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Y3- TO LEARN > Gynaecology + Breast > Flashcards

Gynaecology + Breast Flashcards

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1
Q

What is ‘strawberry vagina’?

A

Trichomoniasis

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2
Q

Metrorrhagia?

A

Regular intermenstrual bleeding

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3
Q

Polymenorrhoea?

A

> 21 day cycle

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4
Q

Oligomenorrhoea?

A

> 35 day cycle

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5
Q

Amenorrhoea?

A

No bleeding >6 months

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6
Q

Some organic causes of menorrhagia?

A 
Fibroids
Polyps
Cervical erosion
Endometrial Hyperplasia
IUD/IUS
Pelvic Inflammatory disease
Endometriosis
Carcinoma
Trauma
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7
Q

Some systemic causes of menorrhagia?

A

Adrenal disease, hyper/hypothyroidism, diabetes, prolactin disorder
Drugs
Liver diseases
Renal diseases

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8
Q

Name a non-organic cause of menorrhagia?

A

Absence of pathology–> Dysfunctional Uterine Bleeding (DUB)

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9
Q

How is DUB divided up?

A

Anovulatory (85%)

Ovulatory

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10
Q

Diagnosis of DUB?

A

Exclusion of other causes

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11
Q

Age and period cycle of anovulatory DUB?

A

Extremes of reproductive age
Irregular cycle

(more common in obese women)

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12
Q

Age and period cycle of ovulatory DUB?

A

35-45 years
Regular heavy periods
(due to inadequate progesterone)

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13
Q

Investigations of DUB?

A

FBC, Hb, coag screen, TSH, LFTs and renal function
Cervical smear
Transvaginal USS
Endometrial sampling

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14
Q

Management of DUB?

A 
Merina IUS/oral contraceptive
GnRH analogues
NSAIDs
Endometrial resection/ablation
Hysterectomy
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15
Q

Which cells secrete progesterone during folliculogenesis?

A

Granulosa cells

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16
Q

What is formed from a secondary follicle?

A

Graffian follicle

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17
Q

What does the follicle form after ovulation of the new oocyte?

A

Corpus Luteum

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18
Q

What lines the fallopian tubes?

A

Simple columnar epithelium + some ciliated cells and secretory cells

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19
Q

What is the endometrium made of?

A

Tubular secretory glands

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20
Q

What is the myometrium made of?

A

3 layers of smooth muscle with collagen + elastic

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21
Q

What is the perimetrium made of?

A

Loose connective tissue

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22
Q

What is the cervix covered by and what does it transition to?

A

Stratified squamous epithelium
Transitions to:
Simple columnar epithelium

+ mucous secreting glands

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23
Q

What is common at the transition zone in the cervix?

A

Cervical cancers

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24
Q

What is the outer layer of the vagina?

