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Reproduction and Sexual Health > Breast Week > Flashcards

Breast Week Flashcards

1
Q

The breast is a ________ gland

A

subcutaneous

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2
Q

The secretory tissue of the breast is made up of ____________

A

15-25 lobes each consisting of a compound tubuloacinar gland which drains via a series of ducts leading to the nipple

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3
Q

What is adjacent to the breast lobules?

A

dense fibrous tissue surrounded by adipose tissue

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4
Q

Explain what an acinus is?

A

a small sac like cavity surrounded by secretory cells

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5
Q

Explain what suspensory ligaments are?

A

these are ligaments amongst the fibrous tissue that extend from the dermis of the skin to the deep fascia overlying the muscle of the anterior chest wall, these support the breast tissue

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6
Q

What is the basic functional secretory unit of the breast?

A

terminal duct lobular unit

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7
Q

In the non lactating breast the TDLU leads to ___1_____ which leads to ____2_____ which leads to ____3_______ passing through ______4________

A

1) intralobular collecting duct
2) lactiferous ducts for that lobe
3) nipple
4) expanded duct region near the nipple termed the lactiferous sinus

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8
Q

Describe the histology of the lobule

A

within the lobule the secretory epithelial cells line the acini and vary from cuboidal to columnar
the secretory cells are surrounded by myoepithelial cells which are epithelial cells with contractile properties thought to help push milk out of the ducts

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9
Q

Describe the histology of the ducts

A

larger ducts such as lactiferous duct are lined by epithelium that varies from stratified squamous to stratified cuboidal
myoepithelial cells are also present

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10
Q

Where do many people believe the mammary glands originated from?

A

many people believe they represent modified sweat glands in particular apocrine glands

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11
Q

Describe the histology of the nipple?

A

the nipple has a wrinkled surface and covered by highly pigmented keratinised stratified squamous epithelium
it has a core of dense irregular connective tissue mixed with bundles of smooth muscle

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12
Q

As lactiferous ducts approach the surface they become lined by ____1_____ deeper it is lined by ____2____ and deeper ______3_____

A

1) stratified squamous epithelium
2) stratified cuboidal
3) one cell thick lining

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13
Q

Describe histological changes to the breasts during the menstrual cycle?

A

During the luteal phase (after ovulation) the epithelial cells increase in height, the lumina of the ducts becomes enlarged and small amounts of secretions appear in the ducts. (typically those secretions don’t actually make it to the nipple just seen histologically)

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14
Q

Describe histological changes to the breasts during pregnancy?

A

In the first trimester there is elongation and branching of the smaller ducts, combined with proliferation of the epithelial cells of the glands and the myoepithelial cells.
In the second trimester glandular tissue continues to develop with differentiation of secretory alveoli. Also, plasma cells and lymphocytes infiltrate the nearby connective tissue.
In the third trimester secretory alveoli continue to mature, with development of extensive rER.

These changes are accompanied by a reduction in the amount of connective tissue and adipose tissue present.

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15
Q

What changes happen to the breast following menopause?

A

Following menopause, the secretory cells of the TDLU’s degenerate leaving only ducts. In the connective tissue, there are fewer fibroblasts and reduced collagen and elastic fibres.

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16
Q

What is the composition of breast milk?

A

88% water
1.5% protein (mainly lactalbumin and casein)
7% carbohydrate (mainly lactose)
3.5% lipid

With small quantities of: ions, vitamins and IgA antibodies

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17
Q

Describe the vasculature of the breast?

A

lateral thoracic artery originating from the axillary artery gives off lateral mammary branches

the internal thoracic (internal mammary) artery originating from the subclavian gives off medial mammary branches

venous drainage corresponds with arteries

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18
Q

Describe the lymph drainage of the breast?

A

most lymph drains to axillary nodes (> 75%)

rest drains to parasternal nodes and some can drain to the abdominal nodes

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19
Q

What does fibrocystic change typically present as?

A

a lump or lumpiness of the breast in pre-menopausal women

tend to get cyclical pain can be asymptomatic though and found on screening

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20
Q

Is fibrocystic change common?

A

yes very common

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21
Q

What is fibrocystic change thought to be due to?

A

abnormal and exaggerated responses of the breast tissues to the cyclical physiological menstrual hormonal stimuli

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22
Q

Pathology of fibrocystic change?

A

usually see cysts with intervening fibrosis, micro and macroscopically

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23
Q

Management of fibrocystic change?

A

exclude malignancy, reassure, excise if necessary

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24
Q

What is the commonest benign tumour of the breast?

A

fibroadenoma

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25
Q

Presentation of fibroadenoma?

A

lump that is small, firm and mobile
usually single, occurring in young women
usually painless

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26
Q

How does a lump appear on ultrasound?

A

solid

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27
Q

Pathological gross and micro appearance of fibroadenoma?

