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Breast Flashcards

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1
Q

Where are the breasts located?

A

On the anterior thoracic wall in the pectoral region
They extend from the lateral border of the sternum to the mid auxiliary line
Cover the 2nd to 6th costal cartilage
Superficial to the pectoralis major and serratus anterior muscles

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2
Q

Where is the axiliary tale located?

A

Runs alongside the inferiolateral edge of the pectoralis major towards the auxiliary fossa

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3
Q

What is the nipple mainly composed of?

A

Smooth muscle

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4
Q

Where are sebaceous glands located within the breast tissue?

A

Within the pigmented aerolae

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5
Q

What does the mammary gland consist of?

A

Series of ducts and secretary lobules (15-20)
Each lobule consists of many alveoli drained by a single lactiferious duct
The ducts converge at the nipple
Surrounded by connective tissue stroma (fiberous and fatty tissue)
The deep aspect lies on the pectoral fascia
Auxiliary tale deals with 75% of the lymphatic flow

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6
Q

What are the levels of the axillary tail?

A

Level 1 - low axilla
Level 2 - mid axilla
Level 3 - apical axilla

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7
Q

How does the breast appear microscopically?

A

Each breast has 15-20 lobes separated by loose adipose tissue
Lobes are divided into lobules (milk secreting glands - alveoli)
Lobules are bilayered with internal epithelium surrounded by a single layer of Myoepithelium
Lactiferous ducts have basement membrane, epithelial cells and myoepithelial cells
Each lobeule has a terminal duct which merges into the lactate lactiferous ducts
Approximately 20-30 lactiforous ducts in the nipple

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8
Q

Where are the lymph nodes within the breast located?

A

Along the edge of the sternum
Axilla

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9
Q

What are the name of the breast quadrants?

A

Upper inner quadrant
Upper outer quadrant
Lower outer quadrant
Lower inner quadrant

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10
Q

What female hormones affect the breast tissue?

A

Oestrogen
Progesterone
Prolactin

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11
Q

How does the breast alter in puberty?

A

Ovaries and pituitary gland produce oestrogen, progesterone and prolactin

Progesterone induces alveolar growth
Oestrogen promotes development of mammary ducts and adipose tissue

Nipple protrudes slightly
Areola enlarges and darkens
Overall size of the breast increases

Males may develop gynecomastia at this stage

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12
Q

What are the BRAC 1 and 2 genes?

A

Breast cancer genes

Both produce proteins that help repair damaged DNA
Mutations 1 or 2 increase the risk of breast, ovarian, prostate, pancreatic and colon cancer

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13
Q

How does the breast alter during the menstrual cycle?

A

First half of the cycle
Oestrogen levels increase
Milk ducts grow
Breast becomes swollen and lumpy

Second half
Oestrogen levels fall and progesterone levels increase
Stimulates formation of milk glands
Breast are still swollen but may become painful or tender as well as lumpy or dense especially in outer areas

If pregnancy doesn’t occur breast return to normal size for the next cycle

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14
Q

How do breasts alter during pregnancy?

A

Breast increase in size over the course of the pregnancy
Nipples and areolas darkening
In colour
Sebaceous glands in the areola increase in size and produce protective lubricant for the nipple as well as antibacterial properties
Placenta oestrogen, progesterone and prolactin all promote mammary growth
Acini (glandular structures - lobules) proliferate the ductal system expands with adipose tissue
High levels of oestrogen and progesterone inhibit milk production
Colostrum is formed instead

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15
Q

How does the breast alter postpartum?

A

At birth delivery of the placenta leads to a decrease in progesterone and increase in prolactin
Milk production occurs
Infant stimulates nipple and areola leading to more prolactin release
Prolactin stimulates milk secretion by the luminal epithelial cells
Oxytocin is also released which stimulates the contraction of the myoepithelial cells to move the milk to the lactiferous ducts
Milk is expelled through the nipple
Overall size of the breast increases
Breasts vary from engorged to deflated whilst lactation occurs
Nipples darken and stretch marks are common on the skin surface

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16
Q

How does breast tissue alter during menopause?

A

Breasts become softer, homogeneous, decrease in size
Atrophy of the secretary glands and ducts these structures are often replaced by adipose tissue

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17
Q

What is the general presentation of breast pathologies?

A

Palpable lump, pain, nipple discharge, rash

Pain is not normally associated with significant pathology
Nipple discharge can be due to intraductal proliferation
Rash is common for padgets disease
Lumps can be palpable or identified on imaging (discrete), solid or cystic (most cystic orbrnign but can be malignant), can increase in size due to hormonal changes (second half of the cycle), can be mobile or tethered (limited movement would be draw the skin along)
Lumps are investigated via triple assessment

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18
Q

What age does the breast screening program cover?

