Repro Session 11 Flashcards
1
Q
Where do the breasts extend to horizontally?
A
Horizontally from lateral border of sternum to mid axillary line
2
Q
Where do the breasts extend vertically?
A
Between 2nd and 6th intercostal cartilages
3
Q
Which muscles are the breasts superficial to?
A
Pec major and serratus anterior
4
Q
What is the circular body of the breast?
A
Largest and most prominent part
5
Q
What is the axillary tail of the breast?
A
Runs along the inferior lateral edge of pec major to the axillary fossa
6
Q
What surrounds the smooth muscle nipple?
A
Pigmented areolae with sebaceous glands
7
Q
What provides arterial supply to the medial aspect of the breast?
A
Internal thoracic
8
Q
What branches of the axillary artery supply the breast?
A
Lateral thoracic and thoracoacromial
9
Q
What branch of the posterior intercostal artery supplies the 2nd, 3rd and 4th intercostal spaces?
A
Lateral mammary branch
10
Q
What branch of the anterior intercostal artery supplies the breast?
A
Mammary branch
11
Q
What are the suspensory ligaments of Cooper?
A
Condensations of fibrous stroma of breast that attach and secure breast to dermis and underlying pectoral fascia and separate secretory lobules
12
Q
What gives innervation to the breast?
A
Anterior and lateral cutaneous branches of 4th and 6th intercostal nerve
13
Q
What innervation do the anterior and lateral branches of the 4th and 6th intercostal provide?
A
Sensory and autonomic to smooth muscle and BV tone
14
Q
What is the retromammary space?
A
Loose CT between breast and pectoral fascia
15
Q
What is the pectoral fascia?
A
CT associated with the pectoral fascia that provides point of attachment for Cooper’s ligament
16
Q
What provides lymphatic drainage to the breast?
A
75% axillary, 20% parasternal, posterior intercostal
17
Q
Where does lymph from the skin of the breast drain?
A
Axillary, inferior deep cervical and infra clavicular nodes
18
Q
Where does lymph from the nipple and areola drain?
A
Subareolar lymphatic plexus
19
Q
What are the mammary glands?
A
15-24 lobulated masses of fibrous tissue with adipose in between embedded in the breasts
20
Q
What does each lobule seen in the mammary glands consist of?
A
Many alveoli drained by a single lactiferous duct and sinus behind the areola
21
Q
What is the purpose of the lactiferous sinus behind the areola?
A
Allows for accumulation of milk
22
Q
How do the lactiferous sinuses drain in the lactating mother?
A
Through 6-16 nipple pores in the areola
23
Q
When does breast development begin?
A
At 6 weeks in utero
24
Q
Describe breast development up until birth.
A
Breast bud arises at 6 weeks and grows inwards to create a few ducts that are present in both the male and female at birth
25
What happens to mammary tissue at puberty?
Ducts begin to sprout and branch
26
What are the effects of oestrogen and progesterone on mammary tissue with each menstrual cycle?
Oestrogen acts on oestrogen-alpha receptors to cause ductal sprouting; oestrogen and progesterone work together on oestrogen-beta receptors to cause ductal hypertrophy
27
What is mammogenesis?
Preparation of breasts by hypertrophy of ductular-lobular-alveolar system and differentiation of alveolar cells
28
What differentiation do alveolar cells undergo in mammogenesis?
Squamous to columnar
29
When can mammary tissue produce milk from during pregnancy?
T2
30
Why is milk not secreted from the time when the mammary tissue is developed so that it can be produced during pregnancy?
Progesterone inhibition of prolactin receptor synthesis
31
What favours further growth of the breast in addition to hypertrophy of the ductular-lobular-alveolar system?
Oestrogen stimulating adipose tissue formation
32
What process is seen in mammogenesis but only in primi gravida?
Angiogenesis
33
What visible breast changes are seen towards the end of pregnancy?
