Week 7- breast week Flashcards
What makes up the secretory tissue of the breast?
15-25 lobes, which each consist of tubule-acinar glands which drain via a series of ducts to the nipple.
What is directly next to the secretory lobules?
What is adjacent to this?
Deep fibrous tissue.
Adipose tissue is then next to this.
What are suspensory ligaments made of?
Condensed fibrous tissue.
Where do the suspensory ligaments in the breast run from?
The dermis of the skin to the deep fascia overlying the muscles on the anterior chest wall.
What is a basic functional secretory unit of the breast?
Terminal duct lobular unit.
In the non-lactating breast, where do the terminal ducts lead?
Into an intralobular collecting duct which leads into the lactiferous duct for that lobe.
Where are the lactiferous ducts?
What is the name for the expanded area in the lactiferous duct.
They lead to the nipples. First it goes through an area of expanded duct called the lactiferous sinus before reaching the nipple.
What is another word for terminal ductal lobular unit?
Acini
Describe the drainage of the breast through the ductal system?
All lobules contain several terminal ductal lobular units. These (also known as acini) drain too the intralobular collecting system, then the extra lobular collecting system and then into the lactiferous duct. The lactiferous duct then enlarges to form the lactiferous sinus and then exits via the nipple.
What lines the acini (terminal ductal lobular unit)?
Secretory epithelial cells. They vary from columnar to cuboidal.
What surrounds the secretory cells of the acini?
What is the function of this cell?
Myoepithelial cells.
They are contractile epithelial cells which in turn are surrounded by basal lamina.
What lines larger ducts (e.g.lactiferous duct)
The epithelium varies from thin stratified squamous to stratified cuboidal.
Also myoepithelial cells are present.
What are mammary glands said to be like?
Sweat glands that are slightly modified.
What covers the surface of the nipple?
Stratified squamous keratinised epithelium.
What makes up the core of the nipple?
Dense connective tissue (fibrocollagenous) mixed with bundles of smooth muscle.
What ducts are present within the nipple?
Lactiferous ducts.
Describe the change in lining of the lactiferous duct from deep to superficial?
Deep- it will be stratified cuboidal epithelium
Nearer the surface- stratified squamous epithelium.
What other glands can be found in the nipple?
Sebaceous glands.
What occurs during the luteal phase of menstruation to the glands in the nipple?
Epithelial cells increase in height.
The lumina of the ducts becomes enlarged
Small amounts of secretion in the ducts.
If pregnancy occurs, what changes take place to the breasts?
Elongation and branching of the smaller ducts.
Proliferation of cells of the glands and myoepithelial cells
In the second trimester- glandular tissue continues to develop with differentiation of secretory alveoli
Plasma and lymphocytes infiltrate into the connective tissue.
In the third trimester alveoli continue to mature, with development of extensive RER.
Also a reduction in connective tissue and adipose tissue.
During pregnancy, what does oestrogen and progesterone stimulate?
Proliferation of secretory tissue and fibro-fatty tissue becomes sparse.
What is the composition of human milk?
88% water
1.5% protein
7% carbs
3.5% lipid
With small quantities of ions, vitamins and IgA antibodies.
What is an apocrine secretion?
Lipid droplets surrounded by membrane and carrying a small amount of cytoplasm.
Where are the proteins in milk made?
What sort of secretion is this?
RER. Packaged in the Golgi body and secreted via vesicles which merge with the apical membrane to release contents into the duct system.
Merocrine secretion.
What occurs to the mammary glands in menopause?
The secretory cells in the terminal ductal lobular units degenerate.
In the connective tissue- there are fewer fibroblasts and reduced collagen and elastic fibres.
Which ways can you obtain cytopathology samples of the breast?
Fine needle aspiration
Fluid
Nipple discharge
Nipple scrape
How would you interpret fine needle aspiration results?
C1- Unsatisfactory sample C2- benign C3- Atypia- probably benign C4- Suspicious of malignancy C5- malignant.
What is the difference between cytopathology and histopathology?
Cytopathology- studies cells
Histopathology- studies whole tissues.
Which ways can you obtain a histopathology sample?
Needle (core) biopsy
Vacuum assisted biopsy (takes a large volume)
Skin biopsy
Incisional biopsy of mass
How would you interpret core biopsy results?
B1- Unsatisfactory B2- benign B3- atypia- probably benign B4- suspicious of malignancy B5-malignant
What distinguishes a carcinoma in situ from an invasive carcinoma on core biopsy results?
B5a- carcinoma in situ
B5b- Invasive carcinoma
What is a mastectomy?