A

Non-keratinised stratified squamous epithelium

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25
What is the use of glycogen in the cells in the vagina?
Glycogen metabolised to lactic acid to INHIBIT PATHOGENIC BACTERIA
26
What kind of glands are present in the labia majora?
Apocrine sweat glands and sebaceous glands
27
What kind of gland are present in the labia minora?
Sebaceous glands
28
What is the most common approach to treatment of psychosexual dysfunction?
Psychodynamic psychotherapy
29
Consideration before vasectomy?
Age >30 Offspring Medical conditions
30
How does female sterilisation work?
Blocks fallopian tubes
31
Effective treatment of premenstrual pain and dyspareunia in endometriosis?
Combined oral contraceptive
32
Which hormone is used to measure ovarian reserve before IVF?
Anti-mullerian hormone (AMH)
33
What forms the indifferent gonads in embryological development?
Genital ridges form primitive sex cords
34
What is another name for the Mesonephric duct?
Wolffian ducts
35
What is another name for the Paramesonephric duct?
Mullerian ducts
36
When does sexual differentiation occur?
Week 7 onwards
37
What triggers male development?
SRY (sex determining region of Y) transcription factor
38
How does the Y chromosome produce a male?
Sex determining region causes development of testes | Testes secrete testosterone and mullerian inhibiting factor
39
What do the male genital tracts arise from?
Wolffian ducts
40
What do the female genital tracts arise from?
Mullerian ducts
41
What are the 3 parts of the uterine cycle, and how long do they last?
Proliferative- day 1-14 Secretory (luteal)- day 16-28 Menstruation- day 1-3
42
What happens in the proliferative stage of the uterine cycle?
Oestrogen causes growth of glands, stroma and vasculature | Increased thickness
43
What happens in the secretory stage of the uterine cycle?
Progesterone causes glands to become more torturous with lumenal secretions
44
When sending an endometrial biopsy to the lab, what information is all important to give?
Date of last period and drug list
45
What is trans-vaginal ultrasound typically used to assess?
Endometrial thickness
46
What is normal endometrial thickness?
<16mm in pre-menopausal | <4mm in post-menopausal
47
What is the most common for endometrial sampling?
Dilatation and curretage
48
How does endometritis occur?
Failure of cervical mucous plug to protect from ascending infection
49
When are endometrial polyps most common?
Around/after menopause
50
What is adenomyosis?
Endometrial glands and stroma with myometrium
51
What is atrophic vaginitis?
Lack of oestrogen causes loss of lubrication, thinning and decreased elasticity
52
Symptoms of atrophic vaginitis?
Burning pain Itch Painful intercourse Discharge
53
Treatment of atrophic vaginitis?
Topical oestrogen creams | HRT
54
What state does the bladder need to be in for transabdominal and transvaginal USS?
transabdominal- full | transvaginal- empty
55
4 indications for CT?
Acute abdo pain Post-surgical complications Staging gynae cancers Response to treatments
56
What is hydrosalpinx?
Blocking of fallopian tube with fluid or serous
57
What is a hysterosalpingography (HSG) and what is it used for?
Real time X ray Assesses tubal patency
58
Stress UI?
After effort or exertion or on sneezing/coughing
59
Urgency UI?
Accompanied by urgency- due to overactive detrusor muscle
60
Causes of incontinence?
``` Age Parity Pregnancy Smoking Obesity Menopause UTI ```
61
Investigations of incontinence?
Urinalysis | Urodynamics
62
Management of incontinence?
``` Reduce caffeine, alcohol, fluids Weight loss Pelvic floor exercises Bladder retraining Anti-muscarinics Mirabegron (relax bladder) Desmopressin Botox injection Topical oestrogen ```
63
Name some anti-muscarinics used in incontinence?
Oxybutynin | Tolterodine
64
Specific management of stress UI?
Physio Pessary Bladder neck bulking agent Autologous sling (surgery)
65
How common is pelvic prolapse in parous women?
50%
66
Causes of pelvic prolapse?
``` Age Obesity Parity/vaginal delivery Chronic constipation Oestrogen deficiency (menopause) Connective tissue disorder ```
67
Important history in pelvic prolapse?
Pressure/dragging Urinary/bowel symptoms (e.g. incomplete emptying) Sexual dysfunction Obs Hx
68
Types of prolapse? (4)
Anterior (cytocele)- bladder through vagina Middle/apical (vault/enterocele)- vaginal/small bowel prolapse Posterior (rectocele)- bowel through vaginal Complete eversion- all compartments
69
Assessment of prolapse?
POP-Q | USS/MRI
70
Management of prolapse?
``` Weight loss Pelvic floor exercises Pessaries- for mild/moderate or elderly Rings/cubes- for young, sexually active Shelves/Gelhorn- severe, not sexually active Surgery ```
71
What is climacteric?
Start of symptoms leading up to menopause
72
What is menopause?
Last ever menstrual period- due to oestrogen deficiency
73
What is the average age of menopause?
