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Life Cycle > LC Exam 2 Breast > Flashcards

LC Exam 2 Breast Flashcards

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1
Q

Risk factor for breast cancer with relation to pregnancy

A

Age at/after pregnancy

Increased age increases risk and delay until protection

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2
Q

AAP recommendation for breast feeding
Advantages for baby
Advantages for mom

A

6 months
Reduces many disease risks in preterm infants (meningitis, nec enterocolitis, ears, UTIs etc)
Decreased risk of SIDS, diabetes, cancer, etc etc
Mom: decreased menstrual bleeding, increased child spacing, faster return to pre-preg weight

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3
Q

Anatomy of human breast

A

7 lobes

Secretory epithelial cells and myoepithelial cells (lobuloalveolar unit)

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4
Q

Lactating vs. non-lactating breast composition

A

Lactating: Glandular = 62%, intraglandular fat = 7%
Non-lac: Glandular = 20%, intraglandular fat = 49%
Subq and retro fat remain the same

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5
Q

Breast development cycles

A 
Embryogenesis (establish gland)
Puberty
Mature
Pregnancy
Lactation cycle (and menstrual cycle, like mini lactation cycle)
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6
Q

Embryogenesis of breast

A

Ectoderm invades mesenchyme
Mesenchyme differentiates into fat pad (mammary mesenchyme)
Driven by PTHrP
No PTHrP = Blomstrands chrondroplasia (amastia)
Neonatal breast tissue can secret under right maternal hormonal conditions

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7
Q

Menstrual cycle changes in breast tissue

A

More ducts with LH/E2 spike
More alveoli with prog (luteal phase)
In preg= alveoli differentiation/side branches are a result of progesterone and PRL secretion by placenta

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8
Q

Pubertal breast changes

A

Glandular expansion driven by E2 and progesterone
E2 + GH induce IGF-1 secretion from stromal cells (TEB)
Progesterone during menstrual phase = side branches (TDLU) development -> regress at end of luteal unless pregnancy
TEB = terminal end bud
TDLU = terminal ductual lobular unit

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9
Q

Initial pregnancy breast changes

Lactogenesis I

A

Differentiation:
Increased lobulation
Alveolar cell differentiation
Inhibition of milk secretion (by high levels of progesterone)
Hormones: E2, prog, placental lactogen, PRL

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10
Q

Later pregnancy breast changes

Lasctogenesis II

A

Removal of placenta (progesterone) -> milk secretion
Elevated PRL levels from pituitary required to maintain
Retained placenta can inhibit breastfeeding

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11
Q

Lactation post-delivery

A

PRL: maintains lactation and inhibits reproductive fxn
OXY: assists milk letdown

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12
Q

Breastfeeding nutrition for infants

A

Maternal igs (mostly IgA)
Macrophages
Lymphocytes
Exclusively breastfed infants require vitamin D supplementation

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13
Q

Breastfeeding decreases risk of which disease for baby

A 
Infections
Asthma
Allergies
DM
Obesity
Bonding
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14
Q

Breastfeeding decreases risk of which cancers for mom

A 
OXY release -> decrease pp hemorrhage
More rapid return to prepartum weight
Breast cancer
Ovarian cancer
Bonding
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15
Q

Milk secretion factors vs. milk letdown factors

A

Secretion: PRL and milk removal
Letdown/ejection: Oxytocin and suckling
Suckling also inhibits dopamine from hypothalamus ->
Stimulates PRL release from anterior pit
Operant conditioning can also stimulate hypothalamus

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16
Q

Other factors affecting breastfeeding

A 
Stress
Delayed initiation
Pituitary damage
Excessive weight ->
(inhibits initiation, duration, PRL response to suckling, reduced ability to modify metabolic demand)
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17
Q

Human vs. bovine milk

A

Human contains necessary oligosacchrides

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18
Q

Milk composition/volume with days postpartum

A 
Composition changes with volume
Volume increases
Tight junctions close
IgA secretion rises then falls
Leukocytes falls
Increased nutrition and decreased immunity with days postpartum
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19
Q

Role of milk removal in breastfeeing

A

Removal of milk is required to maintain tight junction closure in glandular system

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20
Q

Prior pregnancy affect on breastfeeding

A

Prior pregnancy primes glandular system for new round of breastfeeding

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21
Q

Colostrum

A

Milk produced following birth
Yellow
High in IgA, lactoferrin (anti-infection)
High protein, low fat/lactose
Facilitates lactobacillus and passage of meconium

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22
Q

Transitional milk (2-14 days)

A

Igs and proteins decrease
Lactose, fat, and calories increase
Vitamin changes

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23
Q

Mature milk

A

Water: main component
Lipids: 50% calories, content varies with time
Proteins: Casein and whey, lactoferrin (inhibits Fe dependent bacterial growth in GI tract)
IgA/microbal factors
CHO, iron, zinc, vitamins (need vit D supplementation)

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24
Q

Variation during feeding

A

Foremilk: more liquidy, less dense
Hindmilk: more dense

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25
Malnourished mothers
Same proportion of macromolecules | Less amount
26
Maternal contraindications to breastfeeding
Medications Untreated EtOH or drug abuse Infections (TB, HIV in developed countries) Undeveloped countries: HIV okay unless have access to clean water and formula
27
Takeaways from 10 step Baby Friendly Hospital Inititave
``` Written breastfeeding policy Help initiate within 30 min of birth No other food or drink unless medically indicated Mom and baby stay together Feed on demand, no pacifiers ```
28
The Golden Hour (not sunrise/sunset, but the first hour after birth)
Feed within 30 min (baby gets sleepy) Skin to skin (thermoregulation) Breastfeeding crawl (not done but she said it was super "cool", which is odd)
29
Feeding in the first 1-3 days
Colostrum is low volume, high fat/protein/Ig Glycogen stores provide 12 hours Lipogenesis keeps baby going, low volume is enough Milk comes in day 3-4 (later in 1st birth and C-section)
30
Infant weight
Expected to lose 5-7% of birth weight (lipogenesis while milk comes in) Losses stop typically around day 5 Regain of BW by day 7-14
31
Common problems
Pain/damage leads to engorgement, harder to pass milk, more often feedings, more pain/damage (cycle) Primary lactation failure (rare) Insufficient milk syndrome (inadequate removal leading to inadequate production)
32
Alternatives to breastfeeding
Formula 1st line: Cow base (modified for casein:whey ratio) 2nd: Soy Formula generally has more total protein (9 vs 15g)
33
Risks with formula
Increased risk of atopy (developing allergies) Increased risk of T1DM via autoimmune against bovine? Increased risk of obesity (easier to get milk out, try and finish bottle - inhibits self regulation, leading to early/rapid weight gain)
34
Infant growth
Same for first 3 months After: formula fed gain more weight Biggest difference: around 6 months Known for a while, now a concern for later obesity Use WHO growth charts 0-2 yrs of age (not CDC)
35
Galactorrhea causes
1. Excessive nipple stimulation 2. Prolactinoma 3. Drugs
36
Inflammatory breast pathologies
``` Acute mastitis Chronic mastitis Periductal mastitis Mammary duct ectasia Fat necrosis ```
37
Ductal system basics: Epithelium Stroma Lobules male vs. female
Fxnal unit = terminal duct lobular unit Two layered epithelium: epi cells and myoepi cells >2 layers and loss of myoepi = pathologic Interlobular stroma is regular fibrous tissue Intralobular stroma is specialized and responsive to hormones No lobules in male breast (or female prior to menarche)
38
Changes in breast composition with: Lactation Age
Lactation: increased lobular size and space, less stroma Age: decreased interlobular stroma (more fat, less fibrous)
39
Potentially developmental abnormalities of the breast
Accessory breast tissue or increased nipples (anywhere along milk line - inguinal to axilla, most commonly axilla) Congenital inverted/retracted nipples (careful of cancer) Juvenille hypertrophy
40
Gynecomastia
Increased ducts and stroma (mostly stromal) Unilateral or bilateral Increase in E2 Many causes
41
Acute mastitis
Young female, just started lactating Irritation, infection (staph/strep) Tx: continued drainage and abx (diclox) Close follow up warranted (inflammatory carcinoma)
42
Chronic mastitis
Perimenopausal most common Duct ectasia Obstruction due to thickened secretions Fibrosis and irregular mass formation
43
Recurrent subareolar abcess periductal mastitis
Squamous metaplasia leading to closure and abscess | Common in smokers
44
Fat necrosis
Related to trauma Mass with calcifications (saponification) Early: necrotic fat, PMN's Late: macs, giant cells, fibrosis, Ca2+cation
45
Benign neoplasm of breast
Fibroadenoma Lactating adenoma Phyllodes tumor Papilloma
46
Fibroadenoma
Premenopausal women Origin: TDLU, fibrous tissue and ductal tissue Well-circumscribed, mobile E2 sensitive No increased risk of carcinoma (as long as no epithelial hyperplasia)
47
Lactating adenoma
Presents during preg/lactation Circumscribed, soft mass Proliferation of small tubular structures with lactational changes
48
Phyllodes tumor
Fibroadeonma like- increased fibrous component pushing out to from leaves in cystic spaces Can be benign, low grade (recur), high grade (mets) Epi is benign, stroma can be malignant
49
Papilloma
Proliferation of epithelium (finger like projections with 2 cell layer) Present as small mass with bloody discharge Must r/o carcinoma (lack of myo or more than 2 layers)
50
Breast cancer etiologies
1. Sporadic (70-80%) 2. Hereditary (10-15%) - BRCA positive 3. Familial (20-25%) - FHx but BRCA negative (CHEK2, other tumor suppressor genes)
51
Syndromes associated with hereditary breast cancer and mutations
Li Fraumeni: p53 Cowden: PTEN Peutz-Jeghers: STK11/LKB1
52
3 causes for increased incidence of breast cancer in western countries
1. Delayed first pregnancy 2. Fewer pregnancies 3. Adoption of western diet/lifestyle
53
Atypical breast hyperplasia
Can be ductal or lobular On spectrum in between in-situ and hyperplasia Increased risk of invasive carcinoma
54
``` Ductal carcinoma in situ: Characteristics S/Sx Tx Low vs high grade ```
Proliferation of cells in ducts with no BM invasion Calcification on mammography, no mass on exam E-Cadherin POSITIVE Risk of invasive Excision usually cures Low grade: often hormone receptor mutation (ER, PR) High grade: often HER2/NEU overexpression
55
DCIS: subtypes and grade
In general, increasing cells in the ducts Cribiform variant Papillary variant Solid variant Micropapillary (no fibrovascular core, hobnail cells) Comedo: high grade
56
Paget disease of the breast/nipple
Ulcerated nipple (often confused with eczema) Associated with underlying carcinoma Acanthosis (often confused with melanoma)
57
Lobular carcinoma in situ
``` Usually only solid No mass or calcifications, often incidental finding Often multifocal and bilateral E-cadherin NEGATIVE Increased bilateral invasive risk ```
58
Invasive carcinoma of the breast
Mass forming Locally advanced disease: fixation and dimpling Most commonly upper, outer quadrand Mets first to axillary LN
59
Inflammatory carcinoma (invasive ductual)
Inflammed swollen breast Lymph drainage block, diffuse dermal LN involvement Looks like acute mastitis (fail abx) Poor prognosis
60
Invasive ductal carcinoma
Well to poorly differentiated Most common type of invasive carcinoma Mets to lungs and pleura
61
Invasive lobular carcinoma
``` Loss of E-cadherin Express hormone receptors No HER2/Nau overexpression Single-file pattern Mets to CSF, GI, ovaries ```
62
Tubular carcinoma
Really good prognosis, so need to be sure | Well differentiated tubules that lack myoepithelial cells
63
Types of invasive ductal carcinoma
Tubular Mucinous Medullary Inflammatory
64
Mucinous carcinoma
``` carcinoma with tumor cells floating in mucus Well circumscribed Older age group Good prognosis Hormone receptors and BRCA1 positive No HER/Neu over-expression ```
65
Medullary carcinoma
Large, high grade cells in sheets with lymphs and plasma cells Triple negative, BRCA1 Good prognosis
66
Metaplastic carcinoma
Non-glandular growth Usually ER/PR negative Fast growing No differentiation, ugly, high mitotic activity, squamoid
67
Stromal breast tumors
Angiosarcoma
68
Angiosarcoma
Spindle cells | Extravasation of blood vessels
69
Mixed stromal/epithelial
Phyllodes tumor
70
Phyllodes tumor
Fibroadenoma like, but can be malignant | Much higher fibrous/stromal component
71
Lymphoid breast tumors
Mantle cell lymphoma CLL Diffuse Large B cell
72
Pathogenesis: ER positive
ER positive, HER2 negative (50-65%) Gain of 1q, loss of 16q, PIK3 activating Associated with lower grade, better prognosis
73
Molecular pathways of pathogenesis
``` ER positive, HER2 negative (50-65%) HER2 positive (20%) Triple negative (15%) - BRCA1 associated, worst prog ```
74
Pathogenesis: HER2 positive
Associated with Li Fraumeni Amplification of HER2 on 17q Associated with higher grade
75
Biomarkers and response to therapy
ER/PR mutation = tamoxifen HER2 = Herceptin Triple negative = poor prog
76
Male breast cancer
Subareolar mass, involve chest wall and skin Assoc with BRCA2 and Klinefelter Stage for stage/grade for grade equal to females Often present at later stage

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