Nipples become erect, areolar enlarges and darkens
34
What is the advantages of the darkening and enlargening of the areolar towards the end of pregnancy?
Makes it easier for the neonate to identify
35
What are Montgomery tubercles?
Sebaceous glands that have fused with ducts around alveoli
36
What do Montgomery tubercles release?
Oil and pheromones
37
What is the function of the Montgomery tubercles secretions?
Oil hydrates skin around nipples and pheromones signal to neonate
38
What happens to the sensitivity of the breasts towards the end of pregnancy?
Increases
39
What is lactogenesis?
Synthesis of milk
40
What is the ultrastructure of lactocytes adapted for?
Production of fat by the SER, protein secretion by the Golgi apparatus, sugar synthesis and secretion
41
How is the ultrastructure of lactocytes adapted for lactogenesis?
Nucleus is positioned close to the base, hemidemosomes move to allow passage of macrophages and inflammatory cells
42
What does the movement of macrophages and neutrophils between cells in lactogenesis confer?
Maternal ductal system immunity and passive immunity to the neonate
43
What are the 5 mechanisms of entry for substances into breast milk?
Exocytosis, lipid synthesis and secretion, transmembrane secretion, transcytosis, paracellular pathway
44
What substances enter breast milk via exocytosis?
Proteins and lactose
45
How do fat droplets and milk fat globules seen in breast milk differ?
Globules are droplets with a membrane for even distribution
46
Which substances enter breast milk via transmembrane secretion?
Water, sodium and potassium
47
What substances move into breast milk via transcytosis?
Intact proteins
48
What is colostrum?
40ml of breast milk secreted in days 0-3 that has a different composition to intermediate and mature breast milk
49
Describe the composition of colostrum.
Less water, fat and lactose than more mature milk but more proteins, especially IgA, IgM and IgG, white cells present
50
What is the purpose of immunoglobulins in colostrum?
Coat neonatal intestinal mucosa
51
Describe the composition of mature breast milk.
~90% water, 7% lactose, 3% fat, proteins, minerals, vitamins and endocannabinoids
52
Which proteins are seen in mature breast milk?
Lactoalbumin, lactoglobulin, lactoferrin
53
What is the purpose of endocannabinoids in breast milk?
Appetite regulation of the neonate
54
How does cow's milk compare to human breast milk?
Less lactose, more indigestible casein, more lactoalbumin and other proteins, more minerals
55
How long does it take milk production to mature?
2 weeks
56
How much energy does each litre of breast milk provide?
27 MJ
57
How much milk is produced each day by a lactating mother?
800 ml or double if twins
58
What effects does oestrogen have on prolactin?
Increases prolactotroph growth but not secretion
59
How is prolactin controlled?
Inhibition by dopamine
60
Where is prolactin produced in the pregnancy female?
Anterior pituitary and decidua
61
What is special about the control of prolactin produced by the decidua?
Not under inhibitory control by dopamine
62
What is the decidua?
Endometrium of the last menstrual cycle before pregnancy
63
What allows milk ejection?
Let-down reflex
64
What happens in galactokinesis?
Nipple on back of neonatal mouth stimulate mechanoreceptors in nipples --> signal to hypothalamus causing posterior pituitary to release oxytocin --> acts on myoepithelial receptors around alveoli causing ejection
65
What is galactopoeisis?
Maintenance of lactation via neuroendocrine reflex
66
What can stimulate the neuroendocrine reflex in milk let down?
Baby crying, fondling baby, anticipation of feed
67
What is needed for galactopoeisis to occur?
Sufficient sucking stimulus with regular removal of accumulated fluid
68
What are the consequences of infrequent breast feeding?
Turgor-induced damage to to secretory cells
69
Why does infrequent breast feeding rapidly become painful for the mother?
Turgor-induced damage combined with increased breast sensitivity
70
Is prolactin release seen in anticipation of a feed?
No
71
What can cause cessation of lactation?
