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Semester 4 > Repro Session 11 > Flashcards

Repro Session 11 Flashcards

1
Q

Where do the breasts extend to horizontally?

A

Horizontally from lateral border of sternum to mid axillary line

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2
Q

Where do the breasts extend vertically?

A

Between 2nd and 6th intercostal cartilages

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3
Q

Which muscles are the breasts superficial to?

A

Pec major and serratus anterior

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4
Q

What is the circular body of the breast?

A

Largest and most prominent part

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5
Q

What is the axillary tail of the breast?

A

Runs along the inferior lateral edge of pec major to the axillary fossa

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6
Q

What surrounds the smooth muscle nipple?

A

Pigmented areolae with sebaceous glands

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7
Q

What provides arterial supply to the medial aspect of the breast?

A

Internal thoracic

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8
Q

What branches of the axillary artery supply the breast?

A

Lateral thoracic and thoracoacromial

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9
Q

What branch of the posterior intercostal artery supplies the 2nd, 3rd and 4th intercostal spaces?

A

Lateral mammary branch

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10
Q

What branch of the anterior intercostal artery supplies the breast?

A

Mammary branch

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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

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12
Q

What gives innervation to the breast?

A

Anterior and lateral cutaneous branches of 4th and 6th intercostal nerve

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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

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14
Q

What is the retromammary space?

A

Loose CT between breast and pectoral fascia

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15
Q

What is the pectoral fascia?

A

CT associated with the pectoral fascia that provides point of attachment for Cooper’s ligament

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16
Q

What provides lymphatic drainage to the breast?

A

75% axillary, 20% parasternal, posterior intercostal

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17
Q

Where does lymph from the skin of the breast drain?

A

Axillary, inferior deep cervical and infra clavicular nodes

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18
Q

Where does lymph from the nipple and areola drain?

A

Subareolar lymphatic plexus

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19
Q

What are the mammary glands?

A

15-24 lobulated masses of fibrous tissue with adipose in between embedded in the breasts

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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

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21
Q

What is the purpose of the lactiferous sinus behind the areola?

A

Allows for accumulation of milk

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22
Q

How do the lactiferous sinuses drain in the lactating mother?

A

Through 6-16 nipple pores in the areola

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23
Q

When does breast development begin?

A

At 6 weeks in utero

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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

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25
Q

What happens to mammary tissue at puberty?

A

Ducts begin to sprout and branch

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26
Q

What are the effects of oestrogen and progesterone on mammary tissue with each menstrual cycle?

A

Oestrogen acts on oestrogen-alpha receptors to cause ductal sprouting; oestrogen and progesterone work together on oestrogen-beta receptors to cause ductal hypertrophy

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27
Q

What is mammogenesis?

A

Preparation of breasts by hypertrophy of ductular-lobular-alveolar system and differentiation of alveolar cells

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28
Q

What differentiation do alveolar cells undergo in mammogenesis?

A

Squamous to columnar

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29
Q

When can mammary tissue produce milk from during pregnancy?

A

T2

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30
Q

Why is milk not secreted from the time when the mammary tissue is developed so that it can be produced during pregnancy?

A

Progesterone inhibition of prolactin receptor synthesis

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31
Q

What favours further growth of the breast in addition to hypertrophy of the ductular-lobular-alveolar system?

A

Oestrogen stimulating adipose tissue formation

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32
Q

What process is seen in mammogenesis but only in primi gravida?

A

Angiogenesis

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33
Q

What visible breast changes are seen towards the end of pregnancy?

A

Nipples become erect, areolar enlarges and darkens

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34
Q

What is the advantages of the darkening and enlargening of the areolar towards the end of pregnancy?

A

Makes it easier for the neonate to identify

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35
Q

What are Montgomery tubercles?

A

Sebaceous glands that have fused with ducts around alveoli

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36
Q

What do Montgomery tubercles release?

A

Oil and pheromones

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37
Q

What is the function of the Montgomery tubercles secretions?

A

Oil hydrates skin around nipples and pheromones signal to neonate

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38
Q

What happens to the sensitivity of the breasts towards the end of pregnancy?

A

Increases

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39
Q

What is lactogenesis?

