Breast week Flashcards
1
Q
Describe the surface anatomy of the breast
A
Between ribs 2 and 6
T4 dermatome
2
Q
Describe the anatomy of the breast briefly
A
Sits infant of deep fascia and the pectorals major muscle
Made up of 15-25 lobes, each containing ducts leading to the nipple
Fibrous and adipose tissue between lobes
3
Q
Where do the suspensory ligaments attach and what is their function
A
Suspensory ligaments attach between skin and the pec major/ deep fascia
They support the breast tissue
4
Q
What kinds of epithelium lined the lactiferous duct?
A
Stratified squamous epithelium
Stratified cuboidal epithelium
5
Q
What kinds of epithelium lines the acini?
A
Secretory epithelial cells (varies from cuboidal to columnar)
Outer layer of myoepithelial cells
6
Q
What type of epithelium covers the nipple?
A
Keratinised squamous epithelium
7
Q
What changes to breast tissue occur in pregnancy?
A
Reduced connective tissue and adipose tissue
Proliferation of secretory tissue
8
Q
What changes to breast tissue occur with the menopause?
A
Secretory tissue degenerates, leaving only ducts
Reduced connective tissue
9
Q
Describe what is meant by apocrine secretions
A
Lipid droplets are surrounded by a membrane which carry a small amount of cytoplasm with it
10
Q
Describe what is meant by merocrine secretions
A
EXOCYTOSIS
11
Q
Mastalgia is usually cyclical. When does the pain tend to be most intense?
A
During the immediate premenstrual phase of the cycle
12
Q
What is the usual management for mastalgia?
A
Reassure
Well fitting bra and exercise
Tamoxifen/ NSAIDs
13
Q
What is the most common cause of spontaneous nipple discharge?
A
Intraductal papilloma
14
Q
What is the main advantage of breast histopathology over breast cytopathology?
A
Allows for the identification of invasive cancers vs carcinoma in situ
(rather than just identifying something as cytologically malignant)
15
Q
What are 4 examples of developmental anomalies of the breast?
A
Hypoplasia
Juvenile hypertrophy
Accessory breast tissue
Accessory nipple
16
Q
What are some inflammatory examples of benign breast disease?
A
Mastitis/ abscess
Fat necrosis
Duct ectasia
17
Q
List some benign breast tumours
A
Phyllodes tumour
intraduct tumour
Lipoma
Adenolipoma
18
Q
What is a galactocele?
How is it managed?
A
Palpable milk-filled cyst most commonly associated with pregnancy or lactation
Diagnosed and drained by FNA
19
Q
What is gynaecomastia?
A
Breast development in the male
ductal growth without lobular involvement
20
Q
What can cause gynaecomastia in males?
A
Exogenous or endogenous hormones
Cannabis
Prescription drugs
Liver disease
21
Q
Fibrocystic change is very common in women. How does it present?
A
Smooth lumps
Sudden pain / cyclical pain
22
Q
How is fibrocystic change managed?
A
Exclude malignancy
Reassure that they usually resolve after the menopause
Excise if necessary
23
Q
What kind of epithelium lines cysts?
A
Apocrine epithelium
24
Q
Describe the gross pathological appearance of cysts associated with fibrocystic change
A
Blue domed cysts with pale fluid
Intervening fibrosis
Usually multiple
25
What is a hamartoma?
Lesions composed of normal breast cell types but present in an abnormal proportion or distribution
26
What is the most common benign breast condition?
Fibroadenoma
27
Describe how fibroadenoma presents
Painless, firm, mobile mass
28
Which breast condition is described as the "breast mouse"
Fibroadenoma
Because the mass is small firm and mobile like a little mouse
29
Fibroadenomas are described as "biphasic", what does this mean?
Contain both epithelium and stromal elements
30
How are fibroadenomas managed?
Ultrasound core biopsy to confirm diagnosis
Reassure
Excise if the woman wishes (usually decrease in size with the menopause)
31
What are sclerosing lesions of the breast?
Benign disorderly proliferation of acini and stroma
32
How do sclerosing lesions present?
Pain
Lumpiness/ thickening
33
Stellate architecture, central puckering, radiating fibrosis
These are pathological findings of which benign condition?
Sclerosing lesions
34
How are sclerosing lesions managed?
Excise / sample with vacuum biopsy
35
What can cause fat necrosis?
Local trauma (e.g seat belt injuries)
Warfarin therapy
36
How is fat necrosis managed?
Exclude malignancy
Usually subsides spontaneously
37
How does duct ectasia present?
Pain
Bloody discharge
Fistulation
Nipple retraction and distortion
38
How is duct ectasia managed?
Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts
39
What are the two main causes of acute mastitis?
Duct ectasia
Lactation
40
If a case of mastitis is unresponsive to treatment, what condition should be considered?
Inflammatory carcinoma
41
How does breast abscess present?