A

50-70 year olds
Or symptomatic patients

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19
Q

What do breast screening clinics use to visualize the breast?

A

Mammograms

Best results after menopause as breast tissue is less dense
Also risk of cancer increases at this age

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20
Q

What is breast triple assessment?

A

Physical examination
Breast - size, symmetry, shape, lump (mobile/tethered/firm/painful)
Nipple - inversion, Redness, discharge
Skin - tethering, oedema (peau d’orange)

Imaging
Mammogram, ultrasound

Sampling
Biopsy or fine needle aspiration

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21
Q

What are the clinical implications that would lead to a patient being referred to breast screening clinic?

A

Lumps
Nipple abnormalities
Skin changes
Or pain

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22
Q

Who is present at the breast clinic?

A

Breast surgeons - take biopsy/FNA immediately
Nurses - for treatment and counselling

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23
Q

What a symptoms within breast pathology are reassuring?

A

Mobile
Well-defined
Smooth lump
No nipple or skin changes

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24
Q

What symptoms within breast pathologies are concerning?

A

Hard lump
Pukering of skin
Tethering
Indrawn nipple

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25
What type of specimens can be received from the breast?
Aspiration FNA Core biopsy Vacuum assisted biopsy Vacuum assisted excision Punch biopsy Breast reduction Excision for benign pathology Wide local excision Mastectomy Lymph nodes Nipple discharge Dochectomy or microdochectomy Shaving excision Implant capsule Scar revisions
26
Why are aspirations taken from breast specimens?
Microbiology or cytology Draining of cyst
27
Why is an fna taken from the breast?
Cytology +/- needle washings Can replace core biopsy when difficult to take
28
What is a core biopsy of breast tissue and how is it handled within the lab?
Freehand or ultrasound guided Diagnostic Taken using a wide bore needle Count Measure Try to life flat Process all Cut levels and spares at sectioning
29
What is a VAB and how is it dealt with in the laboratory?
Vacuum assisted biopsy Needle biopsy under vacuum Larger bore use than in core biopsy Vacuum helps remove larger sample Diagnostic Measure +/- calc Process all Cut levels and spares at sectioning
30
What is a VAE and how is this dealt with in the laboratory?
Similar to a VAE Used for therapeutic reasons in previously diagnosed benign conditions Eg - papaloma with no atypia, Weigh Measure +/- calc Process all Cut levels and spares at sectioning
31
Why is a punch biopsy taken from the breast and how is it dealt within the laboratory?
Taken for padgets disease and other skin conditions Treat as a skin punch Process all levels and spares at sectioning
32
What does a breast reduction specimen look like and how is it dealt within the laboratory?
Uni/bilateral Surgical removal often in many pieces with some overlying skin Can be for cosmetic or symmetry reasons Weigh Measure Describe+/- skin Blocks from centre below nipple (if possible) and all four quadrants (at least one block and any pathology identified)
33
Why are excessions for benign pathology taken and how are they dealt with in lab?
Includes lesion and narrow margin Weigh Measure Ink Slice transversely Describe external and internal surfaces Process all if small Representative if large plus any significant pathology
34
What is a wide local Excision in breath specimens and how are they dealt with in the laboratory?
Lesion plus >1 mm margin Orientate Weigh Measure Ink in multiple colors Slice transversely Describe cut surface Measure lesion and margins X-ray/photograph Process all
35
What is a mastectomy and how is it dealt with in the laboratory?
Removal of all breast material +/- skin, nipple and auxiliary tail Can be prophylactive (preventative), for symmetry or malignancy also gender reassignment Benign - Orientate Weigh Measure +/- skin Ink Slice at 10mm slices Fix for 48 hours Palpate slices for lesions Describe cut surface Measure lesions and margins ? X-ray/photographs Sample nipple, ducts, all four quadrants plus any pathology, also nipple itself to check for Paget's disease
36
How are lymph nodes from breast pathologies dealt with within the laboratory?
Palpate Measure specimen Remove excess fat Measure lymph node Slice a 2mm intervals Process all of lymph node Describe any pathology
37
How are nipple discharge specimens dealt with with in the laboratory?
Fluid aspirated Processed for cytology or microbiology depending on suspicion
38
How are dochectamy or microdochectomy specimens dealt with within the laboratory?
Removal of some all of the ducts from a breast Weigh Measure Orientate Ink, usually have a suture denoting than sub nipple aspect Slice into 3-4 mm slices transversely and cruciate the deep aspect Major duct excision also called a hadfield's procedure