A

Synthesis of milk

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40
Q

What is the ultrastructure of lactocytes adapted for?

A

Production of fat by the SER, protein secretion by the Golgi apparatus, sugar synthesis and secretion

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41
Q

How is the ultrastructure of lactocytes adapted for lactogenesis?

A

Nucleus is positioned close to the base, hemidemosomes move to allow passage of macrophages and inflammatory cells

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42
Q

What does the movement of macrophages and neutrophils between cells in lactogenesis confer?

A

Maternal ductal system immunity and passive immunity to the neonate

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43
Q

What are the 5 mechanisms of entry for substances into breast milk?

A

Exocytosis, lipid synthesis and secretion, transmembrane secretion, transcytosis, paracellular pathway

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44
Q

What substances enter breast milk via exocytosis?

A

Proteins and lactose

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45
Q

How do fat droplets and milk fat globules seen in breast milk differ?

A

Globules are droplets with a membrane for even distribution

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46
Q

Which substances enter breast milk via transmembrane secretion?

A

Water, sodium and potassium

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47
Q

What substances move into breast milk via transcytosis?

A

Intact proteins

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48
Q

What is colostrum?

A

40ml of breast milk secreted in days 0-3 that has a different composition to intermediate and mature breast milk

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49
Q

Describe the composition of colostrum.

A

Less water, fat and lactose than more mature milk but more proteins, especially IgA, IgM and IgG, white cells present

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50
Q

What is the purpose of immunoglobulins in colostrum?

A

Coat neonatal intestinal mucosa

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51
Q

Describe the composition of mature breast milk.

A

~90% water, 7% lactose, 3% fat, proteins, minerals, vitamins and endocannabinoids

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52
Q

Which proteins are seen in mature breast milk?

A

Lactoalbumin, lactoglobulin, lactoferrin

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53
Q

What is the purpose of endocannabinoids in breast milk?

A

Appetite regulation of the neonate

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54
Q

How does cow’s milk compare to human breast milk?

A

Less lactose, more indigestible casein, more lactoalbumin and other proteins, more minerals

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55
Q

How long does it take milk production to mature?

A

2 weeks

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56
Q

How much energy does each litre of breast milk provide?

A

27 MJ

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57
Q

How much milk is produced each day by a lactating mother?

A

800 ml or double if twins

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58
Q

What effects does oestrogen have on prolactin?

A

Increases prolactotroph growth but not secretion

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59
Q

How is prolactin controlled?

A

Inhibition by dopamine

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60
Q

Where is prolactin produced in the pregnancy female?

A

Anterior pituitary and decidua

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61
Q

What is special about the control of prolactin produced by the decidua?

A

Not under inhibitory control by dopamine

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62
Q

What is the decidua?

A

Endometrium of the last menstrual cycle before pregnancy

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63
Q

What allows milk ejection?

A

Let-down reflex

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64
Q

What happens in galactokinesis?

A

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

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65
Q

What is galactopoeisis?

A

Maintenance of lactation via neuroendocrine reflex

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66
Q

What can stimulate the neuroendocrine reflex in milk let down?

A

Baby crying, fondling baby, anticipation of feed

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67
Q

What is needed for galactopoeisis to occur?

A

Sufficient sucking stimulus with regular removal of accumulated fluid

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68
Q

What are the consequences of infrequent breast feeding?

A

Turgor-induced damage to to secretory cells

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69
Q

Why does infrequent breast feeding rapidly become painful for the mother?

A

Turgor-induced damage combined with increased breast sensitivity

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70
Q

Is prolactin release seen in anticipation of a feed?

A

No

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71
Q

What can cause cessation of lactation?

A

Loss of feedback, pain, menstruation, suppression of prolactin, age

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72
Q

What might pain in the breasts causing cessation of lactation be due to?

A

Incensed turgor or mastitis

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73
Q

How does menstruation cease lactation?

A

Progesterone and oestrogen stimulate alveolar growth instead of secretion, reduce sensitivity to oxytocin by decreasing receptor synthesis

74
Q

How can prolactin be suppressed resulting in a cessation of lactation?

