The female breast

Question 1

Younger woman presents with recent or acute onset red, swollen and warm area in the breast without distinct lump. Skin appears pitted (peau d’orange) or bruised.

Answer 1

Inflammatory breast cancer–a rare, but aggressive form of breast cancer (1-5%)

Question 2

Older female presents with hx of chronic scaly red-colored rash resembling eczema on the nipple/areola that does not heal. Sometimes itches.

Answer 2

Paget’s disease of the breast (Ductal carcinoma in situ). Skin lesion slowly enlarges and evolves to include crusting, ulceration, and/or bleeding on the nipple.

Question 3

Histology of the adult female breast

Answer 3

Glands, ducts, and stroma consisting of fibrous tissue that binds individual lobes together, and adipose tissue within and between the lobes.

Question 4

Each breast contains how many lobes?

Answer 4

12-20 conical lobes.

The base of each lobe is in close proximity to the ribs. The apex, which contains the major excretory duct of the lobe, is deep to the areola and nipple. In turn, each lobe consists of a group of lobules. The lobules have several lactiferous ducts, which unite to form a major duct that drains the lobes as they course toward the nipple–areolar complex. Each of the major ducts widens to form an ampulla as they travel toward the areola and then narrow at its individual opening in the nipple. The lobules are held in place by a meshwork of loose, fatty areolar tissue. The fatty tissue increases toward the periphery of the lobule and gives the breast its bulk and hemispheric shape

Question 5

What percentage of the breast is adipose tissue?

Answer 5

80-85%

Question 6

Breast changes during pregnancy

Answer 6

During pregnancy, the alveoli hypertrophy, and their lining cells proliferate in number. During lactation, the alveolar cells secrete proteins and lipids, which comprise breast milk.

Question 7

Fascial bands that support the breast in its upright position on the chest wall.

Answer 7

Coopers ligaments

Question 8

Skin dimpling by breast cancer is caused by distortion of what?

Answer 8

Coopers Ligaments

Question 9

Breast growth during puberty is a result of

Answer 9

multiglandular stimulation, causing increase in

acinar tissue,

ductal size

branching

deposits of adipose

Question 10

Response of the breast to progesterone

Answer 10

increased breast size and turgidity

Deepened pigmentation of nipple/areola

Nipple enlargement

areolar widening

Increased number and size of lubricating glands in areola

Question 11

In late pregnancy, the fatty tissue of the breast is almost completely replaced with

Answer 11

cellular breast parenchyma

Question 12

Breast resopnse after rapid drop in progesterone (delivery of baby)

Answer 12

Breasts are fully mature

Begin to secrete milk

Question 13

Breast changes at cessation of nursing (or administration of estrogens)

Answer 13

breast rapidly returns to prepregnancy state.

Marked diminution of cellular elements and increase in adipose tissue

Question 14

Breast changes during menopause (5th decade)

Answer 14

Gradual process of atrophy and involution.

Decreased number and size of acinar and ductal elements

Breast tissue regresses to almost infantile state.

Adipose tissue may or may not atrophy with dissappearance of the parenchymal elements

Question 15

Breast location by rib

Answer 15

From just below the level of the second rib inferiorly to the sixth or sevents rib.

(2-6/7)

Question 17

multiple small, elevated nodules on the skin of the areola

Answer 17

sebaceous glands of Montgomery

Question 18

Sebacous glands of Montgomery function

Answer 18

lubrication of the nipple–prevention of cracking during breastfeeding

During the third trimester of pregnancy, the sebaceous glands of Montgomery markedly hypertrophy

Question 19

breast vessels, lymphatics, nerves

Answer 19

Axillary artery and vein

Internal mammary artery and vein

Lateral thoracic artery

Thoracoepigastric vein

Question 20

Nipple and areola–smooth muscle

Answer 20

A circular smooth muscle band surrounds the base of the nipple. Longitudinal smooth muscle fibers branch out from this ring of circular smooth muscle to encircle the lactiferous ducts as they converge toward the nipple. The many small punctate openings at the superior aspect of the nipple represent the terminals of the major lactiferous ducts. As discussed earlier, the ampullae of the lactiferous ducts are deep to the nipple and the areola

Question 22

Breast lymphatic drainage importance

Answer 22

Implications in several disease etiologies including breast cancer.

Question 23

2 main categories of lymphatic drainage

Answer 23

Superficial (including cutaneous) drainage

Deep parenchymatous drainage

Question 24

Superficial lymphatic drainage of the breast

Answer 24

Drains:

areola and nipple–

including cutaneous and subcutaneous tissues adjacent to the nipple-areolar complex.

Question 25

Deep parenchymatous lymphatic drainage

Answer 25

Small periductal and periacinal lymph vessles–larger interlobar lymphatics–axilla

Question 26

Level 1 lymph nodes

Answer 26

Lymph located lateral or below pectoralis minor

Question 27

level 2 lymph nodes

Answer 27

Deep to the pectoralis minor muscle

Question 28

level 3 lymph nodes

Answer 28

located medially or superiorly to the upper margin of the pectoralis minor muscle.

Question 29

Which spinal nerves supply the cutaneous tissue covering the breasts?

Answer 29

T4-6

Question 30

Painful, often multiple, usually bilateral mobile masses in the breast.

Rapid fluctuation in the size of the masses is common.

