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Breast Week Flashcards

1
Q

What types of tissue make up the breast

A

Secretory tissue - 15-20 glands which drain via a series of ducts
Dense fibrous tissue
Adipose tissue - lots of it

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2
Q

How is the breast divided

A

It has lobes which are divided by connective tissue into lobules
There are about 15-20 lobes which each have an acinar gland which drains via ducts
Each lobe is served by a lactiferous duct

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3
Q

What compartment does the breast lie in

A

Subcutaneous compartment of skin

Lies on top of the fascia of pec major with the retromammary space in between

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4
Q

How are the breasts supported

A

Aggregations of connective tissue from between lobules form the suspensory ligaments
They run from clavicle to deep fascia and dermis of the skin
Provides support to the breast tissue

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5
Q

What is the functional secretory unit of the breast

A

The Terminal Duct Lobular Unit (TDLU)

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6
Q

Describe the path from the terminal ductules to the nipples

A

The terminal ductules lead into an intralobular collecting duct which leads into the lactiferous duct for that lobe
This duct then leads to the nipple and passes through an expanded part of the duct called the lactiferous sinus

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7
Q

What changes occur in the breast during pregnancy

A

Duct tissue is epithelial and will proliferate
Myoepithelial cells also proliferate
There is elongation and branching of the smaller ducts
Plasma cells and lymphocytes infiltrate the connective tissue
Secretory alveoli differentiate and mature
rER develops
Reduction in amounts of connective tissue and adipose

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8
Q

How does the connective tissue differ inside and outside the lobule of the breast

A

Inside the lobule the CT is loose and cellular

Outside it is dense and fibrous

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9
Q

What is the function of the myoepithelial cells of the breast

A

They can contract to push material out of the duct system

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10
Q

What lines the larger ducts of the breast

A

Epithelium which varies from thin stratified squamous to stratified cuboidal

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11
Q

Describe the structure of the nipple

A

Covered by a thin, highly pigmented keratinised stratified squamous epithelium
It has a wrinkled surface with multiple sebaceous glands which open directly onto the skin surface
The core of the nipple is dense, irregular connective tissue with bundles of smooth muscle

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12
Q

What happens to the breast during the luteal phase of the menstrual cycle

A

The epithelial cells increase in height, the lumina of the ducts becomes enlarged and small amounts of secretions appear in the ducts.

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13
Q

What is the function of the plasma cells in the breast

A

The secrete IgA antibodies which can be passed to the baby via breastmilk

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14
Q

What drives the development of the breast during pregnancy

A

Oestrogen and progesterone

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15
Q

Describe the composition of breast milk

A

Mostly water - over 80%
Then carbohydrate - mainly lactose
Then lipid
Then protein - mainly lactalbumin and casein

Also has small quantities of ions, vitamins and IgA antibodies

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16
Q

How are lipids secreted from the breast

A

Globules of fat are free in the cytoplasm and are taken up to the membrane for release
When they are released they are surrounded by a bit of membrane and cytoplasm
This is known as apocrine secretion

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17
Q

How are proteins secreted from the breast

A

Protein component of milk is made in the rER
In the golgi apparatus it is packaged into a vacuole which is taken to the apical end of the cell
This merges with the cell membrane and is can be released
Known as merocrine secretion

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18
Q

What is unique about secretion in the breast

A

You get two types of secretion from the one cell

Get apocrine and merocrine secretions

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19
Q

What happens to the breast during menopause

A

The secretory cells of the TDLU’s degenerate leaving only ducts
There are fewer fibroblasts and you lose elastic fibres - sagging

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20
Q

What is the most common cell type to become cancerous in the breasts

A

The epithelial cells as they are constantly changing

Carcinoma is therefore the most common

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21
Q

How do you perform fine needle aspiration

A

Use a 5ml syringe and a fine needle – move around the lesion to get a wide sample
Place it on a slide and stain for analysis
It is a fast and easy test

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22
Q

How can you sample from the breast for cytopathology

A

Fine Needle Aspiration (FNA)
Fluid
Nipple discharge
Nipple scrape

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23
Q

What type of cells are you trying to sample in FNA

A

Epithelial cells

Most likely cancer

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24
Q

What are the result classifications for cytology

A 
C1 - Unsatisfactory
C2 - Benign
C3 - Atypia, probably benign
C4 - Suspicious of malignancy
C5 - Malignant