An operation to remove the breast.
What developmental anomalies can cause benign pathology in the breast?
Hypoplasia- underdevelopment
Juvenile hypertrophy- increase in size of cells
Accessory breast tissue
Accessory nipple- an extra nipple.
What non-neoplastic growths can cause benign breast pathology?
Gynaecomastia- excess prolactin
Fibrocystic change- breasts feel lumpy due to hormonal changes.
Hamartoma- a benign tumor-like structure.
Fibroadenoma
Sclerosing lesions
What inflammatory causes can cause benign breast pathology?
Mastitis
Fat necrosis
Duct ectasia (distention)
What tumours are benign in breast pathology?
Phyllodes tumour
Intraduct papilloma
What occurs in gynaecomastia?
This is breast development in the male due to ductal growth within lobular development.
(Basically the tubes that lead to the nipple grow).
What causes gynaecomastia?
Exogenous/endogenous hormones
Cannabis
Prescription drugs
Liver disease
Who gets fibrocystic change in the breast?
Women aged 20-50.
Tends to occur in people with menstrual abnormalities, early menopause, late menopause.
It often resolves after menopause.
How do fibrocystic changes present?
Small lumps on the breasts
Could have sudden pain, cyclical pain (due to normal monthly changes in hormones), could be incidentally found or on screening.
Describe the gross pathology of fibrocystic changes in the breast?
Blue domed cysts filled with pale fluid. Ranging from 1mm to several cms.
Is fibrocystic breast associated with any other benign pathology?
Yes.
Describe the cell structure of the cysts you are likely to find in fibrocystic breasts?
Thin walled cysts lined by apocrine endothelium. May have a fibrotic wall.
What is metaplasia?
The change from one fully differentiated cell type to another fully differentiated cell type.
How do you manage fibrocystic breasts?
Exclude malignancy
Reassure the patient
Excise if necessary
What is a hamartoma?
Circumscribed lesion made of cell types present in the breast however in an abnormal proportion or distribution.
What is a fibroadenoma?
A solid, non cancerous breast lump. It might feel firm, smooth, rubbery or hard and has a well circumscribed shape.
What ethnicity are fibroadenomas common in?
African women
How are fibroadenomas picked up?
Commonly in screening. Will be solid on ultrasound.
Will have a painless, discrete, MOBILE (as in can be moved) mass.
What is meant by biphasic fibroadenoma?
Two essential components- a stromal and an epithelial component.
(NOTE- determination of the stromal composition aids diagnosis).
How do you manage fibroadenomas?
Diagnose- exclude malignancy
Reassure
Excise if necessary
What is meant by sclerosing?
Hardening of tissues due to infiltration of fibrous interstitial or glial tissue.
What is sclerosing adenosis?
Proliferation of breast tissue where some of it has become hard and sclerosed.
What is a radial scar?
A benign lesion that mimics malignancy on radiographs.
How are sclerosing lesions characterised?
They are benign, disorderly proliferations of acini and stroma. Can cause a mass or calcification and can also mimic carcinoma (radial scar).
How does sclerosing adenosis present?
What age range does it tend to effect?
Pain, tenderness or lumpiness/thickening.
Could be asymptomatic
Tends to affect 20-70.
Is sclerosing adenosis benign?
Yes its benign. There is negligible risk of subsequent carcinoma.
Describe the cell structure in a radial scar?
Stellate architecture (arranged like a star)
Central puckering
Radiating fibrosis
Histologically, how would you describe a radial scar?
Fibroelastotic core
Radiating fibrosis containing distorted ductules
Fibrocystic change
Epithelial proliferation
How would you treat a radial scar?
Excise or sample extensively via vacuum biopsy because although it is not malignant, they can sometimes contain malignancies within them.
What can cause fat necrosis of the breast?
Trauma- e.g. a seat belt injury
Warfarin therapy
What is meant by the term fat necrosis?
Damage and disruption of adipocytes (cells that compose adipose tissue)
Infiltration by acute inflammatory cells
“foamy” macrophages
Subsequent fibrosis and scarring.
How do you manage fat necrosis?
Confirm the diagnosis and exclude malignancy.
Which ducts does duct ectasia affect?
Sub-areolar ducts.
How does duct ectasia present?
Pain Acute episodic inflammatory changes Bloody +/- purulent discharge Fistulation Nipple retraction and distortion
What is duct ectasia associated with? How does this work?
Smoking.
You can get subareolar duct dilatation. This leads to periductal inflammation, scarring and eventually fibrosis.
How do you manage duct ectasia?