A

Ergot Tx, diuretics, retained placenta

75
Q

How does a retained placenta cause cessation of lactation?

A

Produces progesterone and oestrogen

76
Q

Why does age cause a cessation of lactation?

A

Involution of mammary tissue begins around 35 y.o.

77
Q

What are the benefits of breast feeding?

A

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
Q

When are the breasts non-functional?

A

Throughout life except during lactation

79
Q

What change in mammary tissue structure is seen at menarche?

A

Increased number of lobules and increased volume of interlobular stroma

80
Q

Describe the lobules in the breast during the follicular phase of mesntruation.

A

Quiescent

81
Q

What changes in mammary tissue are seen just after ovulation?

A

Cell proliferation and stromal oedema

82
Q

What changes are seen in mammary tissue at menstruation?

A

Decreased lobule size

83
Q

What changes are seen in mammary tissue at pregnancy?

A

Increased lobule size and number, decreases stroma and secretory changes in the epithelium

84
Q

Why does the cytoplasm of epithelial cells in mammary tissue clear during pregnancy?

A

Allow for milk accumulation

85
Q

What happens to the lobules after lactation?

A

Atrophy but do not return to previous state

86
Q

Describe the changes seen in ageing mammary tissue.

A

Terminal duct lobular units decrease in number and stroma is replaced by adipose

87
Q

Why is US imaging of the breast preferred to mammogram in younger patients?

A

Stroma is more fibrous therefore mammograms are hard to interpret

88
Q

What are the four common clinical presentations of breast disease?

A

Pain, palpable mass, nipple discharge, mammographic abnormalities

89
Q

What description of breast pain indicated physiological cause?

A

Cyclical and diffuse

90
Q

What does non-cyclical and focal beast pain indicate?

A

Ruptured cysts, injury, inflammation

91
Q

What is the non-pathological cause of a palpable breast mass?

A

Normal nodularity

92
Q

What does a hard, craggy and fixed palpable breast mass indicate?

A

Invasive carcinoma, fibroadenoma, cyst

93
Q

What presentation of nipple discharge is most concerning?

A

Spontaneous and unilateral

94
Q

What does milky nipple discharge indicate?

A

Endocrine disorder e.g. Pituitary adenoma, OCP S/E

95
Q

What does bloody/serous nipple discharge indicate?

A

Benign lesion e.g. Papilloma, duct ectasia

96
Q

What are the three changes looked for on mammography?

A

Densities, calcification sand deformities

97
Q

What do densities on mammogram indicate?

A

Invasive carcinomas, cysts, fibroadenoma

98
Q

What do calcifications on mammogram indicate?

A

DCIS, benign change

99
Q

What is the most common benign breast tumour?

A

Fibroadenoma

100
Q

At what age does Fibroadenoma typically present?

A
101
Q

Describe the incidence of breast cancer.

A

Most common non-skin malignancy in women, rare 50 y.o.

102
Q

What can often be confused with Fibroadenoma but tends to affect older pts?

A

Phyllodes tumour

103
Q

Why is phyllodes tumour more concerning than Fibroadenoma?

A

Can be malignant

104
Q

What is polythelia/axillary breast tissue?

A

Breast tissue found anywhere on the milk line

105
Q

How might a breast tumour be identified in a location other than the breast?

A

Tumour on milk line that enlarges before menstruation

106
Q

When is acute mastitis almost always seen?

A

During lactation

107
Q

What is the usual pathogenesis of acute mastitis?

A

Staph aureus infection from nipple cracks and fissures

108
Q

How does acute mastitis present?

A

Erythematous painful breast with pyrexia +/- breast abscess

109
Q

How is acute mastitis treated?

A

Expression of milk and Abx

110
Q

What history indicates fat necrosis in the breast?

A

Trauma or surgery

111
Q

How does fat necrosis in the breast present?

A

Mass, skin change, mammographic abnormality

112
Q

How does fat necrosis appear on histological examination?

A

Ail yes surrounded by macrophages and inflammatory cells

113
Q

What is the commonest breast lesion that is almost invariably present in older women?

A

Fibrocystic change

114
Q

How does fibrocystic change present?

A

Mass or mammographic change

115
Q

What does histology show on fibrocystic change of the breast?

