Repro Session 11 Flashcards Preview

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Flashcards in Repro Session 11 Deck (181):
1

Where do the breasts extend to horizontally?

Horizontally from lateral border of sternum to mid axillary line

2

Where do the breasts extend vertically?

Between 2nd and 6th intercostal cartilages

3

Which muscles are the breasts superficial to?

Pec major and serratus anterior

4

What is the circular body of the breast?

Largest and most prominent part

5

What is the axillary tail of the breast?

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

6

What surrounds the smooth muscle nipple?

Pigmented areolae with sebaceous glands

7

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

Internal thoracic

8

What branches of the axillary artery supply the breast?

Lateral thoracic and thoracoacromial

9

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

Lateral mammary branch

10

What branch of the anterior intercostal artery supplies the breast?

Mammary branch

11

What are the suspensory ligaments of Cooper?

Condensations of fibrous stroma of breast that attach and secure breast to dermis and underlying pectoral fascia and separate secretory lobules

12

What gives innervation to the breast?

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

13

What innervation do the anterior and lateral branches of the 4th and 6th intercostal provide?

Sensory and autonomic to smooth muscle and BV tone

14

What is the retromammary space?

Loose CT between breast and pectoral fascia

15

What is the pectoral fascia?

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

16

What provides lymphatic drainage to the breast?

75% axillary, 20% parasternal, posterior intercostal

17

Where does lymph from the skin of the breast drain?

Axillary, inferior deep cervical and infra clavicular nodes

18

Where does lymph from the nipple and areola drain?

Subareolar lymphatic plexus

19

What are the mammary glands?

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

20

What does each lobule seen in the mammary glands consist of?

Many alveoli drained by a single lactiferous duct and sinus behind the areola

21

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

Allows for accumulation of milk

22

How do the lactiferous sinuses drain in the lactating mother?

Through 6-16 nipple pores in the areola

23

When does breast development begin?

At 6 weeks in utero

24

Describe breast development up until birth.

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

25

What happens to mammary tissue at puberty?

Ducts begin to sprout and branch

26

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

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

27

What is mammogenesis?

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

28

What differentiation do alveolar cells undergo in mammogenesis?

Squamous to columnar

29

When can mammary tissue produce milk from during pregnancy?

T2

30

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

Progesterone inhibition of prolactin receptor synthesis

31

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

Oestrogen stimulating adipose tissue formation

32

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

Angiogenesis

33

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

Nipples become erect, areolar enlarges and darkens

34

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

Makes it easier for the neonate to identify

35

What are Montgomery tubercles?

Sebaceous glands that have fused with ducts around alveoli

36

What do Montgomery tubercles release?

Oil and pheromones

37

What is the function of the Montgomery tubercles secretions?

Oil hydrates skin around nipples and pheromones signal to neonate

38

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

Increases

39

What is lactogenesis?

Synthesis of milk

40

What is the ultrastructure of lactocytes adapted for?

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

41

How is the ultrastructure of lactocytes adapted for lactogenesis?

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

42

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

Maternal ductal system immunity and passive immunity to the neonate

43

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

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

44

What substances enter breast milk via exocytosis?

Proteins and lactose

45

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

Globules are droplets with a membrane for even distribution

46

Which substances enter breast milk via transmembrane secretion?

Water, sodium and potassium

47

What substances move into breast milk via transcytosis?

Intact proteins

48

What is colostrum?

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

49

Describe the composition of colostrum.

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

50

What is the purpose of immunoglobulins in colostrum?

Coat neonatal intestinal mucosa

51

Describe the composition of mature breast milk.

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

52

Which proteins are seen in mature breast milk?

Lactoalbumin, lactoglobulin, lactoferrin

53

What is the purpose of endocannabinoids in breast milk?

Appetite regulation of the neonate

54

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

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

55

How long does it take milk production to mature?

2 weeks

56

How much energy does each litre of breast milk provide?

27 MJ

57

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

800 ml or double if twins

58

What effects does oestrogen have on prolactin?

Increases prolactotroph growth but not secretion

59

How is prolactin controlled?

Inhibition by dopamine

60

Where is prolactin produced in the pregnancy female?

Anterior pituitary and decidua

61

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

Not under inhibitory control by dopamine

62

What is the decidua?

Endometrium of the last menstrual cycle before pregnancy

63

What allows milk ejection?

Let-down reflex

64

What happens in galactokinesis?

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

65

What is galactopoeisis?

Maintenance of lactation via neuroendocrine reflex

66

What can stimulate the neuroendocrine reflex in milk let down?

Baby crying, fondling baby, anticipation of feed

67

What is needed for galactopoeisis to occur?

Sufficient sucking stimulus with regular removal of accumulated fluid

68

What are the consequences of infrequent breast feeding?

Turgor-induced damage to to secretory cells

69

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

Turgor-induced damage combined with increased breast sensitivity

70

Is prolactin release seen in anticipation of a feed?

No

71

What can cause cessation of lactation?

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

72

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

Incensed turgor or mastitis

73

How does menstruation cease lactation?