A

gross appearance: well circumscribed, rounded, elastic in consistency, glistening greyish cut surface
micro: composed of connective tissue (stroma) and epithelium

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28
Q

Management of fibroadenoma?

A

managed conservatively if asymptomatic, advice to regularly perform self exam, may excise if causing symptoms

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29
Q

What is a radial scar?

A

small (up to 1cm) firm lesion with dense fibrous core with radiating fingers of fibrosis entrapping and distorting glandular elements
benign but can be confused histologically as carcinoma

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30
Q

What is being described

lesion like radial scar but larger and detected on mammography

A

complex sclerosing lesion

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31
Q

Treatment of radial scar?

A

they are usually excised or vacuumed

as in situ or invasive carcinoma can occur

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32
Q

Are radial scars usually symptomatic?

A

no

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33
Q

What can cause fat necrosis?

A

this can occur due to local trauma (which may not be a clear history of) or warfarin therapy

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34
Q

Histology of fat necrosis?

A

necrotic fat with lipid rich macrophages, giant cells and later fibrosis

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35
Q

What can present as a mass mimicking carcinoma?

A

fat necrosis

36
Q

Management of fat necrosis?

A

involves excluding malignancy and reassurance, lumps generally go away, if become big or uncomfortable surgery can be done

37
Q

What is duct ectasia? What is it associated with?

A

chronic inflammatory reaction associated with ectasia of the ducts/ cystic dilatation

its associated with ageing (often women going through menopause) and smoking

38
Q

Clinical features of duct ectasia?

A

affects sub areolar ducts, pain, acute episodic inflammatory changes, bloody and/ or purulent discharge, fistulation, nipple retraction and distortion

39
Q

Pathology of duct ectasia?

A

sub areolar duct dilatation, periductal inflammation and fibrosis, scarring, distortion

40
Q

Management of duct ectasia?

A

treat acute infections, exclude malignancy, stop smoking, excise ducts

41
Q

2 main aetiologies of mastitis and breast abscess?

A

duct ectasia- mixed organisms, anaeroibes

lactation- staph A, strep pyogenes

42
Q

How does mastitis and breast abscess present?

A

signs of infection

painful, swollen breasts

43
Q

Advice for breastfeeding and mastitis?

A

mastitis in women breastfeeding is generally caused by a build up of milk so should check breastfeeding technique and encourage them to keep feeding and express between feeds to reduce build up

44
Q

Treatment of mastitis and abscess?

A

keep breastfeeding
antibiotics
drain abscess if present

45
Q

Where are duct papillomas most commonly found?

A

in lacteal sinuses at the nipple

46
Q

Symptoms of duct papilloma?

A

discharge from the nipple which may be blood stained (cytological exam would reveal benign epithelial cells)

47
Q

Treatment of papillomas?

A

They should be surgically removed and histology examined as small risk of cancer developing

48
Q

Define DCIS?

A

ductal carcinoma in situ
cells lining the ducts show cytological features of malignancy but have not yet invaded the stroma
graded 1-3 depending on how abnormal the cells are

49
Q

How may DCIS be detected?

A

focal calcification allows it to be detected by mammography screening or it may present as a palpable mass

50
Q

Define LCIS?

A

lobular carcinoma in situ (sometimes called lobular in situ neoplasia)

lesion usually multifocal and bilateral
can progress to infiltrative carcinoma

51
Q

Explain what Paget’s disease of the nipple is and the clinical importance?

A

it is a condition characterised by inflammatory eczema like changes of the nipple that may involve the areola
it is caused by high grade DCIS extending along ducts to reach the epidermis of the nipple
hence if someone presents with inflammatory skin changes around the nipple there could be underlying DCIS

52
Q

What is the commonest form of breast cancer?

A

ductal carcinoma

53
Q

How does ductal carcinoma usually present?

A

as a firm to hard lump

54
Q

How common is lobular carcinoma?

A

10% of cancers are this type

55
Q

Lobular carcinoma has more of a chance of being?

A

multifocal and/or bilateral

56
Q

Microscopically how does lobular carcinoma appear?

A

tumour infiltrates the tissues as single files of malignant cells

57
Q

What is being described?

Tumour infiltrates the tissues as single files of malignant cells

A

lobular carcinoma

58
Q

Describe spread of breast cancer?

A

initially the cancer spreads via lymphatics to axillary nodes
spread via the blood stream to bone marrow occurs
common secondaries are liver, lung and bones

59
Q

50% of those with breast cancer are ___________ and the other 50% __________

A

asymptomatic and picked up on screening

symptomatic

60
Q

50% of those with breast cancer who are symptomatic their symptom is ______

A

a lump

61
Q

List some symptoms of breast cancer?

A 
dimpled or depressed skin
visible lump 
nipple change 
bloody discharge 
texture change
colour change
62
Q

Describe the one stop clinic?