Treat acute infections
Exclude malignancy
Stop smoking
Excise ducts
What can cause acute mastitis?
2 ways
- duct ectasia- mixed organisms, anaerobes
- lactation- infection by staph aureus or strep progenies
How do you manage acute mastitis?
Antibiotics to treat infection
Percutaneous drainage
Incision and drainage
Treat underlying cause
What is a phyllodes tumour?
A benign tumour of the stroma of the breast. The behaviour of it depends on stromal features.
(NOTE- borderline malignant)
Once excised, will a phyllodes tumour come back?
Prone to reoccurrence if not adequately excised. Rarely metastasise.
What three papillary lesions can you get as benign breast pathology?
Intraduct papilloma
Nipple adenoma
Encysted papillary carcinoma.
Who gets intraduct papillomas?
Aged 35-60 women
How does an intraduct papilloma present?
Nipple discharge +/- blood
Can be asymptomatic at screening- nodules or calcification may show.
Which ducts does an intraduct papilloma affect?
Sub-areolar ducts.
How do the papillary look in an intraduct papilloma?
Papillary fronds contain a fibrovascular core
Covered by myoepithelium and epithelium.
Epithelium may show proliferative activity.
How does epithelial progression occur in intraduct papilloma?
Could have none
Could have usual type hyperplasia
Could have atypical ductal hyperplasia
Ductal carcinoma in situ.
What is the definition of a breast carcinoma?
A malignant tumour of breast epithelial cells.
Where do breast carcinomas arise?
In the glandular epithelium of the terminal duct lobular unit.
(NOTE- technically an adenocarcinoma but just referred to as carcinoma usually.)
Name some precursor lesions for breast carcinoma?
Any epithelial proliferations e.g. Ductal causes -usual type hyperplasia of the epithelium -Columnar cell change -Atypical ductal hyperplasia -Ductal carcinoma in situ.
Lobular causes
-Lobular in situ carcinoma.
What is an in situ carcinoma?
Confined within the basement membrane of acini and ducts.
Cytologically malignant but non-invasive
How can an in situ carcinoma be classified?
As lobular or ductal.
What are the two sub-categories of lobular in situ neoplasia? Describe the amount of the lobe involved in both?
Atypical lobular hyperplasia (ALH)-<50% of the lobe involved
Lobular carcinoma in situ (LCIS) >50% of the lobule involved.
Cytologically, what is an lobular in situ neoplasia?
Intralobular proliferation of characteristic cells.
They have small-intermediate sized nuclei. They are a solid proliferation. Intra-cytoplasmic lumens/vacuoles. ER positive. E- cadherin negative.
Lobular in situ neoplasia usually are singular. True or false.
False- they are multifocal and bilateral.
Will lobular in situ neoplasia present with a lump?
No- they are not palpable or visible grossly.
How may a lobular in situ carcinoma be picked up?
May calcify which will be seen on mammogram. Usually an incidental finding.
Do in situ lobular neoplasia’s raise the risk of developing invasive carcinoma?
Yes- they raise your risk 8 fold.
How do you manage lobular in situ neoplasias?
If discovered on core biopsy- excise or vacuum biopsy it to exclude a higher grade lesion.
If discovered on vacuum or excision biopsy- follow up.
What is meant by intraductal proliferation?
Neoplastic growth in the cell ducts.
Name some examples of intraductal proliferation?
Epithelial hyperplasia of usual type
Columnar cell change
Atypical ductal hyperplasia
Ductal carcinoma in situ.
What are the risks associated with intraductal proliferation?
Risk of progression to invasive carcinoma.
Which type of intraductal proliferation increases the risk of acquiring invasive carcinoma the most?
Ductal carcinoma in situ.
What percentage of malignancies does ductal carcinoma in situ make up?
15-20%.
Where do ductal carcinoma in situ’s arise?
Terminal ductal lobular unit.
Characteristically, do ductal carcinomas in situ take up multiple duct systems or just a singular duct system?
Characteristically singular duct systems. (unicentric).
Cytologically, describe a ductal carcinoma in situ?
Malignant epithelial cells
Confined within the basement membrane of the duct.
If a ductal carcinoma in situ involves the nipple skin, what is it known as?
Pagets
What is Pagets disease of the nipple?
High grade DCIS extending along ducts to reach the epidermis of the nipple. Still an in situ carcinoma.
How is DCIS classified?
Mostly by cytological grade. Sometimes by histological type.
How do you manage DCIS?
Surgery with adjuvant radiotherapy
What is a micro invasive carcinoma?