A

Cyst formation (dilated acini), fibrosis and apocrine metaplasia lining the acini

116
Q

What often happens to the mass seen in fibrocystic change when aspirated with a fine needle?

A

Disappears

117
Q

What types of stromal tumours may be seen in the breast?

A

Fibroadenoma, phyllodes tumour, lipoma, leiomyoma, harmatoma

118
Q

What is a breast mouse?

A

Elusive, mobile mass seen in Fibroadenoma

119
Q

Describe the tumour size and location that may be seen in Fibroadenoma.

A

Multiple, bilateral, very large replacing majority of breast

120
Q

How does Fibroadenoma appear histologically?

A

With stromal and epithelial elements

121
Q

How does Fibroadenoma appear macroscopically?

A

Well circumscribed, rubbery and grey-White

122
Q

Is Fibroadenoma true neoplasm?

A

No, localised hyperplasia

123
Q

How do Phyllodes tumours appear histologically?

A

Nodules of atypical cellular stroma covered by epithelium with visible mitoses

124
Q

Describe the incidence of the types of phyllodes tumours.

A

Majority are benign, some borderline and

125
Q

How does malignant phyllodes tumour progress?

A

Aggressive, recur locally and metastasise via blood

126
Q

Why do phyllodes tumours metastasise via the blood?

A

Stromal origin

127
Q

What is required when phyllodes tumours are excised?

A

Wide margin

128
Q

Describe the pathogenesis of gynaecomastia.

A

Relative reduced androgen effect/increased oestrogen effect –> uni/bilateral enlargement of male breast

129
Q

What are some causes of gynaecomastia?

A

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
Q

What types of testicular tumour may lead to gynaecomastia?

A

Leydgig cell tumour, Sertoli cell tumour, germ cell tumour

131
Q

What proportion of malignancies in women are breast cancer?

A

20%

132
Q

How many women will develop breast cancer at some point in their lifetime?

A

1 in 12

133
Q

What is the distribution of tumour types making up all cases of breast cancer?

A

~95% adenocarcinomas, primary sarcomas e.g. Angiosarcoma make up rest

134
Q

Which area of the breast are cancers usually seen?

A

Upper outer quadrant

135
Q

What proportion of breast cancer cases are male?

A

1%

136
Q

What increases the risk of male breast cancer?

A

Klinefelter’s syndrome, male–>female, oestrogen Tx for prostate cancer

137
Q

What are risk factors for breast cancer?

A

Gender, uninterrupted menses, prolonged oestrogen exposure, obesity, geographic location, exogenous oestrogens, older age at first pregnancy, therapeutic radiation

138
Q

What proportion of breast cancers are hereditary?

A

10%

139
Q

What are 3% of all breast cancer cases attributed to?

A

BRCA1/2 mutation

140
Q

What are the consequences of a BRCA1/2 mutation?

A

Dysfunctional tumour suppressor genes –> lifetime risk of 60-85% for female carriers

141
Q

Who does the presenting age of hereditary breast cancer compare to that of spontaneous cases?

A

~20 years earlier

142
Q

What is Li Fraumeni syndrome?

A

p53 mutation –> hereditary breast cancer

143
Q

How are breast carcinomas classified?

A

In situ or invasive

144
Q

Describe the neoplasm seen in in situ carcinoma of the breast.

A

Limited by BM to ducts and lobules, preserving myoepithelial cells and cannot metastasise

145
Q

What causes the cluster/linear mammographic calcification seen in in situ breast carcinoma?

A

Comedo necrosis causing linear calcification through ducts and lobules

146
Q

Why are ducts affected by in situ carcinoma of the breast dilated?

A

Cell proliferation

147
Q

Why is it beneficial to identify in situ carcinoma early?

A

Non-obligate precursor to invasive carcinoma

148
Q

What is Paget’s disease of the breast?

A

In situ carcinoma where neoplastic cells track up ducts to the nipple skin without crossing the BM

149
Q

How does Paget’s disease of the breast present?

A

Unilateral red crusting nipple (like eczema)

150
Q

Describe the neoplasm seen in invasive breast carcinoma.

