Breast Week Flashcards
The breast is a ________ gland
subcutaneous
The secretory tissue of the breast is made up of ____________
15-25 lobes each consisting of a compound tubuloacinar gland which drains via a series of ducts leading to the nipple
What is adjacent to the breast lobules?
dense fibrous tissue surrounded by adipose tissue
Explain what an acinus is?
a small sac like cavity surrounded by secretory cells
Explain what suspensory ligaments are?
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
What is the basic functional secretory unit of the breast?
terminal duct lobular unit
In the non lactating breast the TDLU leads to ___1_____ which leads to ____2_____ which leads to ____3_______ passing through ______4________
1) intralobular collecting duct
2) lactiferous ducts for that lobe
3) nipple
4) expanded duct region near the nipple termed the lactiferous sinus
Describe the histology of the lobule
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
Describe the histology of the ducts
larger ducts such as lactiferous duct are lined by epithelium that varies from stratified squamous to stratified cuboidal
myoepithelial cells are also present
Where do many people believe the mammary glands originated from?
many people believe they represent modified sweat glands in particular apocrine glands
Describe the histology of the nipple?
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
As lactiferous ducts approach the surface they become lined by ____1_____ deeper it is lined by ____2____ and deeper ______3_____
1) stratified squamous epithelium
2) stratified cuboidal
3) one cell thick lining
Describe histological changes to the breasts during the menstrual cycle?
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)
Describe histological changes to the breasts during pregnancy?
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.
What changes happen to the breast following menopause?
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.
What is the composition of breast milk?
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
Describe the vasculature of the breast?
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
Describe the lymph drainage of the breast?
most lymph drains to axillary nodes (> 75%)
rest drains to parasternal nodes and some can drain to the abdominal nodes
What does fibrocystic change typically present as?
a lump or lumpiness of the breast in pre-menopausal women
tend to get cyclical pain can be asymptomatic though and found on screening
Is fibrocystic change common?
yes very common
What is fibrocystic change thought to be due to?
abnormal and exaggerated responses of the breast tissues to the cyclical physiological menstrual hormonal stimuli
Pathology of fibrocystic change?
usually see cysts with intervening fibrosis, micro and macroscopically
Management of fibrocystic change?
exclude malignancy, reassure, excise if necessary
What is the commonest benign tumour of the breast?
fibroadenoma
Presentation of fibroadenoma?
lump that is small, firm and mobile
usually single, occurring in young women
usually painless
How does a lump appear on ultrasound?
solid
Pathological gross and micro appearance of fibroadenoma?
gross appearance: well circumscribed, rounded, elastic in consistency, glistening greyish cut surface
micro: composed of connective tissue (stroma) and epithelium
Management of fibroadenoma?
managed conservatively if asymptomatic, advice to regularly perform self exam, may excise if causing symptoms
What is a radial scar?
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
What is being described
lesion like radial scar but larger and detected on mammography
complex sclerosing lesion
Treatment of radial scar?
they are usually excised or vacuumed
as in situ or invasive carcinoma can occur
Are radial scars usually symptomatic?
no
What can cause fat necrosis?
this can occur due to local trauma (which may not be a clear history of) or warfarin therapy
Histology of fat necrosis?
necrotic fat with lipid rich macrophages, giant cells and later fibrosis
What can present as a mass mimicking carcinoma?
fat necrosis
Management of fat necrosis?
involves excluding malignancy and reassurance, lumps generally go away, if become big or uncomfortable surgery can be done
What is duct ectasia? What is it associated with?
chronic inflammatory reaction associated with ectasia of the ducts/ cystic dilatation
its associated with ageing (often women going through menopause) and smoking
Clinical features of duct ectasia?
affects sub areolar ducts, pain, acute episodic inflammatory changes, bloody and/ or purulent discharge, fistulation, nipple retraction and distortion
Pathology of duct ectasia?
sub areolar duct dilatation, periductal inflammation and fibrosis, scarring, distortion
Management of duct ectasia?
treat acute infections, exclude malignancy, stop smoking, excise ducts
2 main aetiologies of mastitis and breast abscess?
duct ectasia- mixed organisms, anaeroibes
lactation- staph A, strep pyogenes
How does mastitis and breast abscess present?
signs of infection
painful, swollen breasts
Advice for breastfeeding and mastitis?