51 years
74
How is early menopause defined?
<45 years
75
How is premature menopause defined and causes?
<40 years Causes: chemotherapy, infections (e.g. mumps), oophorectomy, Turner's, autoimmune disorders)
76
How is late menopause defined?
>54 years
77
Symptoms of menopause?
``` Hot flushes Night sweats Mood swings/Irritability Palpitations Joint aches Headaches Vaginal dryness Decreased libido Atrophy of breast Dry skin/hair Urinary symptoms of incontinence May have dysfunctional bleeding ```
78
Diagnosis of menopause?
1. Symptoms 2. Pattern of periods 3. Bloods - in women <45, hysterectomy, or merina coil - FSH + LH levels
79
Management of menopause?
``` Increase calcium (osteoporosis) Weight loss Exercise Decreased caffeine HRT (O+P)- for symptoms ```
80
When is oestrogen only HRT used?
For people without uterus
81
When is topical oestrogen used?
In vaginal dryness
82
What is oestrogen + progesterone HRT protective against?
Endometrial cancer Osteoporotic fractures Bowel cancer
83
What is oestrogen only HRT protective against?
Breast cancer
84
What is there a higher risk of in oestrogen + progesterone HRT?
Breast cancer VTE CVA Gallbladder disease
85
When should HRT be avoided?
``` History of: Breast, ovarian/cervical cancers Blood clots Heart disease Stroke Hypertension Liver disease ```
86
When is HRT contraindicated?
History of VTE, stroke, angina/MI, or breast cancer
87
Most common cause of uterine mass?
Fibroids (cancers very rarely present with mass)
88
What is a uterine fibroid?
Leiomyoma (benign smooth muscle)
89
Features of fibroids?
Common in <40s Often multiple OESTROGEN DRIVEN- shrink after menopause
90
Classifications of fibroids?
intramural, submucous, subserous, intracavity, pedunculated
91
Symptoms of fibroids?
``` Often asymptomatic/incidental or menorrhagia pelvic mass pain/tenderness pressure (bowel/bladder) ```
92
Diagnosis of fibroids?
USS (homogenous smooth muscle, often multiple)
93
Treatment of fibroids?
Leave + monitor if asymptomatic Hysterectomy if family complete Myomectomy- remove fibroids Uterine artery embolisation- cut off blood to fibroids
94
Causes of tubal swellings? (6)
``` Ectopic pregnancy (unlikely to cause mass) Hydrosalpinx Pyosalpinx- emergency Paratubal cysts- wolffian tubule remnant Endometriosis Salpingitis ```
95
3 groups of ovarian masses?
Cysts Endometriosis Tumours
96
What are follicular (functional) cysts in the ovary, and what lines them?
Related to ovulation- occur when ovulation DOESN'T occur- follicle turns to cyst Lined by granulosa cells
97
What are endometriotic cysts caused by?
Endometriosis (endometrial glands + stroma in wrong place) | Usually behind ovaries, pouch of Douglas, uterosacral, cervix, vulva, vagina etc.
98
Features of endometriotic cysts?
Under hormonal control- proliferative/secretory phases | Form CHOCOLATE CYSTS when try to menstruate
99
Symptoms of endometriosis?
``` Painful periods Irregular periods Premenstrual bleeding Painful intercourse Subfertility Tender mass (+ nodules) ```
100
What does endometriosis increase the risk of?
Ectopic pregnancy- scarring of tubes prevent egg progression
101
What is unique about the histology of ovarian masses?
Can have a mixture of benign, borderline and malignant tissue all in one tumour
102
When is a mass particularly concerning: solid, or solid and cystic
Solid and cystic
103
Where have secondary metastatic ovarian tumours most likely come from?
Breast, pancreas, stomach and GI
104
When should secondary metastatic ovarian tumours be particularly considered?
When tumours are small or bilateral
105
Which is the most common benign ovarian tumour?
Epithelial
106
Classification of epithelial ovarian tumours, and which is most common? (5)
``` Serous (common, aggressive) Mucinous Endometrioid (often low grade) Clear cell (often low grade) Brenner ```
107
Which ovarian benign tumour is associated with endometriosis?
Endometrioid
108
Which ovarian benign tumours are associated with Lynch Syndrome?
Endometrioid + clear cell | Have younger presentation
109
What is a dermoid cyst?
Benign cystic teratoma (germ cell tumour) Can differentiate into anything- teeth, hair, thyroid etc.
110
Other than dermoid cyst, name 3 other germ cell tumours in the ovary?
Dysgerminoma (children/young women) Yolk sac tumour Choriocarcinoma
111
Clinical triad and pathological features of fibroma?
Clinical- pleural effusion, ascites, uterine bleeding Pathology- looks like potato
112
Name 3 kinds of sex-cord/stromal benign epithelial ovarian tumours, and what do they produce?
Granulosa cell- oestrogen Theca/Leydig cell- androgens Fibromas
113
Risk factors for ovarian cancer?
``` Increase age Nulliparity Family History BRCA 1 +2 (breast + ovarian) Lynch syndrome ```
114
What is protective against ovarian cancer?
ORAL CONTRACEPTIVE PILL (due to decreased number of periods)
115
How can ovarian cancer spread?