A

Invaded beyond BM into stroma so can metastasise via lymph of blood vessels

151
Q

What is the implication of invasive carcinoma presenting as a palpable mass?

A

Must’ve grown to ~2cm by which time 50% have axillary lymph node involvement

152
Q

What is peau D’orange?

A

Blockage of lymphatic drainage to the skin except for fixed hair follicles indicating invasive breast carcinoma

153
Q

What is the most common type of invasive breast carcinoma?

A

Invasive ductal carcinoma, no special type

154
Q

What is the 10 yr survival rate for IDC NST?

A

35-50%

155
Q

How do well differentiated IDC NST appear histologically?

A

Tubules line with atypical cells

156
Q

How do poorly differentiated IDC NST appear histologically?

A

Sheets of pleomorphic cells

157
Q

Why does the stroma also appear abnormal in IDC NST despite not being neoplastic?

A

Under influence of substances released by malignancy

158
Q

What type of invasive breast carcinoma has a similar prognosis to IDC NST but only accounts for 5-15% of cases?

A

Invasive lobular carcinoma

159
Q

How does invasive lobular carcinoma appear histiologically?

A

Infiltrating line of single file cells lacking E-cadherin

160
Q

Which two types of incpvasive breast carcinoma have very good prognosis but only account for a small proportion of cases?

A

Tubular and mucinous

161
Q

Which population are mucinous breast carcinomas more commonly seen in?

A

Older women

162
Q

How do mucinous breast carcinomas appear histologically?

A

Lacked of mucin with epithelial cells floating within

163
Q

How can invasive breast carcinoma metastasise?

A

Lymph, usually to ipsilateral axillary nodes; blood to bone, lungs, liver or brain; invasion to peritoneum, retroperitoneum, leptomeninges, GI tract, ovaries or uterus

164
Q

What is gene expression profiling, used in breast carcinoma?

A

Examination of 17 marker genes to identify metastatic potential for appropriate treatment plan

165
Q

How can breast carcinomas be profiled molecularly?

A

By oestrogen receptor then by Her2 receptor

166
Q

Which molecular profile types are associated with poor prognosis in breast carcinoma?

A

Oestrogen receptor -ve

167
Q

What age are oestrogen receptor -ve Brest tumours more commonly seen in?

A

70 y.o.

168
Q

What age are oestrogen receptor +ve Brest tumours more commonly seen in?

A

50 y.o.

169
Q

Which molecular profile are BRCA1 mutations causing breast carcinoma associated with?

A

Oestrogen receptor -ve, Her2 -ve

170
Q

What is the triple approach used in breast carcinoma investigation and diagnosis?

A

Clinical: Hx, FHx, examination
Radiography: mammogram or US
Pathology: fine needle aspiration cytology and core biopsy

171
Q

What local and regional control approaches can be used in breast carcinoma therapy?

A

Mastectomy, breast conserving surgery, axillary dissection, post-operative radiotherapy to axilla and chest

172
Q

Why should axillary dissection be avoided where possible?

A

Risk of oedema and Fibroadenoma

173
Q

What is sentinel lymph node biopsy?

A

Examination of the draining lymph nodes for metastasis to indicate whether axillary dissection is necessary

174
Q

What systemic control approaches can be used in breast carcinoma?

A

Chemotherapy, including neoadjuvant; hormonal Tx; Herceptin

175
Q

What proportion of breast carcinomas are oestrogen receptor +ve?

A

80%

176
Q

What proportion of breast carcinomas are Her2 +ve?

A

20%

177
Q

Why does the nucleus stains darker in oestrogen receptor positive tumours?

A

This is where the receptors are located

178
Q

What stains darker in a Her2 receptor +ve tumour?

A

CSM

179
Q

What is Herceptin?

A

Monoclonal antibody against Her2 protein

180
Q

What is Her2?

A

Human epidermal growth factor encoding transmembrane tyrosine kinase receptor

181
Q

What improves survival of breast carcinoma?

A

Early detection, neoadjuvant chemotherapy, use of neve therapies e.g. Herceptin, gene expression profiles, genetic screening and prophylactic mastectomies

Semester 4 (33 decks)

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