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
Treatment of mastitis and abscess?
keep breastfeeding
antibiotics
drain abscess if present
Where are duct papillomas most commonly found?
in lacteal sinuses at the nipple
Symptoms of duct papilloma?
discharge from the nipple which may be blood stained (cytological exam would reveal benign epithelial cells)
Treatment of papillomas?
They should be surgically removed and histology examined as small risk of cancer developing
Define DCIS?
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
How may DCIS be detected?
focal calcification allows it to be detected by mammography screening or it may present as a palpable mass
Define LCIS?
lobular carcinoma in situ (sometimes called lobular in situ neoplasia)
lesion usually multifocal and bilateral
can progress to infiltrative carcinoma
Explain what Paget’s disease of the nipple is and the clinical importance?
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
What is the commonest form of breast cancer?
ductal carcinoma
How does ductal carcinoma usually present?
as a firm to hard lump
How common is lobular carcinoma?
10% of cancers are this type
Lobular carcinoma has more of a chance of being?
multifocal and/or bilateral
Microscopically how does lobular carcinoma appear?
tumour infiltrates the tissues as single files of malignant cells
What is being described?
Tumour infiltrates the tissues as single files of malignant cells
lobular carcinoma
Describe spread of breast cancer?
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
50% of those with breast cancer are ___________ and the other 50% __________
asymptomatic and picked up on screening
symptomatic
50% of those with breast cancer who are symptomatic their symptom is ______
a lump
List some symptoms of breast cancer?
dimpled or depressed skin visible lump nipple change bloody discharge texture change colour change
Describe the one stop clinic?
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
Describe the different receptors that can be positive and negative in breast cancer and combinations?
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
Receptors that have best breast cancer prognosis?
ER positive, (PR positive), HER 2 negative
Receptors that have worst breast cancer prognosis?
triple negative cancers aka basal
Describe surgical management of breast cancer?
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
Describe use of radiotherapy in management of breast cancer?
this is usually given as adjuvant therapy as it reduces the risk of local recurrence
Describe use of anti-oestrogen therapy in management of breast cancer?
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
What is tamoxifen?
an oestrogen receptor antagonist
mainly used in those with ER positive cancers who are pre menopausal to reduce risk of breast cancer recurrence
What is letrozole?
aromatase inhibitor that reduces oestrogen mainly used in post menopausal women to reduce risk of breast cancer recurrence
Describe use of chemotherapy in the management of breast cancer?
this can be used in cases with high tumour burdens
better response in triple negative cancers
Describe use of targeted HER2 therapy in the management of breast cancer?
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)
What is trastuzamab/ herceptin?
HER2 receptor blockers can be used in HER2 positive cancer, it is a type of monoclonal antibody
List some risk factors for breast cancer development?
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
What is mammogram?
image of breasts produced by low energy XR machine (low energy machine used as high energy machine wouldn’t bring up image of breasts)
How is mammogram taken?
breast compressed between plates so get even exposure and keeps them still as takes longer than normal XR
Describe breast density and how this affects mammograms?
breast density changes from woman to woman, women with denser breasts will be more difficult to detect abnormalities on mammogram
Advantages of a mammogram?
high sensitivity for detecting DCIS and invasive cancer, only screening modality known to reduce population mortality
Disadvantages of mammogram?
give ionising radiation
some women find them uncomfortable
Describe breast screening in Scotland?
screening done in Scotland age 50-70 every 3 years
Who may mammograms may not be as good in?
younger patients less than 40 as breast tissue is too dense
Indications for breast ultrasound?
palpable masses work up of mammographically detected lesion image guided biopsy breast inflammation breast problems in pregnancy
Advantages and disadvantages of breast ultrasound?
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
Advantages and disadvantages of breast MRI?
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
Describe 3 biopsies and their use?
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
Describe use of axillary US?
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