Frequently, pain occurs or increases, as does size during the premenstrual phase of the cycle.

Most common age is 30–50 years; occurrence is rare in postmenopausal women

Answer 30

Fibrocystic breast

Question 32

Treatment for fibrocystic breats

Answer 32

Reassurance

If treatment still desired:

Avoid trauma with supportive bra

May try abstaining from caffeine

mild analgesics

Danazol and tamoxifen–side effects

Symptoms subside at menopause

Question 34

This common, benign neoplasm occurs most frequently in young women, usually within 20 years after puberty. It is somewhat more frequent and tends to occur at an earlier age in black women than in white women. can increase in size during pregnancy or with estrogen therapy and usually regress after menopause. Multiple tumors in 1 or both breasts are found in 10–15% of patients.

Answer 34

Fibroadenoma of the breast

Question 35

round, firm, discrete, well defined, relatively movable, nontender mass 1–5 cm in diameter. The tumor is usually discovered accidentally.

Answer 35

Fibroadenoma

Difinitive diagnosis with core biopsy

No risk of breast cancer unless proliferative change or complex–then only slight

Question 36

fibroepithelial tumors that tend to grow rapidly–sometimes confused with benign fibroadenomas. Tumor may grow to be large, and if inadequately excised, will recur. Rarely malignant.

Answer 36

Phyllodes tumors of the breast

Question 37

fibroadenoma treatment

Answer 37

local excision with a margin of surrounding normal breast tissue.

Question 38

Most common cause of pathologic nipple discharge

(serous, bloody, or serosanguineous)

Answer 38

Intraductal papillomas

Less frequently, carcinoma and fibrocystic change with ectasia of the ducts.

Question 39

Causes of galactorrhea

Answer 39

Idiopathic

Drug induced: Phenothiazines, butyrophenones, reserpine, methyldopa, imipramine, amphetamine, metoclopramide, sulpiride, pimozide, oral contraceptive agents

Central nervous system (CNS) lesions

Pituitary adenoma, empty sella, hypothalamic tumor, head trauma

Medical conditions:Chronic renal failure, sarcoidosis, Schüller-Christian disease
Cushing’s disease, hepatic cirrhosis, hypothyroidism

Chest wall lesions
Thoracotomy, herpes zoster

Question 40

Bilateral multiductal milky nipple discharge in nonlactating breasts

Answer 40

galactorrhea

result of hyperprolactinemia d/t medications etc…

Question 41

unilateral, spontaneous serous or seosanguineous discharge from a single nipple duct

Answer 41

Pathologic nipple discharge

• intraductal papilloma or intraductal malignancy.*
• Palpable mass may not be present*

Question 42

What type of discharge is more suggestive of cancer?

Answer 42

Bloody–but usually caused by a benign papilloma in the duct

Question 43

Treatment of pathologic nipple discharge

Answer 43

Surgical excision of the involved duct after ruling out additional breast findings

Question 44

Purulent discharge from the nipple

Answer 44

subareolar abscess–escision of abscess and related lactiferous sinus

Question 45

benign condition that produces a mass, accompanied by skin or nipple retraction clinically indistinguishable from carcinoma.

Accompanied by ecchymosis occasionally

Possible tenderness.

Answer 45

Fat necrosis of the breast

Trauma and surgery are presumed etiology, though many have no recollection of trauma to the breast.

If left untreated, mass will disappear. If no regression for several weeks, consider biopsy.

Surgical excision usually not necessary.

Question 46

Redness, tenderness, and induration in the breast of a lactating woman

Answer 46

mastitis

If caught early, continue breastfeeding and administer antibiotic.

Question 47

Palpable mass with local and systemic signs of infection in lactating breast

Answer 47

Breast abscess–I&D

Breastfeeding may still continue and may help control the pain and shorten the duration of infection.

Question 48

Breast abscess in non-lactating women

Answer 48

usually subareolar, and tends to recur after I&D.

Usually requires excision of involved lactiferous duct or ducts at the base of the nipple.

Otherwise, breast infection is rare.

Question 49

If patient with suspected breast infection does not respond to treatment, suspect

Answer 49

Inflammatory breast cancer

Especially with associated lymphadenopathy

Question 50

Complete absence of one or both breasts

Answer 50

amastia

Question 51

accessory nipples

Answer 51

polythelia

Question 52

Early findings: Single, nontender, firm to hard mass with ill-defined margins; mammographic abnormalities and no palpable mass.

Later findings: Skin or nipple retraction; axillary lymphadenopathy; breast enlargement, redness, edema, brawny induration, peau d’orange, pain, fixation of mass to skin or chest wall.

Late findings: Ulceration; supraclavicular lymphadenopathy; edema of arm; bone, lung, liver, brain, or other distant metastases.

Answer 52

Carcinoma of the female breast

Question 53

Breast cancer incidence is highest in which race

Answer 53

White

Question 54

Clinical staging of breast cancer

Answer 54

TNM

Tumor, node, metastasis

Question 55

How are the majority of breast cancer cases diagnosed?

Answer 55

Abnormal mammogram findings–less often because of palpable mass

Question 56

Initial evaluation breast cancer

Answer 56

Assessment of the local lesion

bilateral mammogram

breast ultrasound as indicated

CBC

LFT

Alk phos