If C3 you don’t operate immediately but try and confirm diagnosis

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25
Q

When is a skin biopsy used in breast pathology

A

It is only useful if the lesion has skin involvement

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26
Q

What biopsy techniques are used for diagnosis in breast pathology

A

(Needle) core biopsy
Vacuum assisted biopsy (large volume)
Skin biopsy
Incisional biopsy of mass - only if suspected benign

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27
Q

What biopsy techniques can be used therapeutically in breast pathology

A

Vacuum assisted excision
Excisional biopsy of mass
Resection of cancer - Wide local excision or mastectomy

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28
Q

How do you perform a core biopsy

A

Spring loaded needle which takes a sample very quickly from the centre of the lesion
Less painful than FNA

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29
Q

What are the result classifications for a core biopsy

A 
B1 - Unsatisfactory / normal
B2 - Benign
B3 - Atypia, probably benign
B4 - Suspicious of malignancy
B5 - Malignant
B5a - carcinoma in situ
B5b - invasive carcinoma
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30
Q

How is vacuum assisted biopsy performed

A

The needle can be placed under radio guidance and then left in situ to then take the sample
Suction pulls the tissue into the tube when then closes to cut off a sample
Takes a much bigger section of tissue

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31
Q

Where does a carcinoma tend to spread

A

Within the segment that is began in

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32
Q

List some common developmental abnormalities of the breasts

A

Hypoplasia - can be unilateral
Juvenile hypertrophy - grow massively over a very short period
Accessory breast tissue - most often in axilla
Accessory nipple

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33
Q

What is gynaecomastia

A

Breast development in men
Hormone driven - imbalance between oestrogen relative to androgens
Ductal growth without lobular development

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34
Q

List common non-neoplastic breast diseases

A 
Gynaecomastia
Fibrocystic change
Hamartoma
Fibroadenoma
Sclerosing lesions - sclerosing adenosis or radial scar
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35
Q

List common inflammatory breast diseases

A

Fat necrosis
Duct ectasia
Acute mastitis/abscess

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36
Q

What causes fat necrosis

A

Occurs after trauma to the breast – seatbelt injury common
Some develop it after starting warfarin therapy

There is damage to the adipocytes and fat comes out of the cells
Inflammatory cells come along to destroy it which leads to fibrosis and scarring

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37
Q

What causes gynaecomastia

A

Exogenous/endogenous hormones - can be transferred via breastmilk
Cannabis
Prescription drugs
Liver disease - disrupts metabolism of cholesterol so there can be an excess of oestrogen
Thyrotoxicosis
Oestrogen secreting neoplasms
Testicular and adrenal gland tumours

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38
Q

How do fibrocystic breast changes present

A 
Smooth discrete lumps
Sudden pain - from rupture or bleed 
Cyclical pain
Lumpiness
Incidental finding
Screening
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39
Q

When does fibrocystic change usually occur

A

Women aged 20-50 - childbearing age
Commoner in the upper ages

Often resolve or diminish after menopause

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40
Q

Describe the gross pathology of fibrocystic breast changes

A

Cysts - usually multiple

Intervening fibrosis

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41
Q

Describe the microscopic pathology of fibrocystic breast changes

A

Cysts have thin walls but may be fibrotic
They are lined by apocrine epithelium
Intervening fibrosis

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42
Q

What is metaplasia

A

The change from one fully differentiated cell type to another fully differentiated cell type

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43
Q

How do you manage fibrocystic change

A

Exclude malignancy
Reassure
Excise if necessary - only if causing issue for the patient

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44
Q

What is a hamartoma

A

Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
Right cells but not in the correct structure or proportion
It is benign

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45
Q

How do you manage a hamartoma

A

Exclude malignancy
Reassure
Excise if necessary - only if causing issue for the patient

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46
Q

Which group are fibroadenomas more common in

A

Common in African women
Peak incidence in 3rd decade
Fibroadenoma is the most common lump in young women

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47
Q

How does a fibroadenoma present

A 
Painless or non tender
Discrete solitary mass
Firm but not hard – may feel rubbery 
Will be solid on US 
Mobile 
Breast mouse – move away from your fingers as you try and examine them
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48
Q

What is a fibroadenoma

A

Overgrowth of epithelium and stroma - connective tissue
Biphasic lesion
Contains receptors for progesterone and oestrogen - affected by pregnancy and menstruation