39
What is a breast shave Excision and how are they dealt with within the laboratory?
Can be done a time of initial surgery or later Taken if margins found to be involved or <1mm Usually have a stitch to new cut surface Orientate Weigh Measure Ink in 2 colors Slice transversely so each slice has both old and new cut surfaces Describe cut surface Measure lesions and margins Process all
40
What are implant capsules and how are they dealt with within the laboratory?
Fibrotic material formed around implant Foreign body reaction Measure and describe Representative sampling Always beware of nodules.? associated anaplastic large cell lymphoma (ALCL)
41
What is ALCL?
Anaplastic large cell lymphoma Can the associated with old breast implants
42
Why are scar revision samples from the breast sent to the laboratory and how are they dealt with?
Often to tidy and old scar May query residual tumor Treat as skin excisions
43
What is fibrocystic change?
Non-specific general term used to describe a range of common benign conditions that occur together or in isolation
44
Where is affected by fibrocystic change?
The breast and axilla
45
Who is at most risk of fibrocystic Change?
Around 50% of women Reproductive years (25-45) r Reduced in post menopausal
46
What is the clinical presentation of fibrosystic Change?
Pain Tenderness Lumpiness Cysts or mass c Can be cyclical Associated with polycystic ovary syndrome Usually bilateral though that one may be more affected than the other
47
What are the common causes of fibrocystic Change?
Excess oestrogen leads to proliferation of epithelium in terminal duct/lobular units Induces stromol fibrosis Obstruction can occur leading to cyst Cyst can rupture leading to fibrinflammatory stromal reactions
48
What is the macroscopic appearance of fibrocystic Change?
Tissue is heterogeneously fibrous and indurated +/- cysts ranging from 1-20 mm Clear or blue doomed
49
What is the microscopic appearance of fibrocystic Change?
Adenosis - increased acini per lobule columnar cells that line the acini can be can have atypia or not Fibrosis - stromol, if cysts rupture lead to chronic inflammation (histiocytes and fibrosis) Cyst formation - diluted ducts or lobules May contain foamy macrophages and calcifications Apocrine metaplasia - simple or multi-layered epithelium Granular cytoplasm Apical snouts Enlarged nuclei Columnar cell hyperplasia - without atypia leads to enlargement of terminal duct lobules
50
What is the differential diagnosis of fibrocystic Change?
Duct hyperplasia Cystic fibroadenoma
51
What is a fibroadenoma?
Benign tumour composed of a proliferation of glandular epithelium and stromal components of the terminal duct lobular unit
52
Where do fibroadanomas occur?
Breast and axilla accessory breast tissue
53
Who is most commonly at risk of fibroadenoma?
Adolescent and young women Common Benign
54
What is the clinical presentation of fibroadenoma?
Painless Firm Mobile Slow growing mass Usually solitary but can be multiple or bilateral Usually <3 cm
55
How are fibroadanomas managed?
Clinical follow-up and monitoring Excision if symptomatic or patient choice
56
What is the macroscopic appearance of fibroadenoma?
Well circumscribed Firm Ovoid mass Bossilated surface May have mucoid or fibrotic appearance +/- calcifications Split-like spaces
57
What is the microscopic appearance of fibroadenoma?
Well circumscribed, unencapsulated proliferation of glandular and stromal elements
58
What additional tests can aid in the diagnosis of fibroadenoma?
CD34, B-cat positive Cytokeratins, Ki67 negative
59
What is the differential diagnosis of a fibroadenoma?
Phyllodes tumor Hamartoma Myxoma
60
What is mammary Paget's disease?
A proliferation of malignant glandular epithelial cells (in situ carcinoma) in the nipple, aerola epidemis
61
Where can mammary Paget's disease be located?
Nipple Areola Can extend to adjacent skin Usually unilateral
62
Who is most commonly at risk of mammary Paget's disease?
Wide age range 20-90y F>M 20-30% perimenopausal
63
What is the clinical presentation of mammary Paget's disease?
Slow onset Nipple changes Nipple erythema Scaling, crushed ulceration Eczematoid type rash Puritis Bleeding Bloody discharge Pain Retraction
64
How is mammary Paget's disease diagnosed?
Punch biopsy or incisional biopsy for skin Core biopsy for underlying abnormalities
65
How is mammary Paget's disease treated?
Depends on the severity of the underlying lesion
66
What is the macroscopic appearance of mammary Paget's disease?
Nipple/areola complex with red(pink rusting, discoloration, thickening, ulceration, exudate, nipple retraction
67
What is the microscopic appearance of mammary Paget's disease?
Single or clusters spread throughout the epidemis Abundant pale cytoplasm Large irregular nuclei Chronic inflammation in the dermis Paget cells can phagocytose melanin mimicking melanocytes