Loss of feedback, pain, menstruation, suppression of prolactin, age
72
What might pain in the breasts causing cessation of lactation be due to?
Incensed turgor or mastitis
73
How does menstruation cease lactation?
Progesterone and oestrogen stimulate alveolar growth instead of secretion, reduce sensitivity to oxytocin by decreasing receptor synthesis
74
How can prolactin be suppressed resulting in a cessation of lactation?
Ergot Tx, diuretics, retained placenta
75
How does a retained placenta cause cessation of lactation?
Produces progesterone and oestrogen
76
Why does age cause a cessation of lactation?
Involution of mammary tissue begins around 35 y.o.
77
What are the benefits of breast feeding?
Fewer infections for neonate; deceased risk of breast and ovarian cancer; further contraction of the uterus to pre pregnancy state; binding via oxytocin; loss of pregnancy weight
78
When are the breasts non-functional?
Throughout life except during lactation
79
What change in mammary tissue structure is seen at menarche?
Increased number of lobules and increased volume of interlobular stroma
80
Describe the lobules in the breast during the follicular phase of mesntruation.
Quiescent
81
What changes in mammary tissue are seen just after ovulation?
Cell proliferation and stromal oedema
82
What changes are seen in mammary tissue at menstruation?
Decreased lobule size
83
What changes are seen in mammary tissue at pregnancy?
Increased lobule size and number, decreases stroma and secretory changes in the epithelium
84
Why does the cytoplasm of epithelial cells in mammary tissue clear during pregnancy?
Allow for milk accumulation
85
What happens to the lobules after lactation?
Atrophy but do not return to previous state
86
Describe the changes seen in ageing mammary tissue.
Terminal duct lobular units decrease in number and stroma is replaced by adipose
87
Why is US imaging of the breast preferred to mammogram in younger patients?
Stroma is more fibrous therefore mammograms are hard to interpret
88
What are the four common clinical presentations of breast disease?
Pain, palpable mass, nipple discharge, mammographic abnormalities
89
What description of breast pain indicated physiological cause?
Cyclical and diffuse
90
What does non-cyclical and focal beast pain indicate?
Ruptured cysts, injury, inflammation
91
What is the non-pathological cause of a palpable breast mass?
Normal nodularity
92
What does a hard, craggy and fixed palpable breast mass indicate?
Invasive carcinoma, fibroadenoma, cyst
93
What presentation of nipple discharge is most concerning?
Spontaneous and unilateral
94
What does milky nipple discharge indicate?
Endocrine disorder e.g. Pituitary adenoma, OCP S/E
95
What does bloody/serous nipple discharge indicate?
Benign lesion e.g. Papilloma, duct ectasia
96
What are the three changes looked for on mammography?
Densities, calcification sand deformities
97
What do densities on mammogram indicate?
Invasive carcinomas, cysts, fibroadenoma
98
What do calcifications on mammogram indicate?
DCIS, benign change
99
What is the most common benign breast tumour?
Fibroadenoma
100
At what age does Fibroadenoma typically present?
101
Describe the incidence of breast cancer.
Most common non-skin malignancy in women, rare 50 y.o.
102
What can often be confused with Fibroadenoma but tends to affect older pts?
Phyllodes tumour
103
Why is phyllodes tumour more concerning than Fibroadenoma?
Can be malignant
104
What is polythelia/axillary breast tissue?
Breast tissue found anywhere on the milk line
105
How might a breast tumour be identified in a location other than the breast?
Tumour on milk line that enlarges before menstruation
106
When is acute mastitis almost always seen?
During lactation
107
What is the usual pathogenesis of acute mastitis?
Staph aureus infection from nipple cracks and fissures
108
How does acute mastitis present?
Erythematous painful breast with pyrexia +/- breast abscess
109
How is acute mastitis treated?
Expression of milk and Abx
110
What history indicates fat necrosis in the breast?
Trauma or surgery
111
How does fat necrosis in the breast present?
Mass, skin change, mammographic abnormality
112
How does fat necrosis appear on histological examination?