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49
Q

How do you manage a fibroadenoma

A

Diagnose - US and histology
Mammogram if >40

Reassure - most are reabsorbed

Excise - easily done, if small enough it can be done by vacuum
Done if symptomatic or rapidly growing

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50
Q

What are sclerosing lesions

A

Benign, disorderly proliferation of acini and stroma

Can cause a mass or calcification

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51
Q

Describe sclerosing adenosis

A

Disordered myoepithelial cells

Doesn’t infiltrate the surrounding tissue - benign

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52
Q

How are radial scars defined

A

If over 10mm its called a complex sclerosing lesion

If less just called a radial scar

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53
Q

Describe the structure of a radial scar

A 
Stellate architecture 
Central puckering
Radiating fibrosis - contains distorted ducts 
Fibrocystic change
Fibroelastic core 
Epithelial proliferation
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54
Q

What does a radial scar mimic

A

Carcinoma
Has epithelial proliferation
Appears similar on radiology

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55
Q

How do you treat a radial scar

A

Excise or sample extensively by vacuum biopsy

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56
Q

How do you manage fat necrosis

A

Confirm diagnosis

Exclude malignancy

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57
Q

How does fat necrosis present

A

Firm round lump
May be tender
Surrounding skin can be dimpled or thickened
Nipple can become retracted

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58
Q

What are the clinical features of duct ectasia

A 
Pain
Acute episodic inflammatory changes
Bloody and/or purulent D/C
Fistulation
Nipple retraction and distortion
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59
Q

What happens in duct ectasia

A 
Sub-areolar duct dilatation
Periductal inflammation
Periductal fibrosis
Scarring and distortion
Ducts get blocked and inflamed – can form an abscess
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60
Q

How do you manage duct ectasia

A

Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts

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61
Q

Which lifestyle choice is associated with duct ectasia

A

Smoking

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62
Q

What are the 2 main causes of acute mastitis

A

Duct ectasia - non infectious blockage of lactiferous duct
Seen in heavy smokers

Foreign body such as piercing

Lactation (cracked nipples) - staph aureus or strep pyogenes
Seen in breastfeedin mums

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63
Q

How do you manage acute mastitis and abscesses

A

Antibiotics
Percutaneous drainage or incisional drainage for an abscess
Treat underlying cause

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64
Q

Describe a phyllodes tumour

A

Slow growing unilateral breast mass
Biphasic tumour caused by stromal
Can be benign or malignant

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65
Q

Which papillary lesions can affect the breast

A

Intraduct papilloma
Nipple adenoma
Encapsulated papillary carcinoma

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66
Q

How does an intraduct papilloma present

A

Nipple discharge +/- blood
May have nodules or calcification at screening
Can be asymptomatic

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67
Q

What is the current trend in breast cancer incidence and mortality

A

Incidence is rising

Mortality is falling

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68
Q

How does breast cancer present

A

50% asymptomatic via screening route

50% symptomatic and half with a lump

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69
Q

When is breast screening started

A

Age 50
After the menopause - more effective then
Screening is difficult in a young, dense breast

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70
Q

List some risk factors for breast cancer

A

Age - risk increases from 40 if pre-meno and 50 for post-meno
Being female
Family history
Prior history of breast cancer
Genetics - BRCA1 and 2
Multiple exposures to therapeutic radiation
Nulliparity or first pregnancy over 30
Combination hormone replacement therapy
BMI over 25, exercise, smoking, diet and alcohol consumption

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71
Q

What is involved in the triple assessment carried out in breast clincis

A

See symptomatic ladies in clinic
They get a clincial diagnisis - breast exam,
Radiological diagnosis - mammogram and US
And pathological diagnosis - a biopsy

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72
Q

What type of imaging is used in breasts

A

Mammography - 4 views

US

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73
Q

How can breast cancer be treated

A

Locally - surgery (wide excision or mastectomy) or radiotherapy

Systemic - chemo, hormonal or targeted therapies

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74
Q

What is oncoplastic breast surgery

A

Where you remove the tumour but try and conserve the breast as much as possible
Makes reconstruction easier

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75
Q

How do hormone therapies work in the treatment of breast cancer

A

Block production of oestrogen as this drives the division and growth of breast cancer cells
Most common example is tamoxifen

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76
Q

What is Herceptin

A

A targeted therapy for breast cancer

The monoclonal antibody trastuzumad is used to target Human Epidermal Growth Factor Receptor 2

