✓ Neuropathy (long thoracic nerve [wing scapula], thoracodorsal nerve [latissimus
dorsi muscle -> limitation of arm & shoulder movement], medial pectoral nerves
[partial atrophy of pectoralis minor])
✓ Hematoma (POD1)
✓ Wound infection (POD3)
✓ Seromas (collection of serous fluid in a surgically created cavity)
✓ Skin flap necrosis
✓ Restricted shoulder mobility
✓ Pain and numbness in the upper arm and axilla
✓ Lymphedema (either cause by post-radiation, post-operation, pre-operative [locally
advance])

Question 15

Characteristics of phyllodes tumour

Answer 15

▪ Large massive tumour
▪ Fast growing mass
▪ Unevenly bosselated surface
▪ Mobile despite size
▪ Skin may show ulcerations dt pressure necrosis

Question 16

Characteristics of fibroadenoma

Answer 16

▪ In young women (15-30 yo)
▪ Smooth, firm, well-circumscribed
▪ Very mobile (breast mice)

Question 17

Characteristic of fibrocystic breast changes

Answer 17

▪ Mobile
▪ Not fixed
▪ Cyclical mastalgia

Question 18

Pathophysiology of peau d’orange

Answer 18

The primary cause of peau d’orange in the breast is fluid buildup within the breast tissue
* cutaneous lymphatic obstruction by tumour leads to oedema of skin with intact sweat glands.

Question 19

Pathophysiology ofskin dimpling , puckering and tethering

Answer 19

Infiltration of Cooper’s ligament by tumour causing it to be shortened and
inelastic, pulling the skin inwards, puckering the skin surface.

Question 20

Chemotherapy drug

Answer 20

o 5-Florouracil, Epirubicin, Cyclophosphamide for 6-8 cycles

o Anthracycline (epirubicin) + taxanes (paclitaxel)

5-Fluorouracil (5-FU): Antimetabolite that disrupts DNA synthesis.
Epirubicin: Anthracycline that damages DNA and interferes with cell division.
Cyclophosphamide: Alkylating agent that damages DNA and kills cancer cells.
Anthracycline (epirubicin) + taxanes (paclitaxel): This refers to a sequential therapy combining two types of drugs: