L31, 32 + 33: The Breast Flashcards
1
Q
What is the milk line? What is the significance of it?
A
- it extends from the axilla to the pelvis
- pathologies occur here
2
Q
What is the function of the lobes/lobules of the breast?
A
they produce milk
3
Q
What is the function of the ducts of the breast?
A
it transports milk to the nipple
4
Q
What is the terminal duct lobular unit (TDLU)? Why is it significant?
A
- functional unit
- terminal branches of ducts, lobules + surrounding connective tissue
- most cancers arise here
5
Q
Which part of the breast do most cancers arise in?
A
the terminal duct lobular unit (TDLU)
6
Q
What is the normal thickness of the ducts and lobules of the breast?
A
2 cell layer (superficial and deep layer)
7
Q
What are the 2 cell layers of the ducts and lobules of the breast?
A
- Superficial Layer - epithelial cells
2. Deep Cell Layer - myoepithelial cells
8
Q
What cell type makes up the deep cell layer of the ducts and lobules of the breast?
A
myoepithelial cells
9
Q
What cell type makes up the superficial cell layer of the ducts and lobules of the breast?
A
epithelial cells
10
Q
Describe the histology of the breast before puberty (pre-pubertal)
A
- branching ducts connected to nipple
- no glandular component
- similar to a male breast
11
Q
Describe the histology of the breast after puberty (post-pubertal)
A
- terminal ducts give rise to lobules
12
Q
What is galactorrhoea?
A
- milk production outside of lactation
- not a symptom of breast cancer
- may occur to a pituitary tumour (prolactinoma)
13
Q
What are supernumerary nipples/breasts?
A
- most common congenital anomaly
- heterotropic glands along the milk line
14
Q
What is the most common congenital anomaly associated with the breast?
A
supernumerary nipples/breasts
15
Q
List the common clinical presentations of breast disease (in general)
A
- breast pain (mastalgia)
- palpable mass
- nipple discharge
- mammographic abnormality
- skin (peau-d’orange)
- nipple retraction
16
Q
Why is a mammogram difficult to do in younger patients?
A
b/c breast tissue is more dense
17
Q
What imaging technology is used in younger women to examine their breasts?
A
Ultrasound
18
Q
What is Triple Assessment of the breast? What is it used for?
A
Triple Assessment = clinical, radiology and pathology
if all 3 tests are benign = leave lump - do not need to remove
19
Q
What is the point of “BreastCheck”, a breast screening program?
A
to detect small NON-PALPABLE breast carcinomas at an early stage
- mammogram done every 2 years
- usually done in women 50-64
20
Q
List some of the mammographic signs of breast malignancy
A
- calcifications* (small, irregular, clustered, linear or branching)
- densities
- architectural distortion
- asymmetry
21
Q
What biopsy method is used to examine breast tissue for a pathological diagnosis?
A
needle core biopsy
22
Q
When is an open biopsy of a breast tissue done?
A
if there is uncertainty following triple assessment
23
Q
What is acute mastitis?
A
- acute inflammatory condition of the breast
- usually from cracked nipple during lactation
- bacteria invades through ducts (usually S. aureus or Strep)
- fever, pain, erythema, purulent nipple discharge
- treat w/ antibiotics
24
Q
What are the symptoms of acute mastitis?
A
fever, pain, erythema, purulent nipple discharge
25
How can acute mastitis be treated?
w/ antibiotics
| rarely surgical drainage
26
What is the most common organism a/w acute mastitis?
Staph. aureus
27
What is periductal mastitis?
- chronic inflammatory condition of the breast
- squamous metaplasia of ducts (therefore keratin production which plugs the duct and causes inflammation
- painful subareolar mass, inverted/retraction of nipple
- needs surgical excision of involved duct
28
What is the clinical presentation of periductal mastitis?
painful subareolar mass, inverted/retracation of nipple
29
What is the treatment of a periductal mastitis?
surgical excision of the involved duct
30
What is a mammary duct ectasia?
- chronic inflammatory condition of breast
- have inflammation and dilation of subareolar ducts
- have palpable periareolar mass w/ thick green/brown nipple discharge
31
What is the clinical presentation of a mammary duct ectasia?
palpable periareolar mass with thick green/brown nipple discharge
32
What is the presentation of fat necrosis on mammography?
dystrophic calcification
33
Dystrophic Calcification vs. Metastatic Calcification
Dystrophic Calcification - in injured or necrotic tissue in a normal serum calcium level
-- Abnormal Tissue, Normal Calcium
Metastatic Calcification - with hypercalcemia occurs when calcium deposits in previously normal tissue
--- Normal Tissue, Raised Calcium
34
What is lymphocytic mastitis?