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77
Q

Where does breast cancer metastasise to

A

Primarily bone mets

Then soft tissue – liver, brain, lung

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78
Q

What causes a breast cyst to form

A

Caused by a milk duct not reabsorbing the fluid it has produced – common at end of cycle as body has been prepping for pregnancy

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79
Q

What age group is most commonly affected by cysts

A

More common in 40s-50s

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80
Q

What is a papilloma

A

It is like a skin tag within a duct that produces fluid
Creates a more complex cysts
Very rarely they can contain malignant cells

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81
Q

How can you manage benign breast pain

A

Making sure bra fits and reducing caffeine can help with pain
Can be affected by cycle
Some women can get low does tamoxifen which reduces effect of oestrogen

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82
Q

Which groups are prone to mastitis

A

Breastfeeding women

Smokers

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83
Q

What commonly causes angiosarcoma

A

previous radiotherapy

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84
Q

Which tumours often metastasise to the breast

A 
Bronchial carcinoma 
Ovarian serous carcinoma
Clear cell carcinoma of kidney
Malignant melanoma
Leiomyosarcoma - often from uterus
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85
Q

Define a breast carcinoma

A

A malignant tumour of breast epithelial cells

Technically an adenocarcinoma as it’s a glandular epithelium

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86
Q

Where does a breast carcinoma usually arise

A

Arises in the glandular epithelium of the terminal duct lobular unit

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87
Q

List ductal lesions that are often precursor lesions to carcinoma

A

Epithelial hyperplasia
Columnar cell change
Atypical Ductal Hyperplasia
Ductal Carcinoma in situ

88
Q

List lobular lesions that are often precursor lesions to carcinoma

A

Lobular in situ neoplasia

May be atypical

89
Q

What is meant by carcinoma in situ

A

Confined within basement membrane of acini and ducts
Cytologically malignant but non - invasive
A precursor to invasive cancer

90
Q

Describe the cells commonly seen in lobular in situ neoplasia

A

Small-intermediate sized nuclei
Solid proliferation
ER positive
E-cadherin negative - dyscohesive cells as lacking this adhesion protein

91
Q

What drives the growth of lobular in situ neoplasia

A

Oestrogen

So incidence drops after menopause (less oestrogen)

92
Q

What are the features of lobular in situ neoplasia

A

Frequently multifocal and bilateral
Not usually palpable or visible grossly
May appear as calcification on mammography
Often an incidental finding

93
Q

How do you manage a lobular in situ neoplasia

A

If found on core biopsy then proceed to excision or vacuum biopsy
Need to exclude higher grade lesions
If nothing else found then just follow up

94
Q

Where does DCIS usually affect

A

Arises in the terminal duct lobule unit

Usually affects a single segment – one duct

95
Q

What is Paget’s disease of the breast

A

An eczemoid change of teh nipple
When underlying malignancy involves the nipple skin - typically high grade DCIS
Still considered in situ as its stays within the basement membrane
Risk factors are the same as for breast cancer

96
Q

Describe the cells found in DCIS

A

Cytologically malignant epithelial cells in the ducts
Can be subtyped based on cell architecture
Confined by basement membrane of duct - don’t invade BM
Can involve the lobules and nipples

97
Q

Which grade of DCIS features necrosis

A

High grade only

98
Q

How do you manage DCIS

A

Surgery with adjuvant chemotherapy

Can use endocrine therapy

99
Q

What is a micro invasive carcinoma

A

It is a high grade DCIS which has invaded <1mm past the basement membrane
Low risk of metastasis
Treat as a high grade DCIS

100
Q

What is the definition of an invasive breast carcinoma

A

Malignant epithelial cells which have breached the BM
Infiltration of normal tissues
Risk of metastasis and death

101
Q

In what age group is breast cancer incidence the highest

A

Older women

Starts to peak at late 40’s and rises

102
Q

What are the risk factors for breast carcinoma

A 
Age
Early menarche 
Age at first birth 
Later menopause 
Hormones - endo/exo including OCP and HRT 
Previous breast disease 
More common in the West 
Lifestyle - overweight, lack of exercise, high alcohol consumption, smoking 
Genetics
103
Q

What factors can protect you from breast cancer

A

Having more children and breastfeeding them reduces your risk
Fewer cycles = less oestrogen
Exercise
NSAID use