Into peritoneum via open fimbrae Haematogenous Lymphatic
116
Symptoms of ovarian cancer?
``` Bloating Mass, swelling, pressure ASCITES (peritoneal spread) Low back pain Fatigue Weight loss/anorexia Heartburn Early satiety Bowel/bladder changes (pressure) Leg oedema SOB/pleural effusion ```
117
Investigations of ovarian cancer? (5)
``` Tumour markers- CA125, CEA USS CT for spread Biopsy/fluid aspiration cytology Risk of malignancy score ```
118
What is CA125 an indication of, and why can it be raised?
Marker of PERITONEAL INFLAMMATION High in 80% of ovarian cancer (+ endometriosis, peritonitis, pregnancy, pancreatitis, ascites etc.)
119
What is CEA an indication of?
Main function is to EXCLUDE METS FROM GI PRIMARY
120
What USS findings would make a tumour more likely be malignant?
``` Mixture of solid + cyctic Multi-loculated Thick septations Ascites Bilateral ```
121
How to calculate 'Risk of Malignancy score' and what is normal?
Menopausal status x serum CA125 x USS score Normal= <200-250
122
Staging 1-4 of ovarian cancer (FIGO)?
I- confined to ovaries II- ovaries + pelvic extension III- ovaries + peritoneal mets/LN IV- distant mets
123
Prognosis of each stage of ovarian cancer?
Stages 1 + 2 are usually curable with surgery Stages 3 + 4 are treatable but not curable
124
Treatment of ovarian cancer?
Laparotomy- surgical debulking + examination/staging + fertility conserving surgery
125
When should adjuvant chemotherapy be used to treat ovarian cancer?
Improve surgery outcomes as need less radical surgery Stage IC or grade 3= use adjuvant chemotherapy
126
When should chemotherapy after surgery be used to treat ovarian cancer?
Stage II, III and IV | or just chemo
127
How is ovarian cancer followed up?
Guided by symptoms | Serum CA 125 levels
128
What does endometrial hyperplasia cause?
DUB or post-menopausal bleeding
129
Why does endometrial hyperplasia occur?
Due to persistent oestrogen stimulation
130
Features of simple endometrial hyperplasia?
``` General process- entire endometrium Cytology normal (often) Common around menopause ```
131
Features of complex endometrial hyperplasia?
Focal in one part Crowded GLANDS Not premalignancy
132
Features of atypical endometrial hyperplasia?
Focal in one part Crowded GLANDS ABNORMAL cytology
133
Which kind of endometrial hyperplasia is pre-malignant?
Atypical endometrial hyperplasia
134
Management of atypical endometrial hyperplasia?
Hysterectomy (prevent cancer formation)
135
Peak age of endometrial cancer?
50-60 Uncommon <40 (lynch syndrome, PCOS etc.)
136
Presentation of endometrial cancer?
Abnormal, post-menopausal bleeding
137
Risk factors for endometrial cancer?
``` Obesity Lynch Syndrome Hypothyroidism HRT Tamoxifen ```
138
How does obesity increase the risk of endometrial cancer?
Adipocytes express aromatase- convert androgens to oestrogens= endometrial proliferation Higher insulin levels= endometrial proliferation
139
What is Lynch Syndrome?
HNPCC Predispose to colorectal, endometrial and ovarian cancer --> Yearly screening
140
How does Lynch syndrome occur?
AD inheritance of defective DNA mismatch repair genes
141
What is the hallmark of Lynch Syndrome on histology?
Microsatellite instability
142
What kind of carcinoma are most endometrial cancers?
Endometrioid (+mucinous) carcinoma --> type 1 tumours
143
What kind of carcinoma are type 2 endometrial tumours?
Serous (+ clear cell) carcinoma
144
Features of serous (+ clear cell) carcinoma of endometrium and who do they affect?
Unrelated to oestrogen More aggressive + high grade TP53 mutated/overexpressed Affect elderly post-menopausal women
145
How can endometrial cancers spread?
To myometrium/cervix Lymphatic Haematogenous
146
Staging 1-4 of endometrial cancer?
I- confined to body of uterus II- uterus and cervix III- uterus + peritoneal cavity/LN IV- distant mets
147
Investigations of endometrial cancer?
Transvaginal USS Biopsy CT for mets
148
Treatment of endometrial cancer?
``` Total hysterectomy + BSO Lymph node dissection Adjuvant radiotherapy- reduce recurrence Adjuvant chemotherapy- for high grade Merina coil ```
149
What is a BSO?
Bilateral salpingo-oophorectomy
150
Why is chemotherapy sometimes used before radiotherapy?
To sensitise tumour
151
Side effects of radiotherapy in endometrial cancer treatment?
``` Cystitis N+V Diarrhoea Colitis PR bleeding Infertility ```
152
What can the Merina coil be used in endometrial cancer treatment?
Young women to maintain fertility or If surgery contraindicated
153
How is endometrial cancer followed up?
Screen for surgery complications Lose weight Patient led- signs and symptoms
154
What is a leiomyosarcoma, and where does it occur?
Occurs in myometrium Rare- poor prognosis Women >50 Spindle cell morphology
155
What is Bartholin’s gland abscess due to?
Blockage of gland duct
156
What is most Vulvar and Vaginal Pathology related to?
HPV
157
What is grade 3 VIN?
Squamous cell carcinoma in-situ
158