Ail yes surrounded by macrophages and inflammatory cells
113
What is the commonest breast lesion that is almost invariably present in older women?
Fibrocystic change
114
How does fibrocystic change present?
Mass or mammographic change
115
What does histology show on fibrocystic change of the breast?
Cyst formation (dilated acini), fibrosis and apocrine metaplasia lining the acini
116
What often happens to the mass seen in fibrocystic change when aspirated with a fine needle?
Disappears
117
What types of stromal tumours may be seen in the breast?
Fibroadenoma, phyllodes tumour, lipoma, leiomyoma, harmatoma
118
What is a breast mouse?
Elusive, mobile mass seen in Fibroadenoma
119
Describe the tumour size and location that may be seen in Fibroadenoma.
Multiple, bilateral, very large replacing majority of breast
120
How does Fibroadenoma appear histologically?
With stromal and epithelial elements
121
How does Fibroadenoma appear macroscopically?
Well circumscribed, rubbery and grey-White
122
Is Fibroadenoma true neoplasm?
No, localised hyperplasia
123
How do Phyllodes tumours appear histologically?
Nodules of atypical cellular stroma covered by epithelium with visible mitoses
124
Describe the incidence of the types of phyllodes tumours.
Majority are benign, some borderline and
125
How does malignant phyllodes tumour progress?
Aggressive, recur locally and metastasise via blood
126
Why do phyllodes tumours metastasise via the blood?
Stromal origin
127
What is required when phyllodes tumours are excised?
Wide margin
128
Describe the pathogenesis of gynaecomastia.
Relative reduced androgen effect/increased oestrogen effect --> uni/bilateral enlargement of male breast
129
What are some causes of gynaecomastia?
Secondary to circulating maternal and placental oestrogens in the neonate, earlier oestrogen peak in normal puberty, drugs e.g. Spironolactone, Klinefelter's syndrome, liver cirrhosis, testicular tumours causing gonadotrophin excess
130
What types of testicular tumour may lead to gynaecomastia?
Leydgig cell tumour, Sertoli cell tumour, germ cell tumour
131
What proportion of malignancies in women are breast cancer?
20%
132
How many women will develop breast cancer at some point in their lifetime?
1 in 12
133
What is the distribution of tumour types making up all cases of breast cancer?
~95% adenocarcinomas, primary sarcomas e.g. Angiosarcoma make up rest
134
Which area of the breast are cancers usually seen?
Upper outer quadrant
135
What proportion of breast cancer cases are male?
1%
136
What increases the risk of male breast cancer?
Klinefelter's syndrome, male-->female, oestrogen Tx for prostate cancer
137
What are risk factors for breast cancer?
Gender, uninterrupted menses, prolonged oestrogen exposure, obesity, geographic location, exogenous oestrogens, older age at first pregnancy, therapeutic radiation
138
What proportion of breast cancers are hereditary?
10%
139
What are 3% of all breast cancer cases attributed to?
BRCA1/2 mutation
140
What are the consequences of a BRCA1/2 mutation?
Dysfunctional tumour suppressor genes --> lifetime risk of 60-85% for female carriers
141
Who does the presenting age of hereditary breast cancer compare to that of spontaneous cases?
~20 years earlier
142
What is Li Fraumeni syndrome?
p53 mutation --> hereditary breast cancer
143
How are breast carcinomas classified?
In situ or invasive
144
Describe the neoplasm seen in in situ carcinoma of the breast.
Limited by BM to ducts and lobules, preserving myoepithelial cells and cannot metastasise
145
What causes the cluster/linear mammographic calcification seen in in situ breast carcinoma?
Comedo necrosis causing linear calcification through ducts and lobules
146
Why are ducts affected by in situ carcinoma of the breast dilated?
Cell proliferation
147
Why is it beneficial to identify in situ carcinoma early?
Non-obligate precursor to invasive carcinoma
148
What is Paget's disease of the breast?