104
Q

What risks are associated with the BRCA genes

A

High risk of breast, ovarian, prostate cancer for both
BRCA 1 often have prophylactic surgery as the risk is so high
BRCA 2 not ass high risk so often just get regular MRI follow up

105
Q

What is the commonest female cancer

A

Invasive breast carcinoma

It is also the 2nd commonest cause of cancer death in women

106
Q

Where can invasive breast cancer spread to

A

Locally to stroma and skin of breast and the muscles of the chest wall
Via lymphatics to the nodes
Via blood to the Bone, liver, brain, lungs, abdominal viscera, female genital tract

107
Q

What are the sentinel nodes

A

The first nodes that the cancer would drain to

This is the one you may need to biopsy

108
Q

What is the difference between stage and grade of tumour

A

Stage is how far the tumour has spread

Grade is how differentiated the cells are (and their behaviour)

109
Q

How do you grade breast carcinoma

A 
Tubular differentiation (1-3)
Nuclear pleomorphism (1-3)
Mitotic activity (1-3)

Total out of 9
Low(3,4,5) , intermediate (6 or 7) or high classes (8 or 9)

110
Q

What hormone receptors do you look for in breast cancer

A

Oestrogen receptors
Progesterone receptors
HER2

111
Q

if a cancer is ER positive how can it be treated

A

May have a response to anti-oestrogen therapy
Tamoxifen
Aromatase inhibitors
Oophorectomy

112
Q

How can you treat HER2 positive cancers

A

Should respond to trastuzamab (Herceptin) which is a monoclonal antibody

113
Q

HER2 positive cancer has a better prognosis - true or false

A

False

Worse prognosis

114
Q

What scores can you use to predict the prognosis of breast cancer

A

Nottingham Prognostic Index - uses grade, node status and size
NHS PREDICT

115
Q

What is adjuvant treatment

A

Adjuvant is back-up treatment – wont cure on its own but will help survival
Neo-adjuvant is the same but is given before the main treatment – e.g. before surgery

116
Q

Which treatments are used as neoadjuvant in breast cancer

A

Hormonal therapy given to ER positive tumours to try and shrink them before surgery - better outcomes
Chemo to shrink the tumour

117
Q

How is radiotherapy used in breast cancer

A

Used routinely after wide local excision
It reduces recurrence risk by about half
Usually external beam therapy with a boost for younger patients or those with positive margins

118
Q

What are the side effects of tamoxifen

A

More clotting so can get DVT or PE
Can cause hot flushes and vaginal dryness
Can affect endometrium – can lead to bleeding, polyps or even endometrial cancers

119
Q

How can tamoxifen be used as adjuvant treatment

A

5 years of Tamoxifen helps reduce risk of relapse by 15%

120
Q

Which chemo drugs are use in adjuvant therapy for breast cancer

A

Usually include anthracycline and often a taxane

121
Q

What are some of the side effects of chemotherapy

A 
Anorexia 
Malaise 
Alopecia 
Pain - myalgia and bone pain 
Infections
122
Q

What are the side effects of Herceptin (trastuzumab)

A

Causes allergic reactions and cardiac failure

Need cardiac monitoring during treatment

123
Q

How is Herceptin given as adjuvant treatment

A

Given by s/c injection (sometimes IV)#

One year of 3-weekly treatment

124
Q

What palliative treatments are available from advanced breast cancer

A

Localised cancer – radio or surgery
If systemic cancer you need a systemic treatment – ER blockers or chemo
Bisphosphonates appear to reduce the risk of crush fractures from bone mets

125
Q

What organs are at risk of exposure in breast radiotherapy

A

Lungs and heart
Risk of IHD
More techniques to help protect them

126
Q

How can you determine if bone pain is caused by Mets

A

The worse the tumour (high grade) the more likely the bone pain is due to bone metastasis from the original breast cancer
Need to request a Ct or MRI of the affected bone
Only useful if you see a shower of mets in the axial skeleton

127
Q

How do you deal with neutropenia during chemotherapy

A

Neutropenia is very common in chemo – don’t need to worry if they are well
Need to get them in for antibiotics urgently and get oncologist if they have signs of sepsis

128
Q

What are tumour markers used for

A

Good for monitoring
Not good for diagnosis – common to get false positive

Only used to monitor confirmed metastatic disease

129
Q

How are bisphosphonates used in breast cancer

A

Used if metastatic disease

If a patient is on aromatase inhibitors they are given to prevent the associated osteoporosis

