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Life Cycle > LC Exam 2 Breast > Flashcards

LC Exam 2 Breast Flashcards

1
Q

Risk factor for breast cancer with relation to pregnancy

A

Age at/after pregnancy

Increased age increases risk and delay until protection

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2
Q

AAP recommendation for breast feeding
Advantages for baby
Advantages for mom

A

6 months
Reduces many disease risks in preterm infants (meningitis, nec enterocolitis, ears, UTIs etc)
Decreased risk of SIDS, diabetes, cancer, etc etc
Mom: decreased menstrual bleeding, increased child spacing, faster return to pre-preg weight

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3
Q

Anatomy of human breast

A

7 lobes

Secretory epithelial cells and myoepithelial cells (lobuloalveolar unit)

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4
Q

Lactating vs. non-lactating breast composition

A

Lactating: Glandular = 62%, intraglandular fat = 7%
Non-lac: Glandular = 20%, intraglandular fat = 49%
Subq and retro fat remain the same

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5
Q

Breast development cycles

A 
Embryogenesis (establish gland)
Puberty
Mature
Pregnancy
Lactation cycle (and menstrual cycle, like mini lactation cycle)
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6
Q

Embryogenesis of breast

A

Ectoderm invades mesenchyme
Mesenchyme differentiates into fat pad (mammary mesenchyme)
Driven by PTHrP
No PTHrP = Blomstrands chrondroplasia (amastia)
Neonatal breast tissue can secret under right maternal hormonal conditions

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7
Q

Menstrual cycle changes in breast tissue

A

More ducts with LH/E2 spike
More alveoli with prog (luteal phase)
In preg= alveoli differentiation/side branches are a result of progesterone and PRL secretion by placenta

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8
Q

Pubertal breast changes

A

Glandular expansion driven by E2 and progesterone
E2 + GH induce IGF-1 secretion from stromal cells (TEB)
Progesterone during menstrual phase = side branches (TDLU) development -> regress at end of luteal unless pregnancy
TEB = terminal end bud
TDLU = terminal ductual lobular unit

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9
Q

Initial pregnancy breast changes

Lactogenesis I

A

Differentiation:
Increased lobulation
Alveolar cell differentiation
Inhibition of milk secretion (by high levels of progesterone)
Hormones: E2, prog, placental lactogen, PRL

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10
Q

Later pregnancy breast changes

Lasctogenesis II

A

Removal of placenta (progesterone) -> milk secretion
Elevated PRL levels from pituitary required to maintain
Retained placenta can inhibit breastfeeding

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11
Q

Lactation post-delivery

A

PRL: maintains lactation and inhibits reproductive fxn
OXY: assists milk letdown

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12
Q

Breastfeeding nutrition for infants

A

Maternal igs (mostly IgA)
Macrophages
Lymphocytes
Exclusively breastfed infants require vitamin D supplementation

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13
Q

Breastfeeding decreases risk of which disease for baby

A 
Infections
Asthma
Allergies
DM
Obesity
Bonding
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14
Q

Breastfeeding decreases risk of which cancers for mom

A 
OXY release -> decrease pp hemorrhage
More rapid return to prepartum weight
Breast cancer
Ovarian cancer
Bonding
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15
Q

Milk secretion factors vs. milk letdown factors

A

Secretion: PRL and milk removal
Letdown/ejection: Oxytocin and suckling
Suckling also inhibits dopamine from hypothalamus ->
Stimulates PRL release from anterior pit
Operant conditioning can also stimulate hypothalamus

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16
Q

Other factors affecting breastfeeding

A 
Stress
Delayed initiation
Pituitary damage
Excessive weight ->
(inhibits initiation, duration, PRL response to suckling, reduced ability to modify metabolic demand)
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17
Q

Human vs. bovine milk

A

Human contains necessary oligosacchrides

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18
Q

Milk composition/volume with days postpartum

A 
Composition changes with volume
Volume increases
Tight junctions close
IgA secretion rises then falls
Leukocytes falls
Increased nutrition and decreased immunity with days postpartum
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19
Q

Role of milk removal in breastfeeing

A

Removal of milk is required to maintain tight junction closure in glandular system

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20
Q

Prior pregnancy affect on breastfeeding

A

Prior pregnancy primes glandular system for new round of breastfeeding

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21
Q

Colostrum

A

Milk produced following birth
Yellow
High in IgA, lactoferrin (anti-infection)
High protein, low fat/lactose
Facilitates lactobacillus and passage of meconium

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22
Q

Transitional milk (2-14 days)

A

Igs and proteins decrease
Lactose, fat, and calories increase
Vitamin changes

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23
Q

Mature milk

A

Water: main component
Lipids: 50% calories, content varies with time
Proteins: Casein and whey, lactoferrin (inhibits Fe dependent bacterial growth in GI tract)
IgA/microbal factors
CHO, iron, zinc, vitamins (need vit D supplementation)