Rare
Its a ductal carcinoma in situ with less than 1mm invasion.
How would you treat a high grade DCIS?
As a high grade DCIS.
What is an invasive breast carcinoma?
Malignant epithelial cells which have breached the BM.
It infiltrates normal tissues.
Risk factors for invasive breast carcinoma?
Old age Reproductive history- age at menarche. Age at first birth. Parity. Breastfeeding. Age at menopause. Hormones-oral contraception or HRT. Previous breast disease Lifestyle
What lifestyle factors can increase your risk of carcinoma of the breast?
Bodyweight- high body weight is bad Physical activity- protective Alcohol consumption- bad Diet- high fat is bad NSAID- lower the risk Smoking
What does an affected 1st degree relative do to the risk?
Doubles the risk.
What percentage of all breast cancers are BRCA 1 and BRCA 2?
2%
What are the different ways invasive breast cancer can be classified?
Morphologically- by type or grade
Gene expression profiling
Hormone receptor expression-oestrogen receptor (ER), progesterone receptor (PR), HER2
Describe specifically the grading of breast carcinomas and what this equates too in scores?
Objective assessment of:
- tubular differentiation (1-3)
- nuclear pleomorphism (1-3)
- mitotic activity (1-3)
Score 3,4 or 5- grade 1
Score 6 or 7- grade 2
Score of 8 or 9- grade 3
What does HER2 stand for?
Human epidermal growth receptor 2.
When is HER2 over expression seen?
In 15% of all breast cancers.
What is trastuzamab?
A new class of anti-cancer agents. Active in HER2 positive disease.
What does HER2 do?
If you have too much HER2 expression, it makes the cells in the breast divide in an uncontrollable way.
What does the triple assessment consist of?
Clinical examination
Imaging
Pathology
What is meant by the term ANDI?
Stands for abberations in the normal development
Its basically what happens to the breast with age.
What is a papilloma?
A benign tumour
Is breast pain associated with breast cancer?
Nope.
What may be a pathological sign of breast cancer?
Blood in nipple discharge
Principles of surgical oncology?
Surgical excision with a clear margin
Assess surgical feasibility
Assess patient suitability
Assess potential impact on quality of life
With breast conservation surgery what is the adjuvant therapy that is needed?
Need to have adjuvant radiotherapy. This can shrink the cancer.
Name some examples of breast conservation therapy?
Lumpectomy
Wide local incision
Wire guided local excision
Oncoblastic breast conservation
Is it true that a mastectomy reduces the chances of the cancer coming back more than breast conservation therapy?
No both equally effective. Sometimes patients will have the state of mind that the cancer will come back and its hard to change this. But you have to have radiotherapy along with the breast conservation surgery.
With breast conservation therapy, what does the margin of tissue need to be to make it safe?
> 1mm
What Is the margin needed for wide surgical excision?
1cm
What neoadjuvant treatment can you use to add to breast conservation surgery?
Chemotherapy using FEC100 and taxmen +/- Herceptin
Endocrine- Aromatase inhibitors (post menopausal women) or tamoxifen
Radiotherapy
What imaging technique would you use to assess the response to chemotherapy?
Mammography, ultrasound and MRI
When is chemotherapy used as the adjuvant treatment?
Currently used to control local and systemic disease.
If the patient has a large breast or a large tumour, what surgical technique will you use?
Therapeutic mammoplasty
If the patient has small breasts, what surgical/cosmetic techniques will you use?
Volume replacement techniques.
What is a mastectomy?
Removal of all breast tissue. They spare the skin usually if immediate reconstruction.
What are the reconstruction options after a mastectomy?
Implant (with an autologous cellular matrix)
Lattimus dorsi pedicled flap
Deep inferior epigastric artery perforator free flap
Inferior gluteal artery perforator free flap
What are some issues with implants?
Infection
Capsular contracture- tissue tightens around the implant giving it a weird shape
Implant rippling (appears to move/ripple when the patient bends over)
Implant migration
40% require revisional surgery.
Where is the implant inserted?
Has to be inserted below something other than skin e.g. some tissue or muscle.
What is an acellular dermal matrix?
Soft tissue replacement to be put in with the implant.
What are the advantages of acellular dermal matrix?
Provides coverage of the lower pole of the breast so the surgery can be done in one stage.
Better expansion at the lower pole of the breast.
Reduced post op pain
A permanent implant can be used at the first operation
Better aesthetic outcomes
What are the axillary treatment options?
Axillary clearance
Axillary radiotherapy
Need to preoperatively stage the nodes with USS axilla +/- core biopsy.