130
Q

What is the risk with giving bisphosphonates

A

Risk of jaw osteonecrosis

Need to get dental work done before starting

131
Q

What are the side effects of radiotherapy straight to the breast

A

Erythema and swelling
Can be pretty painful
Larger the cup size the higher the risk

132
Q

What is the main complication of axillary node clearance

A

Lymphoedema of the arm

If they show signs then refer to nurses immediately so they can start treatment early – sleeves etc

133
Q

What is the most likely diagnosis if you find a new lump after surgery

A

Usually it is fat necrosis as a result of the trauma of surgery
If unsure then investigate via the one stop clinic

134
Q

What are the signs of cord compression

A

radicular pain, severe back pain, loss of sensation, cant really walk properly
Common if spinal mets

135
Q

Which type of medication can interfere with tamoxifen

A

Antidepressants

Need to weigh up pros/cons on an individual basis

136
Q

If some with HER2 positive breast cancer gets recurrent headaches or blurred vision what must you consider

A

headaches = brain mets
Must do a head scan

Vision = retinal mets
Refer to optho

137
Q

Where does lobular breast cancer often spread to

A

Preferential metastases to peritoneum and gut

May present with sub-acute bowel obstruction

138
Q

What happens to breast density with age

A

It decreases with age from puberty onwards

HRT and weight can affect it

139
Q

What is the gold standard diagnostic test in breast

A

MRI

140
Q

What is a mammogram

A

Low energy x-ray of the breast
Gives contrast between tumour and fat
Taken in 2 views - oblique and cranial caudal

141
Q

Describe a contrast enhanced spectral mammogram

A

Mammogram taken after IV injection of contrast
Take 2 images: 1 like a standard mammogram and 1 sensitive to contrast
Subtract the 2 images (so only shoes what is enhancing)
Useful if have a very dense breast

142
Q

When is US used in breast medicine

A

Used in women under 50 Used in women with symptoms (better than mammography in women with a lump)
Used to further investigate lumps found on mammography
Image guided biopsy

143
Q

What is stain elastography

A

US test
Provides a colourmap of stiffness of a lump - qualitative
Allows clues for diagnosis as cancer is harder
Not a great test

144
Q

What is shear wave elastography

A

US test
Provides a measurement of the stiffness of the lump - quantitative
Better than the stain elastography

145
Q

What is the structure of collagen like in breast cancer

A

It is more irregular than in normal breast tissue

Can be picked up on US

146
Q

When is MRI used to image breasts

A

Used in patients where not sure how big the tumour is

E.g. lobular, didn’t show up on mammogram or in Paget’s (look for it in breast)

147
Q

What is the most common type of biopsy

A

Core - almost all

FNA is hardly ever used

148
Q

Which pathologies can be removed by vacuum biopsy

A

Papilloma’s and radial scars

They both have malignant potential

149
Q

What is the most common lump in the under 30s

A

Fibroadenoma

150
Q

What is the most common lump in those age 30-50

A

Cysts

Need oestrogen in system for a cyst so not likely after menopause

151
Q

What is the most common lump in the over 50s

A

Cancer

152
Q

In what age do you use mammograms

A

Over 40s will get mammograms

Not effective in under 40s are breast too dense but can use if cancer is suspected

153
Q

What other area should be imaged if breast cancer is found

A

Always do an axillary USS if have cancer

Measure thickness of cortex, if >3mm then do a core biopsy

154
Q

How do you manage breast abscesses

A

USS guided drainage + antibiotics

155
Q

Which type of cancer often has nipple discharge

A

DCIS

If suspected do a mammogram

156
Q

Describe the breast screening programme

A

Mammography alone
Women 50-70
Every 3 years

If they have a FH of breast cancer then mammography is offered annually
High risk patients (BRCA carriers) are offered annual MRIs

157
Q

What is considered a good margin on a breast cancer excision

A

Aim to take out 1cm either side of the tumour

Need at least 1mm of a margin on microscopy to be considered excised

158
Q

Which cancer may present as calcification on mammogram

A

DCIS

in a branching pattern

159
Q

Which pathologies can present with a stellate abnormality on mammograms

A

Radial scar or a low grade carcinoma

160
Q

How can you identify the sentinel nodes

A

Can identify by injecting blue dye or a radioisotope and then imaging

Used to find the correct nodes to biopsy

161
Q

What is the prognosis of tubular carcinoma of the breast

A

It is always grade one and has a good prognosis

162
Q

Where is HER2 expressed

A

cell membrane

163
Q

Is breast cancer painful

A

Not typically

The rare exception is inflammatory breast cancer - ducts become blocked by tumour cells