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24
Q

Variation during feeding

A

Foremilk: more liquidy, less dense
Hindmilk: more dense

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25
Q

Malnourished mothers

A

Same proportion of macromolecules

Less amount

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26
Q

Maternal contraindications to breastfeeding

A

Medications
Untreated EtOH or drug abuse
Infections (TB, HIV in developed countries)
Undeveloped countries: HIV okay unless have access to clean water and formula

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27
Q

Takeaways from 10 step Baby Friendly Hospital Inititave

A 
Written breastfeeding policy
Help initiate within 30 min of birth
No other food or drink unless medically indicated
Mom and baby stay together
Feed on demand, no pacifiers
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28
Q

The Golden Hour (not sunrise/sunset, but the first hour after birth)

A

Feed within 30 min (baby gets sleepy)
Skin to skin (thermoregulation)
Breastfeeding crawl (not done but she said it was super “cool”, which is odd)

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29
Q

Feeding in the first 1-3 days

A

Colostrum is low volume, high fat/protein/Ig
Glycogen stores provide 12 hours
Lipogenesis keeps baby going, low volume is enough
Milk comes in day 3-4 (later in 1st birth and C-section)

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30
Q

Infant weight

A

Expected to lose 5-7% of birth weight (lipogenesis while milk comes in)
Losses stop typically around day 5
Regain of BW by day 7-14

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31
Q

Common problems

A

Pain/damage leads to engorgement, harder to pass milk, more often feedings, more pain/damage (cycle)
Primary lactation failure (rare)
Insufficient milk syndrome (inadequate removal leading to inadequate production)

32
Q

Alternatives to breastfeeding

A

Formula
1st line: Cow base (modified for casein:whey ratio)
2nd: Soy
Formula generally has more total protein (9 vs 15g)

33
Q

Risks with formula

A

Increased risk of atopy (developing allergies)
Increased risk of T1DM via autoimmune against bovine?
Increased risk of obesity (easier to get milk out, try and finish bottle - inhibits self regulation, leading to early/rapid weight gain)

34
Q

Infant growth

A

Same for first 3 months
After: formula fed gain more weight
Biggest difference: around 6 months
Known for a while, now a concern for later obesity
Use WHO growth charts 0-2 yrs of age (not CDC)

35
Q

Galactorrhea causes

A
  1. Excessive nipple stimulation
  2. Prolactinoma
  3. Drugs
36
Q

Inflammatory breast pathologies

A 
Acute mastitis
Chronic mastitis
Periductal mastitis
Mammary duct ectasia
Fat necrosis
37
Q

Ductal system basics:
Epithelium
Stroma
Lobules male vs. female

A

Fxnal unit = terminal duct lobular unit
Two layered epithelium: epi cells and myoepi cells
>2 layers and loss of myoepi = pathologic
Interlobular stroma is regular fibrous tissue
Intralobular stroma is specialized and responsive to hormones
No lobules in male breast (or female prior to menarche)

38
Q

Changes in breast composition with:
Lactation
Age

A

Lactation: increased lobular size and space, less stroma
Age: decreased interlobular stroma (more fat, less fibrous)

39
Q

Potentially developmental abnormalities of the breast

A

Accessory breast tissue or increased nipples (anywhere along milk line - inguinal to axilla, most commonly axilla)
Congenital inverted/retracted nipples (careful of cancer)
Juvenille hypertrophy

40
Q

Gynecomastia

A

Increased ducts and stroma (mostly stromal)
Unilateral or bilateral
Increase in E2
Many causes

41
Q

Acute mastitis

A

Young female, just started lactating
Irritation, infection (staph/strep)
Tx: continued drainage and abx (diclox)
Close follow up warranted (inflammatory carcinoma)

42
Q

Chronic mastitis

A

Perimenopausal most common
Duct ectasia
Obstruction due to thickened secretions
Fibrosis and irregular mass formation

43
Q

Recurrent subareolar abcess periductal mastitis

A

Squamous metaplasia leading to closure and abscess

Common in smokers

44
Q

Fat necrosis

A

Related to trauma
Mass with calcifications (saponification)
Early: necrotic fat, PMN’s
Late: macs, giant cells, fibrosis, Ca2+cation

45
Q

Benign neoplasm of breast

A

Fibroadenoma
Lactating adenoma
Phyllodes tumor
Papilloma

46
Q

Fibroadenoma

A

Premenopausal women
Origin: TDLU, fibrous tissue and ductal tissue
Well-circumscribed, mobile
E2 sensitive
No increased risk of carcinoma (as long as no epithelial hyperplasia)

47
Q

Lactating adenoma

A

Presents during preg/lactation
Circumscribed, soft mass
Proliferation of small tubular structures with lactational changes

48
Q

Phyllodes tumor

A

Fibroadeonma like- increased fibrous component pushing out to from leaves in cystic spaces
Can be benign, low grade (recur), high grade (mets)
Epi is benign, stroma can be malignant