- chronic inflammatory condition of breast
- a/w T1DM (diabetic mastopathy)
- palpable mass (usually bilateral + subareolar)
35
What is the presentation of lymphocytic mastitis?
palpable mass (usually bilateral + subareolar)
36
What is granulomatous mastitis?
- chronic inflammatory condition of breast
| - idiopathic or a/w systemic granolumatous disease (e.g. sarcoidosis)
37
What is a galactocoele?
- cystic dilation of duct during lactation (it contains milk)
- may become infected (acute mastitis)
- may form an abscess
38
Why do fibrocystic changes of the breast occur?
due to oestrogen/progesterone imbalance
39
What are the clinical features of fibrocystic disease of the breast?
- discomfort (cyclical)
- nodularity
- discrete lump (firm/rubbery)
- nipple discharge
note: atypical hyperplasia a/w increased risk of carcinoma
40
What is non-proliferative fibrocystic change of the breast?
- increase in cysts + apocrine metaplasia
| - fibrosis of stroma
41
What is proliferative fibrocystic change of the breast?
- epithelial hyperplasia (more than 2 cell layers)
- -- can have no atypia or atypia
- intraductal papilloma
42
What is an intraductal papilloma?
- type of proliferative fibrocystic change of the breast
- benign growth w/in lactiferous duct
- premenopausal women
- presents w/ serous or bloody nipple discharge
- can recur
43
Which population do intraductal papillomas normally affect?
premenopausal women
44
How does an intraductal papilloma present?
serous or bloody nipple discharge
45
What is gynecomastia?
enlargement of the male breast (usually unilateral)
46
List the 3 possible causes of gynecomastia
1. Oestrogen Excess
2. Drugs
3. Prolactin Excess (e.g. pituitary tumour)
47
List the drugs that can lead to gynecomastia
- spirinolactone
- chlorpromazine
- cimetidine
- androgens
- alcohol
- marijuana
- heroin
48
List some of the risk factors for developing breast cancer [lots of them!]
- female
- increasing age
- early menarche + late menopause
- exposure to oestrogen (e.g. oral contraceptive)
- nullparity and older age @ first birth
- family history + genetic predisposition
- carcinoma of the endometrium
- atypical epithelial hyperplasia (fibrocystic disease)
- radiation exposure
- post-menopausal obesity
- alcohol
- race
- radiation exposure
49
What are the main 2 genes are associated with an increased risk of breast cancer? Which chromosome is each gene on?
BRCA 1 - Chromosome 17
| BRCA 2 - Chromosome 13
50
List the 2 mechanisms by which oestrogen and its metabolites can cause sporadic breast cancer
1. Oestrogen causes proliferation of pre-malignant lesions + cancers
2. Metabolites of Oestrogen cause mutations or generate DNA damaging free radicals
51
List 4 genetic conditions/mutations that can lead to hereditary breast cancer
1. BRCA 1
2. BRCA 2
3. Li-Fraumeni Syndrome
4. Cowden's Disease
52
What symptoms/presentation would be present to suggest a hereditary breast cancer?
- bilateral breast cancer
- breast and ovarian cancer
- male breast cancer
- breast cancer < 40
- multiple 1st degree relatives w/ breast cancer
53
What are the 2 types of carcinoma in-situ of the breast?
1. Ductal Carcinoma In-Situ (DCIS)
| 2. Lobular Carcinoma In-Situ (LCIS)
54
What is DCIS of the breast?
Ductal Carcinoma In-Situ
- malignant cells in TDLU
- classified as low grade, intermediate and high grade
- 5 architectural subtypes
55
What are the 5 different types of architectural subtypes of DCIS?
- comedo
- solid
- cribriform
- papillary
- micropapillary
56
Which architectural subtype of DCIS has the worst prognosis?
comedo necrosis DCIS
57
What is the treatment/management plan for DCIS?
- wide local excision ± radiotherapy
| - mastectomy (sometimes
58
What is Paget's Disease of the nipple?
- form of ductal carcinoma
- malignant cells arising from DCIS extend into ducts and into nipple skin w/o crossing BM
- erythematous eruption w/ scale crust
- ulceration of nipple + redness
59
What is lobular carcinoma in-situ (LCIS)?