164
Q

Do breast cysts fluctuate

A

No

They become very tense and sore

165
Q

What surgical options are available for breast conservation

A

Lumpectomy
Partial or segemental mastectomy
Wide local excision
Wire guided local excision

166
Q

What are the options for mastectomy

A

Traditional transverse

Skin sparing with immediate reconstruction

167
Q

How is chemotherapy used in neoadjuvant breast cancer treatment

A

Currently used to control local disease as well as systemic

Can allow for less surgery eg breast conservation

168
Q

How is oncoplastic breast conservation carried out

A

Larger breasts you can do a mammoplasty

Small breast will need a volume replacement technique

169
Q

What are the options for breast replacement post mastectomy

A

External prosthesis
Reconstruction: Immediate or delayed
Implant only (+/- autologous cellular matrix)
Latissimus dorsi (LD) pedicled flap +/- implant
Deep inferior epigastric artery perforator (DIEP) free flap
Inferior gluteal artery perforator (IGAP) free flap

170
Q

What are the issues with breast implants

A

Infection - leads to loss of implants
Capsular contracture
Implant rippling
Implant migration

171
Q

How are chest expanders used

A

First surgery is the mastectomy and you create a submuscular pocket with expander inserted
Clinic visits every 2 weeks for expansion
2nd surgery the expander is replaced with a permanent implant

172
Q

What muscles is the breast tissue in contact with

A

Mainly lies on the pec major

Also in contact with serratus anterior and superior part of the external oblique

173
Q

Which ribs does the breast tissue lie between

A

Ribs 2-6

174
Q

How are the lymph nodes around the breasts classified (levels)

A

Level 1 = lateral and inferior affected
Level 2 = deep affected
Level 3 = superior and medial affected

175
Q

What are the 6 groups of axillary lymph nodes

A 
Anterior 
Posterior 
Infraclavicular 
Central 
Apical 
Lateral
176
Q

Where does lymph from the breast drain to

A

Most drains to the axillary nodes
These then drain to the supraclavicular nodes
Some lymph will drain to the parasternal nodes and some can even go to the abdomen

177
Q

What changes occur to the breasts during pregnancy

A

They get bigger - fastest growth in first 8 weeks
Ducts develop and enlarge
Fat content decreases as ducts take up more room
Nipples get larger and more erect
Areola enlarges and gets darker

178
Q

What changes occur to the breasts during menopause

A

Loss of elastin = sagging

Increased fat content - make mammograms more effective

179
Q

What is the blood supply to the uterus

A

The uterine artery - branches off the internal iliac

There is also an anastomosis from the ovarian artery

180
Q

What are the histological features of fibroadenoma

A

Made of epithelial and stromal cells
nucleus:cytoplasm ratio is normal
Some have muscle/bone cells in them

181
Q

Should you continue breastfeeding with mastitis

A

Yes - if they can tolerate the pain

Hand express if unable to feed

182
Q

What is the most common organism causing mastitis

A

Staph aureus

183
Q

How does nipple thrush present

A

Typically bilateral
Sharp burning pains in the nipple and retro areolar tissue
Red, swollen areas
Can be associated with severe itching leading to inflammation and fissures

184
Q

How can a baby be affected by nipple thrush

A

Can the transmitted to them via breastfeeding

Will present with oral thrush - white patches in mouth

185
Q

How is nipple thrush treated

A

Mother should apply topical miconazole after feeds for 2 weeks
Baby can be treated with oral miconazole gel (licensed in babies over 4 months old)

186
Q

What can cause lactational mastitis

A

Commonly linked to improper breastfeeding technique.
Trauma to the breast and subsequent milk stasis and ineffective milk release make the breast
more likely to harbour bacteria and therefore be more prone to infection

187
Q

How does mastitis present

A 
inflammation -  warmth, pain, swelling,
firmness, erythema
Nipple discharge
Systemic infection symptoms - fever, malaise etc 
Decreased milk output - stasis 
Abscess - tender lump
188
Q