49
Q

Papilloma

A

Proliferation of epithelium (finger like projections with 2 cell layer)
Present as small mass with bloody discharge
Must r/o carcinoma (lack of myo or more than 2 layers)

50
Q

Breast cancer etiologies

A
  1. Sporadic (70-80%)
  2. Hereditary (10-15%) - BRCA positive
  3. Familial (20-25%) - FHx but BRCA negative
    (CHEK2, other tumor suppressor genes)
51
Q

Syndromes associated with hereditary breast cancer and mutations

A

Li Fraumeni: p53
Cowden: PTEN
Peutz-Jeghers: STK11/LKB1

52
Q

3 causes for increased incidence of breast cancer in western countries

A
  1. Delayed first pregnancy
  2. Fewer pregnancies
  3. Adoption of western diet/lifestyle
53
Q

Atypical breast hyperplasia

A

Can be ductal or lobular
On spectrum in between in-situ and hyperplasia
Increased risk of invasive carcinoma

54
Q 
Ductal carcinoma in situ:
Characteristics
S/Sx
Tx
Low vs high grade
A

Proliferation of cells in ducts with no BM invasion
Calcification on mammography, no mass on exam
E-Cadherin POSITIVE
Risk of invasive
Excision usually cures
Low grade: often hormone receptor mutation (ER, PR)
High grade: often HER2/NEU overexpression

55
Q

DCIS: subtypes and grade

A

In general, increasing cells in the ducts
Cribiform variant
Papillary variant
Solid variant
Micropapillary (no fibrovascular core, hobnail cells)
Comedo: high grade

56
Q

Paget disease of the breast/nipple

A

Ulcerated nipple (often confused with eczema)
Associated with underlying carcinoma
Acanthosis (often confused with melanoma)

57
Q

Lobular carcinoma in situ

A 
Usually only solid
No mass or calcifications, often incidental finding
Often multifocal and bilateral
E-cadherin NEGATIVE
Increased bilateral invasive risk
58
Q

Invasive carcinoma of the breast

A

Mass forming
Locally advanced disease: fixation and dimpling
Most commonly upper, outer quadrand
Mets first to axillary LN

59
Q

Inflammatory carcinoma (invasive ductual)

A

Inflammed swollen breast
Lymph drainage block, diffuse dermal LN involvement
Looks like acute mastitis (fail abx)
Poor prognosis

60
Q

Invasive ductal carcinoma

A

Well to poorly differentiated
Most common type of invasive carcinoma
Mets to lungs and pleura

61
Q

Invasive lobular carcinoma

A 
Loss of E-cadherin
Express hormone receptors
No HER2/Nau overexpression
Single-file pattern
Mets to CSF, GI, ovaries
62
Q

Tubular carcinoma

A

Really good prognosis, so need to be sure

Well differentiated tubules that lack myoepithelial cells

63
Q

Types of invasive ductal carcinoma

A

Tubular
Mucinous
Medullary
Inflammatory

64
Q

Mucinous carcinoma

A 
carcinoma with tumor cells floating in mucus
Well circumscribed
Older age group
Good prognosis
Hormone receptors and BRCA1 positive
No HER/Neu over-expression
65
Q

Medullary carcinoma

A

Large, high grade cells in sheets with lymphs and plasma cells
Triple negative, BRCA1
Good prognosis

66
Q

Metaplastic carcinoma

A

Non-glandular growth
Usually ER/PR negative
Fast growing
No differentiation, ugly, high mitotic activity, squamoid

67
Q

Stromal breast tumors

A

Angiosarcoma

68
Q

Angiosarcoma

A

Spindle cells

Extravasation of blood vessels

69
Q

Mixed stromal/epithelial

A

Phyllodes tumor

70
Q

Phyllodes tumor

A

Fibroadenoma like, but can be malignant

Much higher fibrous/stromal component

71
Q

Lymphoid breast tumors

A

Mantle cell lymphoma
CLL
Diffuse Large B cell

72
Q

Pathogenesis: ER positive

A

ER positive, HER2 negative (50-65%)
Gain of 1q, loss of 16q, PIK3 activating
Associated with lower grade, better prognosis

73
Q

Molecular pathways of pathogenesis

A 
ER positive, HER2 negative (50-65%)
HER2 positive (20%)
Triple negative (15%) - BRCA1 associated, worst prog
74
Q

Pathogenesis: HER2 positive

A

Associated with Li Fraumeni
Amplification of HER2 on 17q
Associated with higher grade

75
Q

Biomarkers and response to therapy

A

ER/PR mutation = tamoxifen
HER2 = Herceptin
Triple negative = poor prog

76
Q

Male breast cancer

A

Subareolar mass, involve chest wall and skin
Assoc with BRCA2 and Klinefelter
Stage for stage/grade for grade equal to females
Often present at later stage

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