Symptoms of mastitis with a central mass
42
What antibiotics should be used for mastitis caused by duct ectasia?
Metronidazole to cover anaerobes
As well as what other antibiotic is required
43
What organisms are most likely to cause mastitis from lactation?
Staph aureus
Strep pyogenes
44
How does mastitis present?
Fever
Erythema
Induration
Tenderness
Swelling
45
What investigation is used for abscess?
Ultrasound
46
How is mastitis / abscess managed?
Antibiotics
Percutaneous drainage
47
What is the advice about breastfeeding that should be given to patients with mastitis?
Breast feeding should be continued if already begun
Should check and advise on breastfeeding technique
48
What is mondor's disease?
phlebitis and clot formation in the superficial veins of the breast
49
How do phyllodes tumours present?
Slow growing unilateral breast mass
50
How intraduct papillomas present?
Slight bloody nipple discharge
or asymptomatic
51
What is the most common type of malignant breast disease?
Ductal invasive and in situ carcinoma
52
What factors in a women reproductive history increase and decrease breast cancer risk?
Early menarche and late menopause increase risk
Early pregnancy and breastfeeding decrease risk
53
What things increase breast cancer risk?
Oestrogen (hormonal contraceptives, more menstrual cycles e.g late menopause/ early menarche
Obesity
Alcohol and smoking
Genetics
54
What things decrease breast cancer risk?
Breastfeeding and early pregnancy
NSAIDs
Physical activity
55
What are some of the possible symptoms and signs of breast cancer?
Hard, painless lump
Swelling/ lumps in the armpit
Dimpling of the skin
Bloody discharge
Nipple inversion
Colour and texture changes of the skin
56
Where does breast cancer metastasise to?
```
Bone
Liver
Brain
Lungs
Female genital tract (oestrogen rich site for the cancer to grow)
```
57
What causes the "pea d'orange" skin appearance?
Spread of cancer to lymph which builds up in the interstitial space
Suspensory ligaments don't allow the skin to stretch so it becomes thick and dimpled
58
What is the guidance about use of chemotherapy for breast cancer in pregnant females?
Ok after 14 weeks of pregnancy
Should be stopped within 3-4 weeks of delivery to reduce risks of infection etc
59
What is the guidance about use of radiotherapy and hormonal treatments for breast cancer in pregnant females?
Avoid both radiotherapy and hormonal therapy
60
Which malignant breast tumour is associated with almost always occurring post radiotherapy?
Angiosarcoma
61
Breast carcinomas are malignant tumours of which cell type?
Epithelial cells
62
What is meant by in situ carcinoma?
Cytologically malignant but has not crossed the basement membrane
63
What is lobular in situ neoplasia called depending on whether there is <50% or >50% of the lobule involved?
<50% = atypical lobular hyperplasia (ALH)
>50% = lobular carcinoma in situ
64
Ductal carcinoma in situ is typically "unicentric", what does this mean?
Arises in a single duct system
65
What is paget's disease?
High grade DCIS extending along ducts to the nipple
66
Calcification on mammography is often the first sign of DCIS. Which other breast condition may also present with calcification?
Benign duct ectasia
67
What are the advantages of mammography?
Images the whole breasts
High sensitivity for detecting DCIS and invasive cancers
68
What are the disadvantages of mammography?
Uses ionising radiation
Can be uncomfortable
69
What is tomosynthesis?
3D mammography with multiple images from different angles
70
How does contrast enhanced spectral mammography work?
Contrast is injected
Mammogram is done at two different energies
Low and high energy images are subtracted from each other
The subtraction image only shows breast tissue with a lot of vascularity
71
What are the indications for doing breast ultrasound over a mammogram?
Breast problems during pregnancy
Palpable masses in younger women
Image guided biopsy
72
What are the advantages of breast ultrasound?
No ionising radiation
Not uncomfortable for the patient
Good sensitivity and specificity
Can tell solid from cystic
73
What are the advantages of MRI?
Most sensitive test there is for breast cancer
Most accurate method for sizing and locality assessment for breast cancer
74
What are the disadvantages of MRI?
Find lots of extra bits of cancer you weren't looking for - would have been mopped up by systemic therapies but now need to do surgery
75
What are the indications for using MRI to image the breasts?
Poor assessment with US or mammography
High risk women/ FH
Positive axillary nodes
Looking at implant integrity
76
What are the most common causes of breast lumps by age?
<30 fibroadenoma
30-50 cysts
>50 cancer
77
What are the two main surgical options for breast cancer?
Breast conservation surgery
Masectomy
78
What are the types of breast conservation therapy which can be done?
Lumpectomy
Wide local excision
Wire guided local excision
Oncoplastic breast conservation
79
What are the survival rates like for breast conservation therapy vs mastectomy
Same survival
As long as breast conservation therapy is is done in combination with radiotherapy and the operation has clear margins > 1mm
80
When is wire guided local excision surgery done?