What is the antibiotic of choice for lactational mastitis

A

Fluclox

Most commonly caused by staph aureus

189
Q

What is colostrum

A

Thick, yellow-ish substance
First milk a breastfed baby receives and is more protein and vitamin rich than later milk
Essential for early immunological protection

190
Q

What is the let-down reflex

A

The mechanism of milk release from the breast during feeding

Triggered by oxytocin release following baby suckling

191
Q

How long should a baby be breastfed

A

Rceommended exclusively for first 6 months of life

Then up to 2 years alongside the introduction of solid food

192
Q

What are the indications of ultrasound in breast disease

A

First-line diagnostic imaging
method in symptomatic women < 40 years

Useful adjunct in patient with dense parenchymal pattern on mammogram

Useful to differentiate cysts from solid masses

193
Q

How often should a woman examine her own breasts

A

At least once a month
Menstruating women - 5 to 7 days after the beginning of their period
Menopausal women - same date each month

194
Q

How does Paget’s disease of the breast present

A

Gradual onset
Unilateral
It appears as a red, scaly rash on the skin of the nipple and gradually extends to areola
Can be sore and inflamed and may discharge
Nipple may be retracted or deformed
Associated breast lump

195
Q

How do you diagnose Paget’s disease of the breast

A

Punch biopsy of the nipple - histologic hallmark is Paget cells in the nipple epidermis
Bilateral mammogram to look for micro-calcifications and underlying masses

196
Q

How do you treat Paget’s disease of the breast

A

Largely depends on the TNM staging
May do breast conservation therapy or mastectomy
Test for ER, PR and HER-2 as specific therapies can be used

197
Q

Pus discharging from the nipple is suggestive of what

A

Breast abscess

198
Q

Green/serous discharge from the nipple is suggestive of what

A

Duct ectasia

199
Q

Bloody discharge from the nipple is suggestive of what

A

Duct papilloma

Carcinoma

200
Q

Milky discharge from the nipple is suggestive of what

A

Galactocele

201
Q

How do you investigate gynaecomastia

A 
Medication review - look for cause 
First line - US scan 
Hormone testing 
liver, thyroid and kidney function tests to look for cause
Genital exam if tumour suspected
202
Q

How do you manage gynaecomastia

A

Treat underlying cause
Discontinue causative medication
If severe, acute and no underlying cause you can give medical treatment - first line Tamoxifen

203
Q

Which cancers can cause gynaecomastia

A

Testicular - leydig cell, sertoli cell, gonadal germ cell
Ovarian - granulosa cell tumour
Adrenal tumours
Extragonadal germ cell - lung, gastric, renal, hepatocellular

204
Q

How does medullary breast cancer appear histologically

A

large, high grade cells growing in sheets with associated lymphocytes and plasma cells

205
Q

How does invasive ductal breast carinoma appear histologically

A

Duct like structures in a desmoplastic stroma

206
Q

How does tubular breast cancer appear histologically

A

Well-defined tubules that lack myoepithelial cells

Good prognosis

207
Q

How does mucinous breast cancer appear histologically

A

Abundant extracellular mucin

208
Q

How does inflammatory breast cancer appear histologically

A

Carcinoma in dermal lymphatics

Poor prognosis

209
Q

Mucinous breast carcinoma is more common in which women

A

Older - 70 and over

Relatively good prognosis

210
Q

Medullary breast carcinoma is more common in which women

A

Increased incidence in BRCA1 carriers

211
Q

What is the first line treatement for early breast cancer

A

Remove the tumour
Breast conserving surgery or mastectomy
Must also check the axilliary nodes - may need clearance

212
Q

When is a sentinel node biopsy indicated

A

Indicated in the majority of invasive breast cancers

213
Q

Describe axilliary lymph node dissection

A

1,2 or 3 levels of axilliary nodes are removed

Typically 10-15 nodes removed and stained for examination

214
Q

How does a breast cysts present

A

May be multiple and/or bilateral

Will have a discrete, smooth surface

215
Q

How does a cancerous breast lump feel

A

Usually a single lump
Will be hard and ill-defined
May be associated with lymph nodes and/or skin changes
May be fixed to surrounding tissues

216
Q

How does a breast abscess feel/present

A

Tender, red, hot

Can be lactational or occur in smokers

217
Q

How does gynaecomastia present

A

Can be unilateral or bilateral

‘Lump’ will be well defined, often tender and only be within the breast

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