What does VIN often occur with?
CIN + vaginal neoplasia
159
VIN in young people?
Multifocal, recurrent, persistent
160
VIN in older people?
Greater risk of progression to invasive squamous carcinoma
161
Presentation of vulvar invasive squamous carcinoma?
Elderly women Related to HPV + VIN Ulcer/mass Mostly low grade, can spread to inguinal LN
162
Presentation of vulvar Paget's disease?
Crusting rash- tumour confined to epidermis, spread lateral May become invasive Paget's Contains mucin
163
Cells of the endocervix?
Columnar epithelium (+ goblet cells producing mucin)
164
Cells of the ectocervix?
Squamous epithelium | Nuclei become smaller as they get closer to the surface
165
What is the transformational zone?
Squamo-columnar junction between ectocervix and endocervix | Squamous epithelium over glands= indicative
166
What happens to the transformational zone throughout life?
Changes position (e.g. at menarche, pregnancy and menopause)
167
Why is the transformational zone significant?
More replication and so more chance for mutations in this area
168
What is cervical erosion (ectropion or eversion)?
Exposure of delicate endocervical epithelium to acid environment of vagina, leading to physiological squamous metaplasia (squamous grows over columnar)
169
When does cervical erosion occur?
Hormone changes (e.g. in young women) Oral contraceptive pill Pregnancy
170
Causes and complications of cervicitis?
Caused by chlamydia, herpes simplex etc. Can lead to damage of fallopian tubes
171
Which HPV causes CIN/cancer in 70% of cases?
16+18
172
What does HPV do to cells?
Infects squamous cells Takes over cell reproduction + replicates Produce proteins to inhibit tumour suppressor genes
173
What are koilocytes?
HPV infected squamous cells with large nuclei
174
Who is at high risk of HPV? (6)
Many sexual partners (increased exposure) Age at first intercourse (increased exposure) Long term use of oral contraceptive Not using condoms (esp. in MSM) Smoker (x3 risk) Immunosuppression
175
Incubation of HPV before high grade CIN occurs?
6 months-3 years
176
How long does it take to develop cancer after high grade CIN?
5-20 years
177
Where is a cervical smear taken?
Transformational zone
178
Difficult groups for cervical screening?
``` Minority ethnic groups Domestic violence/assault victims Immigrants/travellers Prisoners Students Disabled Transgender patients Illiteracy, deprived etc. ```
179
When should someone be referred for colposcopy after a smear?
Any result over moderate dyskaryosis
180
What is moderate dyskaryosis consistent with?
CIN II
181
What is severe dyskaryosis consistent with?
CIN III
182
What 4 steps are taken in colposcopy?
1. Magnified inspection 2. Acetic acid staining 3. Iodine staining 4. Biopsy or LLETZ
183
Why is acetic acid used during colposcopy?
Abnormality appears white
184
Why is iodine used during colposcopy?
Abnormality appears negative (no uptake of brown iodine)
185
What is LLETZ?
Large loop excision of transformation zone- for histology
186
Treatments of CIN?
LLETZ- excision | Cold coagulation- 100 degree probe causes cells to burst
187
How is test of cure carried out for CIN?
Smear + HPV test after 6 MONTHS | Positive- further colposcopy
188
What is CIN and where does it occur?
Cervical Intraepithelial Neoplasia | Pre-invasive stage of cervical cancer- at TZ
189
Symptoms of CIN?
Asymptomatic
190
Histology of CIN?
``` Dysplasia of squamous cells Large nuclei Excess mitotic activity Koliocytosis Delay in maturation (immature basal cells) ```
191
How is grade of CIN determined?
By 1/3s of epithelium affected CIN I = 1/3 CIN II= 2/3 CIN III= 3/3 (full thickness)
192
What is important to check in CIN III?
Basement membrane for breakthrough (one cell through= cancer)
193
Prognosis of CIN?
Some regress, some persist, and some progress to higher grades, or to invasive cervical cancer
194
When is cervical cancer most common?
<35 years
195
When does screening for cervical cancer occur?
3 years- 25-49 | 5 years-50-64
196
When is screening not appropriate?
If patient is SYMPTOMATIC
197
Symptoms of cervical cancer?
``` Abnormal bleeding (post coital, post menopause, inter-menstrual, brownish/bloody discharge) Pelvic pain Dyspareunia Haematuria/UTI Ureteric obstruction ```
198
Risk factors for cervical cancer?
Parity Smoking FH/personal history
199
What kind of carcinoma are 75-95% of cervical cancers?
Squamous carcinoma
200
What does squamous cervical cancer occur from?
Pre-existing CIN
201
Staging of squamous cervical cancer (FIGO)?
I- confined to cervix II- to parametrium or top of vagina III- to pelvic side wall or lower vagina IV- to adjacent organs or distant mets
202
At what stage are most cervical cancers found?
Stage 1A/B
203
Prognosis for cervical cancer?
stage 1 -80-95% 5 year survival
204
Grading of cervical cancers?
Well differentiated Moderately differentiated Poorly differentiated Undifferentiated/anaplastic