68
What is a intraductal papilloma?
Benign intraductal proliferation of epithelial cells with fibrovascular cores and underlying myoepithelial cells
69
Where can intraductal papillomas occur?
Can be lactiferous ducts (solitary) or the terminal ducts (multiple)
70
Who is most at risk of intraductal papilloma?
Women of all ages
71
What is the clinical presentation of an intraductal papilloma?
Solitary (central) can present as a mass with serous nipple discharge Peripheral are often discovered incidentally
72
How are intraductal papillomas diagnosed?
Mammogram Core needle biopsy VAB
73
How are intraductal papillomas treated?
If no atypia monitor or excise If atypia is present then excision
74
What is the macroscopic appearance of introductal papilloma?
Well circumscribed, polyploid nodule in a cystically dilated duct (central) Peripheral are not grossly visible
75
What is the microscopic appearance of an intraductal papilloma?
Circumscribed intraductal proliferation Fibrovascular core lined by an inner epithelial layer and an outer myoepithelial layer Associated with hyperplasia and apocrine metaplasia +/- ischemia, haemorrhage, fibrosis, atypia
76
What additional tests can aid in the diagnosis of intraductal papilloma?
CK5, p63 positive
77
What is the differential diagnoses of intraductal papilloma?
Ductal hyperplasia Intraductal papillary carcinoma
78
What is duct ectasia?
Disorder of the extra lobular ducts characterized by ductal inflammation, fibrosis, dilation
79
Who is usually affected by duct ectasia
Perry menopausal and post menopausal age (40-70y)
80
What is the clinical presentation of duct ectasia
Pain Nipple discharge (clear/cloudy/bloody) Nipple retraction Mass
81
How is duct ectasia diagnose?
Mammogram can resemble DCIS
82
How is duct ectasia treated?
Circumareolar incision Excision of affected duct and fistula tract if present
83
What is the macroscopic appearance of duct ectasia
Firm, fibrotic tissue with prominent dilated thick walled ducts filled with tan-white, creamy-brown, pasty or granular secretions +/- calcifications
84
What is the microscopic appearance of duct ectasia
Dilation of ducts Foamy histiocytes within luminal secretions and infiltrating the walls of the duct +!/- inflammation If the duct ruptures fibrosis and obliteration of the duct
85
What additional tests can you be used to diagnose duct ectasia?
CD68 positive
86
What is the differential diagnosis of duct ectasia?
Breast abscess Ductal carcinoma in situ
87
What is a phyllodes tumour?
Fiber epithelial neoplasm with leaf-like (phyllodal) epithelial pattern and stromal proliferation
88
Where can a phyllodes tumour occur?
Breast Ectopic breast tissue eg vulva
89
Who is at risk of a phyllodes tumour?
1% of all breast tumors Can be benign, borderline or malignant 40-50y Benign in younger females
90
What is the clinical presentation of phyllodes tumour?
Firm, asymptomatic, mobile breast mass if large (up to 20 cm) can cause skin ulceration and pain
91
How are phyllodes tumours treated?
Excision with clear margins
92
What is the macroscopic appearance of a phyllodes tumor?
Rounded Shelled-out borders Whorled cut surface with leaf-like pattern If large +/- ulceration/hemorrhage/cystic changes/necrosis
93
What is the microscopic appearance of a phyllodes tumour?
Leaf-like epithelial pattern Mild-marked stromal atypia depending on grade
94
What additional tests can aid in the diagnosis of phyllodes tumor?
ER, PR, Vimentin positive P40, p63 negative
95
What is the differential diagnoses of phyllodes tumor?
Fibroadenoma Metastatic sarcoma
96
What is gynaecomastia?
Benign enlargement of the male breast typically presenting as a palpable subareola mass
97
Where can gynaecomastia commonly occur?
Usually bilateral and retroareola Can be localized or generalized
98
Who is at risk of gynaecomastia?
Infancy Neonatal Puberty Older males (50-80y)
99
What are the courses of gynaecomastia?
Imbalance of estrogens and androgens
100
How is gynaecomastia diagnosed?
Hormone assays Mammograms
101
How is gynaecomastia treated?
Spontaneous regression within two years Sudden or symptomatic are treated with inhibitors Excision for suspected malignancy or cosmetic reasons
102
What is the macroscopic appearance of gynecomastia?
Soft, rubbery-firm grey-white subareola mass Can be ill-defined induration
103
What is the microscopic appearance of gynaecomastia?
Increasing number of ducts with three layer epithelium Proliferation of branching ducts Epithelia and stromal hyperplasia Later on dense fibrous stroma Atypical hyperplasia Apocrine or squamous metaplasia
104
What additional tests can aid in the diagnosis of gynecomastia?
ER, PR, BCL2 positive
105
What is the differential diagnosis of gynecomastia?
Male breast cancer Ductdal hyperplasia Fibroadenoma

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