- abnormal cells fill lobules
- does not cross BM
- have dyscohesive cells lacking E-Cadherin
60
A DCIS increases the risk of what type of carcinoma?
ductal carcinoma only
61
A LCIS increases the risk of what type of carcinoma?
lobular OR ductal carcinoma
62
If there are dyscohesive cells lacking E-Cadherin what does this suggest?
a LCIS
63
Is invasive ductal or lobular breast cancer more common?
invasive ductal cancer
64
What type of breast cancer is the most comon?
invasive ductal cancer
65
How does an invasive ductal carcinoma of the breast normally present?
- hard mass detected by exam or mammogram
- have irregular border
- advanced tumour have dimpling of skin + retraction of the nipple
66
List the 5 type of "special type" invasive carcinomas
1. Invasive Lobular Carcinoma
2. Invasive Mucinous (Colloid) Carcinoma
3. Invasive Medullary Carcinoma
4. Invasive Tubular Carcinoma
5. Invasive Papillary Carcinoma
67
What is an invasive lobular carcinoma?
- special type invasive carcinoma of breast
- young women
- bilateral
- cells invade cords (single-file)
- -- "Indian Filing"
- have loss of adhesion molecules (E-cadherin)
68
What is an invasive tubular carcinoma?
- special type invasive carcinoma of breast
- well differentiated (prominent tubules/ducts)
- good prognosis
69
What is an invasive mucinous (colloid) carcinoma?
- special type invasive carcinoma of breast
- elderly women
- has abundant extracellular pools of mucin
- good prognosis
70
What is an invasive medullary carcinoma?
- special type invasive carcinoma of breast
- circumscribed edge
- large malignant cells
- surrounding lymphocytic response
71
What is an inflammatory cancer of the breast?
- any type of breast cancer that has infiltrated the dermal lymphatics
- red, swollen and oedematous breast
- a/w poor prognosis
72
What is the Scarff Bloom Richardson used for? What are the 3 features that are calculated?
- used for histological grading of breast cancer
1. % of Tubule Formation
2. Mitotic Count
3. Nuclear Pleomorphism
73
According to the Scarff Richardson score, what is considered grade 1 breast cancer?
score 3 -5
74
According to the Scarff Richardson score, what is considered grade 2 breast cancer?
score 6-7
75
According to the Scarff Richardson score, what is considered grade 3 breast cancer?
score 8-9
76
List some of the prognostic factors for breast cancer
- invasive or in-situ
- stage
- inflammatory carcinoma (a/w higher stage)
- histological grade
- histological subtype of tumour
- adequacy of excision
- lymphovascular invasion
- proliferative rate
- angiogenesis
77
List 2 factors which predict a breast tumour's response to treatment
1. expression of hormone receptors (oestrogen + progesterone)
2. expression of c-erb B2 (HER-2)
78
What is considered a triple negative tumour?
negative for ER, PR, and HER2
| - has a poor prognosis b/c treatment is more difficult
79
List the 5 possible treatments for breast cancer
1. Surgery
2. Axilla - Sentinel Lymph Node Biopsy ± Axillary Clearance
3. Radiotherapy
4. Systemic Therapy (hormonal therapy e.g. tamoxifen, trastuzumab)
5. Chemotherapy
80
What is the typical presentation of a carcinoma of the male breast?
invasive carcinoma
81
What are the 3 stromal tumours of the breast?
1. Fibroadenoma (benign)
2. Phyllodes Tumour (in between)
3. Sarcomas (malignant)
82
What is the most common benign tumour of the breast?
fibroadenoma
83
What is a fibroadenoma of the breast?
- benign tumour
- solitary lesion
- freely movable mass
- responds to oestrogen and progesterone (may change w/ menstrual cycle and pregnancy)
84
What is Phyllodes tumour?
- stromal tumour of breast
- resembles fibroadenoma
- -- "leaf-like" clefts and slits
- can be benign or malignant
85
How old/young must a woman be for them to be considered for an ultrasound rather than an MRI for investigating breast lumps?
< 35 years old
86
What 3 chemotherapy drugs are used for treating breast cancer?
- cyclophosphamide
- methotrexate
- 5-fluorouracil
87
What is Lead Time Bias?
an apparent increase in survival time without reduction in mortality
88
What is Length Bias?
clinical outcome observations that are not adjusted for the rate of progression of disease