205
Where can cervical cancer spread to?
Lymphatic early- pelvis, para-aortic nodes Haematogenous late- liver, lungs, bone
206
Features of cervical adenocarcinoma?
Glandular formation Can be mixed with squamous Worse prognosis
207
Risk factors for cervical adenocarcinoma?
Later onset of sexual activity, Smoking Higher socioeconomic class HPV 18
208
What is cervical adenocarcinoma preceded by and what is it equivalent to?
Cervical glandular intraepithelial neoplasia (CGIN)- adenocarcinoma in-situ No grading- equivalent to CIN III
209
First step in managing cervical cancer?
Planning with CT scan, PET scan or EUA - Identify tumour borders and affected lymph nodes
210
How are cervical cancers that are confined to the cervix treated?
Surgery: LLETZ Wertheim- remove cervix, vaginal sutured to uterus Hysterectomy
211
How are cervical cancers that have spread out of the cervix treated (1B and above)?
Radiotherapy/chemotherapy/brachytherapy
212
When is radiotherapy used in cervical cancers, and how does it work?
In post-menopausal/family complete | Produces free radicals to attack DNA normal tissue recovers better than cancer
213
What is brachytherapy?
Internal radiation treatment- intrauterine tube using a ring applicator (CT guided)
214
Why is brachytherapy used? (3)
Greatly increases dose given Spares dose to bladder/rectum Reduces recurrence rate
215
What might affect brachytherapy effectiveness?
Anaemia (need adequate blood flow)
216
3 ways that chemotherapy can be used in cervical cancer treatment?
1. Concomittant with radiotherapy (more radiosensitive)- routine 2. Neoadjuvant- before definitive treatment (shrink tumour) 3. Palliative (disease outside pelvis)
217
What is cisplatin, and name some side effects?
Chemotherapy drug VOMITING, pins and needles, tinnitus
218
Carboplatin and paclitaxel can be used as chemotherapy for cervical cancers. What side effects do they have?
Renal failure Bone marrow suppression- bleeding + neutropenia Hair loss (paclitaxel)
219
Describe breast gross anatomy?
Subcutaneous fat + glands in front of deep fascia and pectoralis major muscle
220
In young women, what is the tissue of the breast like (compared to older women)?
Younger- more dense tissue | Older- more fat
221
What are women with more dense breasts at higher risk of?
Breast cancer
222
How many lobes are in the breast, and how do they drain?
15-25 (each with compound tubule-acinar gland) via ducts leading to nipple
223
What surrounds the secretory lobe of the breast?
Dense fibrous tissue (suspensory ligaments)- dermis to deep fascia
224
Why does puckering/dimpling of the skin sometimes occur with breast tumours?
Puts pressure on the ligaments which is attached to the dermis- pull the skin inwards
225
What is the TDLU of the breast?
Terminal Duct Lobular Unit – basic functional secretory unit
226
Pathway of milk from the TDLU of the breast?
Terminal ductules Intralobular collecting ducts Lactiferous ducts Lactiferous sinus Nipple
227
What contracts to release the milk?
Myoepithelial cells around lobules
228
Why are plasma cells present in the breast?
To release antibodies (IgA) into breastmilk
229
What happens in the breast during pregnancy?
Longer + more branched ducts Proliferation of epithelial cells Form secretory alveoli- mature + lots of rough ER
230
What happens in the breast in menopause?
Secretory cells degenerate- duct left only | Reduced collagen and elastic fibres
231
How are lipids secreted into breastmilk?
Apocrine secretion- surrounded by membrane
232
How are proteins secreted into breastmilk?
Merocrine secretion- in vesicles then exocytosis
233
Which is the most common breast lump in <30s?
Fibroadenoma
234
Which is the most common breast lump in 30-50s?
Cyst
235
Which is the most common breast lump in >50s?
Breast cancer
236
What is a hamartoma?
Benign solid mass-rare | normal breast cells, in abnormal proportion or distribution
237
Symptoms of breast cyst?
Smooth, mobile lump Cyclical pain Sudden pain in rupture/bleed Blue domed with pale fluid
238
How do breast cysts occur?
Ducts fill with fluid quickly- system can’t absorb quick enough
239
What are breast cysts associated with?
Menstrual abnormalities, early menarche and late menopause
240
Management of breast cyst?
Exclude cancer Reassure (most resolve after menopause)
241
Examination findings in fibroadenoma?
Painless Firm Smooth Mobile (breast mouse- move away from fingers)
242
How is a fibroadenoma investigated?
USS- solid | US core biopsy
243
Management of fibroadenoma?
Reassure (most resolve after menopause) | Excise if growth/change
244
What is fat necrosis?
Damage to adipocytes + inflammatory infiltration Often due to local trauma (e.g. seatbelt) May be associated with warfarin
245
What can be seen on fat necrosis biopsy?
Foamy macrophages
246
What is the pathology behind both sclerosing adenosis and radial scar?
Benign proliferation of the TDLU Increased acini and their glands May cause calcification