In situ carcinoma where neoplastic cells track up ducts to the nipple skin without crossing the BM
149
How does Paget's disease of the breast present?
Unilateral red crusting nipple (like eczema)
150
Describe the neoplasm seen in invasive breast carcinoma.
Invaded beyond BM into stroma so can metastasise via lymph of blood vessels
151
What is the implication of invasive carcinoma presenting as a palpable mass?
Must've grown to ~2cm by which time 50% have axillary lymph node involvement
152
What is peau D'orange?
Blockage of lymphatic drainage to the skin except for fixed hair follicles indicating invasive breast carcinoma
153
What is the most common type of invasive breast carcinoma?
Invasive ductal carcinoma, no special type
154
What is the 10 yr survival rate for IDC NST?
35-50%
155
How do well differentiated IDC NST appear histologically?
Tubules line with atypical cells
156
How do poorly differentiated IDC NST appear histologically?
Sheets of pleomorphic cells
157
Why does the stroma also appear abnormal in IDC NST despite not being neoplastic?
Under influence of substances released by malignancy
158
What type of invasive breast carcinoma has a similar prognosis to IDC NST but only accounts for 5-15% of cases?
Invasive lobular carcinoma
159
How does invasive lobular carcinoma appear histiologically?
Infiltrating line of single file cells lacking E-cadherin
160
Which two types of incpvasive breast carcinoma have very good prognosis but only account for a small proportion of cases?
Tubular and mucinous
161
Which population are mucinous breast carcinomas more commonly seen in?
Older women
162
How do mucinous breast carcinomas appear histologically?
Lacked of mucin with epithelial cells floating within
163
How can invasive breast carcinoma metastasise?
Lymph, usually to ipsilateral axillary nodes; blood to bone, lungs, liver or brain; invasion to peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries or uterus
164
What is gene expression profiling, used in breast carcinoma?
Examination of 17 marker genes to identify metastatic potential for appropriate treatment plan
165
How can breast carcinomas be profiled molecularly?
By oestrogen receptor then by Her2 receptor
166
Which molecular profile types are associated with poor prognosis in breast carcinoma?
Oestrogen receptor -ve
167
What age are oestrogen receptor -ve Brest tumours more commonly seen in?
70 y.o.
168
What age are oestrogen receptor +ve Brest tumours more commonly seen in?
50 y.o.
169
Which molecular profile are BRCA1 mutations causing breast carcinoma associated with?
Oestrogen receptor -ve, Her2 -ve
170
What is the triple approach used in breast carcinoma investigation and diagnosis?
Clinical: Hx, FHx, examination
Radiography: mammogram or US
Pathology: fine needle aspiration cytology and core biopsy
171
What local and regional control approaches can be used in breast carcinoma therapy?
Mastectomy, breast conserving surgery, axillary dissection, post-operative radiotherapy to axilla and chest
172
Why should axillary dissection be avoided where possible?
Risk of oedema and Fibroadenoma
173
What is sentinel lymph node biopsy?
Examination of the draining lymph nodes for metastasis to indicate whether axillary dissection is necessary
174
What systemic control approaches can be used in breast carcinoma?
Chemotherapy, including neoadjuvant; hormonal Tx; Herceptin
175
What proportion of breast carcinomas are oestrogen receptor +ve?
80%
176
What proportion of breast carcinomas are Her2 +ve?
20%
177
Why does the nucleus stains darker in oestrogen receptor positive tumours?
This is where the receptors are located
178
What stains darker in a Her2 receptor +ve tumour?
CSM
179
What is Herceptin?
Monoclonal antibody against Her2 protein
180
What is Her2?
Human epidermal growth factor encoding transmembrane tyrosine kinase receptor
181
What improves survival of breast carcinoma?
Early detection, neoadjuvant chemotherapy, use of neve therapies e.g. Herceptin, gene expression profiles, genetic screening and prophylactic mastectomies