For impalpable cancers
81
What is oncoplastic breast surgery?
Plastic surgery is used to reshape the breasts at the time of resection
82
Masectomy is the removal of all breast tissue. What are the options for reconstruction?
Implant
Latissmus dorsi flap and implant
Deep inferior epigastric artery perforator (DIEP) free flap
Inferior gluteal artery perforator (IGAP) free flap
83
What are the complications that can occur with breast implants?
Loss of implants due to infection
Capsular contracture (body forms scar tissue around the implant)
Implant migration
Implant rippling (esp if the patient is very slim)
84
What % of patients require revision surgery for their implant?
40%
85
What are the advantages of breastfeeding for mother and baby?
Mother baby bond
Maternal protection for the baby
Reduced risk of breast cancer in the mother
Acts as a natural contraceptive
86
What is colostrum?
The first milk produced
High levels of immune proteins
Laxative effect for the baby
87
Describe the physiology of lactation
Baby suckles
Sensory impulses from nipple to brain
Prolactin produced
Milk glands produce ilk
Oxytocin causes contraction and ejection of milk
88
What is neo-adjuvant therapy?
Treatment before the main treatment to improve outcomes
89
What is adjuvant therapy?
Back up treatment given after the main treatment
90
When can hormonal therapy be given?
When tumours have hormone receptors
Given as both neo adjuvant and adjuvant therapy
Also useful for patients who are not suitable for surgery
Aromatase inhibitors are more effective in post menopausal women
91
What are the advantages and disadvantages of doing chemotherapy pre surgery?
Chemotherapy is associated with some overall survival advantage in younger women when it is done pre surgery
Shrinks the tumour pre surgery
Can render the patient unsuitable for surgery due to complications
92
What adjuvant therapy is always necessary with breast conservation therapy?
Radiotherapy
93
In which situations does radiotherapy need to be done post mastectomy?
Involvement of 3+ nodes
+ve surgical margins
Tumours >5cm
94
What are the indications for boost therapy as part of radiotherapy?
Young age
Positive margins
95
Which drug blocks oestrogen receptors and can be used in the management of breast cancer?
Tamoxifen
96
Give some examples of aromatase inhibitors, hormonal therapy which can be used in the management or breast cancer
How do aromatase inhibitors work?
Letrozole, anastrozole
Aromatase converts androgens to oestrogen - so inhibitors decrease oestrogen levels
97
Which chemotherapy drugs are used for breast cancer?
Taxane and anthracycline
98
Which monoclonal antibody drug can be used in the management of breast cancer?
How does it work?
Trastuzumab (Herceptin)
Antibody against HER2 receptor
99
Bisphosphonates can given as palliative treatment.
Give an example of a bisphosphonate
Why are they given?
Oral ibandronic acid
Used in metastatic disease when DXA scan is abnormal
100
How does trastuzumab-emtansine work?
Delivers chemotherapy directly to the tumour
101
What are some of the side effects of tamoxifen?
Vaginal bleeding
Endometrial hyperplasia/ polyps
Venous thromboembolism
Hot flushes
102
Tamoxifen, a hormonal therapy for breast cancer, is associated with causing a slight increased risk of which cancer?
Endometrial cancer
103
What are the side effects of aromatase inhibitors which can be used for breast cancer in post menopausal women?
Stiffness and sore joints/ bones
Hot flushes
104
What are the possible side effects of herceptin (trastuzumab), a monoclonal antibody which can be used in the management of breast cancer?
Allergic reactions
Cardiac failure
105
What are the possible side effects of radiotherapy?
Skin reactions
Lymphoedema
106
When does a patient with neutropenia post chemotherapy need to be admitted?
Neutropenia can be ignored if the patient is well without fever
Patient needs to be admitted if they are septic or have a fever
107
Which hormonal contraceptive needs to be removed in patients with hormone receptor +ve breast cancer?
Mirena coil
108
What is the most likely cause of a breast lump appearing soon after breast cancer surgery?
Fat necrosis
109
Which drugs used in the management of breast cancer can cause hot flushes?
Tamoxifen
Aromatase inhibitors
110
Which drug can be used to manage hot flushes in patients who have developed this side effect from tamoxifen or aromatase inhibitor therapy?
Clonidine
111
Spinal cord compression is common in breast cancers with multiple bone metastasis. How does it present?
Severe back pain
Difficulty walking
112
Where is HER2 positive breast cancer most likely to metastasise to?
Pleura and the CNS
113
Where is lobular breast cancer most likely to metastasise to?
Peritoneum and gut
114
Why are aromatase inhibitors most effective in post menopausal women?
Aromatisation accounts for the majority of oestrogen production in post-menopausal women
115
What is the medication of choice for suppressing lactation when breastfeeding cessation is indicated?
Cabergoline