A

triple assessment in one clinic: clinical assessment, imaging and pathology
imaging will depend on age group
only 10% of people attending the clinic will have cancer

63
Q

Describe the different receptors that can be positive and negative in breast cancer and combinations?

A

LUMINAL A CANCERS: ER positive, (PR positive), HER2 negative- best prognosis

HER2 CANCERS: HER2 positive, other receptors negative

TRIPLE NEGATIVE CANCERS / BASAL CANCERS - worse prognosis

64
Q

Receptors that have best breast cancer prognosis?

A

ER positive, (PR positive), HER 2 negative

65
Q

Receptors that have worst breast cancer prognosis?

A

triple negative cancers aka basal

66
Q

Describe surgical management of breast cancer?

A

can range from wide local excision to mastectomy
should be noted that mastectomy doesn’t necessarily reduce the risk of the cancer coming back as WLE with adjuvant radiotherapy has been shown to be just as effective

67
Q

Describe use of radiotherapy in management of breast cancer?

A

this is usually given as adjuvant therapy as it reduces the risk of local recurrence

68
Q

Describe use of anti-oestrogen therapy in management of breast cancer?

A

in those with ER positive cancers this can reduce the risk of recurrence
pre menopausal women should be given tamoxifen (ER receptor antagonist) for 5 years at least
post menopausal women should get tamoxifen or an aromatase inhibitor eg. letrozole for at least 5 years
AIs in post menopausal worm thought to be better

69
Q

What is tamoxifen?

A

an oestrogen receptor antagonist

mainly used in those with ER positive cancers who are pre menopausal to reduce risk of breast cancer recurrence

70
Q

What is letrozole?

A

aromatase inhibitor that reduces oestrogen mainly used in post menopausal women to reduce risk of breast cancer recurrence

71
Q

Describe use of chemotherapy in the management of breast cancer?

A

this can be used in cases with high tumour burdens

better response in triple negative cancers

72
Q

Describe use of targeted HER2 therapy in the management of breast cancer?

A

HER2 receptor blockers can be used in HER2 positive cancer, it is a type of monoclonal antibody
e.g. trastuzamab / herceptin
(remember anything with mab on end of it is a monoclonal antibody)

73
Q

What is trastuzamab/ herceptin?

A

HER2 receptor blockers can be used in HER2 positive cancer, it is a type of monoclonal antibody

74
Q

List some risk factors for breast cancer development?

A 
increasing age
genetics e.g. BRCA1 and 2
commoner in nulliparous women 
early menarche and late menopause increase risk due to prolonged cyclical exposure to sex hormones 
breast feeding reduces risk 
obesity increase risk as adipose tissue increases oestrogen
smoking 
lack of physical activity 
alcohol
75
Q

What is mammogram?

A

image of breasts produced by low energy XR machine (low energy machine used as high energy machine wouldn’t bring up image of breasts)

76
Q

How is mammogram taken?

A

breast compressed between plates so get even exposure and keeps them still as takes longer than normal XR

77
Q

Describe breast density and how this affects mammograms?

A

breast density changes from woman to woman, women with denser breasts will be more difficult to detect abnormalities on mammogram

78
Q

Advantages of a mammogram?

A

high sensitivity for detecting DCIS and invasive cancer, only screening modality known to reduce population mortality

79
Q

Disadvantages of mammogram?

A

give ionising radiation

some women find them uncomfortable

80
Q

Describe breast screening in Scotland?

A

screening done in Scotland age 50-70 every 3 years

81
Q

Who may mammograms may not be as good in?

A

younger patients less than 40 as breast tissue is too dense

82
Q

Indications for breast ultrasound?

A 
palpable masses 
work up of mammographically detected lesion 
image guided biopsy
breast inflammation
breast problems in pregnancy
83
Q

Advantages and disadvantages of breast ultrasound?

A

good specificity and sensitivity for detecting invasive cancer
can differentiate solid from cystic
however has a low sensitivity for DCIS and has a low specificity if used for screening (as picks up lots of small abnormalities that aren’t harmful)
overall breast US is good for looking at a particular area but to look at whole breast is time consuming and pick up stuff that isn’t meaningful

84
Q

Advantages and disadvantages of breast MRI?

A

this is the most accurate method for sizing and focality assessment of breast cancer
however it increases mastectomy rates but not positive margins as it picks up such small tumour foci that radiotherapy would have got

85
Q

Describe 3 biopsies and their use?

A

FNA - basically not used anymore
Core biopsy- standard biopsy used and good for diagnosing masses
vacuum- more expensive than core, used when there is no lump or calcifications present as allows better chance of diagnosis

86
Q

Describe use of axillary US?

A

abnormal nodes can be identified by cortical thickness and shape
not a great test of nodal involvement so if invasive cancer sentinel node biopsy should still be done

Reproduction and Sexual Health (20 decks)

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