247
Symptoms of sclerosing adenosis?
Asymptomatic or pain, tenderness, lumpiness/thickening
248
Where are radial scars mostly found?
Bilateral + multiple (may cause puckering)
249
What is a radial scar called what it's >10mm?
Complex sclerosing lesion
250
Investigations of radial scar?
USS- spiculations, may look like cancer | Vacuum biopsy
251
Treatment of radial scar?
Excision
252
What is duct ectasia?
Blocked/clogged sub-arerolar ducts causing inflammation and fibrosis
253
Symptoms of duct ectasia?
Pain Bloody/purulent discharge Nipple retraction/distortion FISTULA between duct + skin (around nipple)
254
What is duct ectasia associated with?
Smoking
255
Management of duct ectasia?
Treat acute infections Exclude malignancy Stop smoking Excise ducts in extreme cases
256
2 main causes of mastitis?
Duct ectasia | Lactation
257
Causative bacteria in mastitis caused by duct ectasia?
Mixed + anaerobes | use metronidazole
258
Causative bacteria in mastitis caused by lactation?
Staph aureus | Strep pyogenes
259
Complication of mastitis?
Abscess
260
Mastitis + breastfeeding?
Continue | and/or the infected breast can be pumped until the mastitis clears
261
Management of mastitis?
Antibiotics Percutaneous drainage Incision and drainage
262
Inflammatory changes in breast + no response to antibiotic therapy?
Inflammatory carcinoma
263
Causes of mastalgia?
Mastitis Cysts Lump Menstruation
264
Management of mastalgia?
Take paracetamol Well-fitting bra Evening Primrose Oil Dopaminergic agonists- e.g. Bromocriptine, Cabergoline
265
Causes of nipple discharge?
``` Physiological Intraductal papilloma Malignancy Paget’s disease of the nipple Eczema ```
266
What is a phyllode tumour?
BENIGN Slow growing unilateral breast mass- can resemble fibroadenoma Looks like leaf in histology
267
When do phyllode tumours occur?
40-50s
268
Management of phyllode tumour?
Excise | prone to recur if not done fully
269
Symptoms of an intraductal papilloma?
Nipple discharge +/- blood | or asymptomatic
270
Pathology of intraductal papilloma?
Like skin tag inside duct Sometimes fluid/cysts May have nodules/calcifications
271
Diagnosis and treatment of intraductal papilloma?
US guided core biopsy Excise
272
What is gynaecomastia?
Ductal growth with lobular development- not fat overgrowth IN BOYS
273
Causes of gynaecomastia?
Result of excess oestrogen or reduced androgens: ``` Persistent pubertal gynecomastia - 25% Drugs - 10-25% e.g. cannabis, verapamil, steroids, spironolactone, heroin, methotrexate, Obesity Liver cirrhosis Prolactinoma Primary hypogonadism Hyperthyroidism Kleinefelter Syndrome (47XXY) etc. ```
274
Treatment of gynaecomastia?
Often resolve spontaneously Weight loss Tamoxifen Mastectomy
275
In-situ breast carcinoma is a precursor of invasive cancer, confined to the basement membrane. It may be...?
Ductal (80%) or lobular (20%)
276
Types of ductal precursor?
Atypical ductal hyperplasia Ductal carcinoma in situ (DCIS) Paget's Disease of nipple
277
What does DCIS look like on screening?
Enlarged ducts | MICROCALCIFICATION
278
What is Paget's Disease of the nipple?
High grade DCIS extending along duct to reach epidermis of nipple (still in-situ- non invasive)
279
Types of lobular precursor?
Atypical lobular hyperplasia- ALH (<50% of lobule involved) Lobular carcinoma in situ- LCIS (>50% of lobule involved) - multifocal and bilateral
280
What is invasive breast carcinoma?
Malignant epithelial cells (from the TDLU) which have breached the basement membrane
281
How many will have breast cancer?
1/8
282
Average age of breast cancer?
65-69
283
10 year survival of breast cancer?
8%
284
How is breast carcinoma staged?
TNM staging
285
Where can breast carcinoma metastases to?
Bone, liver, brain, lungs, abdominal viscera, ovaries, uterus
286
Risk factors for breast carcinoma?
``` Female Increased age Early age of menarche Late menopause Nulliparity Oral contraceptive + HRT Preview breast disease FH (1st degree) BRCA 1+2 mutations (tumour suppressor genes) Alcohol High fat diet Smoking Obesity (esp post-menopausal) ```
287
Which contraceptive is contraindicated in diagnosed breast cancer?
Merina coil
288
Name 2 protective factors for breast cancer?
Breastfeeding | Physical activity
289
Symptoms of breast cancer?
``` 50% asymptomatic Lump Dimpled/depressed skim Nipple change Bloody discharge Texture/colour change ```
290
Breast cancer on examination?
More likely to be painless, solid/craggy, and immobile
291
When is breast screening carried out?
From 50-70, every 3 years= mammography | more if high risk + MRI
292
Breast carcinomas can express hormone receptors- what are they? (3)
``` Oestrogen receptor (ER) Progesterone receptor (PR) Human epidermal growth factor receptor 2 (HER2) ```
293
Tumours which are 'triple negative' have a ... prognosis?
Very poor
294
Breast carcinoma has which 2 main features on imaging?
Calcification | Spiculations (star-like lesion)
295
Which imaging modalities are used in breast carcinoma?
USS= <40s Mammogram= >40s (younger= more dense= not suitable) or MRI + USS of axilla!! CT for mets
296
Why can breast screening lead to over-diagnosis?
Find low grade tumours that are then treated, despite would have never been systemic or symptomatic
297
What is tomosynthesis?
3D mammogram
298
Which breast problem can MRI be useful for?
Breast implant rupture
299
What is the next stage in breast carcinoma after imaging?
Biopsy for cyto/histo-pathology
300
Which biopsy type is most common for breast?
Core (needle) biopsy
301
Advantage of using vacuum biopsy over core biopsy?
Can leave in breast until enough tissue is sampled
302
Advantage of using core biopsy over vacuum biopsy?
Can use big needles to take out papillomas and radial scars (malignant potential) completely
303
How else can a biopsy sample be tested?
Xray to see that area of calcification has been removed
304
B1-5 classification of breast biopsy?
``` B1- normal/unsatisfactory B2- benign B3- atypical, probably benign B4- suspicious B5- malignant ```
305
How is the prognosis of breast cancer determines?
Nottingham Prognostic Index (0.2 x tumour diameter, tumour grade, lymph node status) ``` <3.4 = good >5.41= bad ```
306
What treatment for breast cancer can be used before surgery?
Chemotherapy or hormonal therapy --> Reduce need for radical surgery + smaller incisions required
307
3 types of surgery for breast cancer?
Breast Conservation Oncoplastic Breast Reconstruction Mastectomy
308
What is a radical mastectomy?
Breast tissue + axillary nodes + pectoralis major
309
What does breast conservation surgery involve?
Wide local incision + radiotherapy
310
What does oncoplastic breast reconstruction surgery involve?
Implant (saline/silicon- may use expander) +/- ADM (acellular dermal matrix) or Autologous- using own tissue (free/pedicle flap- tissue for abdomen, back, bum, thigh)
311
Advantage of autologous oncoplastic breast reconstruction surgery?
NO tissue rejection/allergic reactions
312
Which breast surgery is best for psychological wellbeing?
Breast conservation
313
Some finishing touches of breast cancer surgery?
Nipple reconstruction, lipomodelling, contralateral symmetrising
314
Complications of surgery for breast cancer?
``` Surgical risks Delayed wound healing Loss of nipple sensation Infection Recurrence Pain Body image LYMPHOEDEMA- poor lymph drainage in arm ```
315
How are lymph nodes cleared in breast cancer treatment?
Sentinel node biopsy (using blue dye) Axillary level 1 + 2 clearance Radiotherapy
316
Why is radiotherapy given after surgery in breast cancer treatment?
To reduce rate of local recurrence
317
Why is chemotherapy sometimes given in breast cancer treatment?
Improves 10 year survival
318
When and why is ER blockade used in breast cancer treatment?
In tumours +ve for oestrogen receptors | - to reduce relapse
319
Name the method of ER blockade used in breast cancer treatment?
Tamoxifen
320
Side effects/complications of tamoxifen?
Menopausal symptoms, alopecia, anaemia | Increased risk of endometrial cancer, endometrial hyperplasia + polyps
321
When should Tamoxifen be avoided?
Pregnancy
322
When and why are aromatase inhibitors used in breast cancer treatment?
In post-menopausal women For ER +ve tumours: Blocks aromatase enzyme which converts androgens to oestrogen in adipose tissue- reduce oestrogen levels
323
Examples of aromatase inhibitors?
Letrozole | Anastrozole
324
Side effects of aromatase inhibitors?
Joint stiffness/pain
325
When can antibody therapy be used in breast cancer treatment, and what is used?
``` Use Trastuzumab (Herceptin) to target HER-2 receptor (over-expressed in 15% of breast cancers) For 1 year ```
326
Side effects of Trastuzumab?
Allergic reactions | Reversible cardiac failure
327
When can breast angiosarcomas occur?
2-5 years post radiation therapy
328
Which metastatic tumours are common in the breast?
``` Lung Ovarian CC carcinoma of kidney Melanoma Leimyosarcoma ```
329
Which type of breast cancer can also occur in men?
Ductal carcinoma | no lobules present in men
330
Risk factors for breast cancer in men?
``` Age High BMI Alcohol Lack of exercise High levels of oestrogen Low testosterone History of prostate cancer Family history Radiation ```
331
Which pelvic structures drain into the para-aortic nodes?
Fallopian tubes Ovaries Uterine fundus
332
Which pelvic structures drain into the inguinal nodes?
Vulva + vagina
333
Which pelvic structures drain into the external iliac nodes?
Cervix | Uterine body
334
Being nulliparous increases the risk of which cancer?
Ovarian + endometrial cancer
335
Being multiparous increases the risk of which cancer?
Cervical cancer
336
Being multiparous decreases the risk of which cancer?
Ovarian cancer

Y3- TO LEARN (13 decks)

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