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

74

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

Ergot Tx, diuretics, retained placenta

75

How does a retained placenta cause cessation of lactation?

Produces progesterone and oestrogen

76

Why does age cause a cessation of lactation?

Involution of mammary tissue begins around 35 y.o.

77

What are the benefits of breast feeding?

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

When are the breasts non-functional?

Throughout life except during lactation

79

What change in mammary tissue structure is seen at menarche?

Increased number of lobules and increased volume of interlobular stroma

80

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

Quiescent

81

What changes in mammary tissue are seen just after ovulation?

Cell proliferation and stromal oedema

82

What changes are seen in mammary tissue at menstruation?

Decreased lobule size

83

What changes are seen in mammary tissue at pregnancy?

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

84

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

Allow for milk accumulation

85

What happens to the lobules after lactation?

Atrophy but do not return to previous state

86

Describe the changes seen in ageing mammary tissue.

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

87

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

Stroma is more fibrous therefore mammograms are hard to interpret

88

What are the four common clinical presentations of breast disease?

Pain, palpable mass, nipple discharge, mammographic abnormalities

89

What description of breast pain indicated physiological cause?

Cyclical and diffuse

90

What does non-cyclical and focal beast pain indicate?

Ruptured cysts, injury, inflammation

91

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

Normal nodularity

92

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

Invasive carcinoma, fibroadenoma, cyst

93

What presentation of nipple discharge is most concerning?

Spontaneous and unilateral

94

What does milky nipple discharge indicate?

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

95

What does bloody/serous nipple discharge indicate?

Benign lesion e.g. Papilloma, duct ectasia

96

What are the three changes looked for on mammography?

Densities, calcification sand deformities

97

What do densities on mammogram indicate?

Invasive carcinomas, cysts, fibroadenoma

98

What do calcifications on mammogram indicate?

DCIS, benign change

99

What is the most common benign breast tumour?

Fibroadenoma

100

At what age does Fibroadenoma typically present?

101

Describe the incidence of breast cancer.

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

102

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

Phyllodes tumour

103

Why is phyllodes tumour more concerning than Fibroadenoma?

Can be malignant

104

What is polythelia/axillary breast tissue?

Breast tissue found anywhere on the milk line

105

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

Tumour on milk line that enlarges before menstruation

106

When is acute mastitis almost always seen?

During lactation

107

What is the usual pathogenesis of acute mastitis?

Staph aureus infection from nipple cracks and fissures

108

How does acute mastitis present?

Erythematous painful breast with pyrexia +/- breast abscess

109

How is acute mastitis treated?

Expression of milk and Abx

110

What history indicates fat necrosis in the breast?

Trauma or surgery

111

How does fat necrosis in the breast present?

Mass, skin change, mammographic abnormality

112

How does fat necrosis appear on histological examination?

Ail yes surrounded by macrophages and inflammatory cells

113

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

Fibrocystic change

114

How does fibrocystic change present?

Mass or mammographic change

115

What does histology show on fibrocystic change of the breast?

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

116

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

Disappears

117

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

Fibroadenoma, phyllodes tumour, lipoma, leiomyoma, harmatoma

118

What is a breast mouse?

Elusive, mobile mass seen in Fibroadenoma

119

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

Multiple, bilateral, very large replacing majority of breast

120

How does Fibroadenoma appear histologically?

With stromal and epithelial elements

121

How does Fibroadenoma appear macroscopically?

Well circumscribed, rubbery and grey-White

122

Is Fibroadenoma true neoplasm?

No, localised hyperplasia

123

How do Phyllodes tumours appear histologically?

Nodules of atypical cellular stroma covered by epithelium with visible mitoses

124

Describe the incidence of the types of phyllodes tumours.

Majority are benign, some borderline and

125

How does malignant phyllodes tumour progress?

Aggressive, recur locally and metastasise via blood

126

Why do phyllodes tumours metastasise via the blood?

Stromal origin

127

What is required when phyllodes tumours are excised?

Wide margin

128

Describe the pathogenesis of gynaecomastia.

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

129

What are some causes of gynaecomastia?

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

What types of testicular tumour may lead to gynaecomastia?

Leydgig cell tumour, Sertoli cell tumour, germ cell tumour

131

What proportion of malignancies in women are breast cancer?

20%

132

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

1 in 12

133

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

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

134

Which area of the breast are cancers usually seen?

Upper outer quadrant

135

What proportion of breast cancer cases are male?

1%

136

What increases the risk of male breast cancer?

Klinefelter's syndrome, male-->female, oestrogen Tx for prostate cancer

137

What are risk factors for breast cancer?

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

138

What proportion of breast cancers are hereditary?

10%

139

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

BRCA1/2 mutation

140

What are the consequences of a BRCA1/2 mutation?

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

141

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

~20 years earlier

142

What is Li Fraumeni syndrome?

p53 mutation --> hereditary breast cancer

143

How are breast carcinomas classified?

In situ or invasive

144

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

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

145

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

Comedo necrosis causing linear calcification through ducts and lobules

146

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

Cell proliferation

147

Why is it beneficial to identify in situ carcinoma early?

Non-obligate precursor to invasive carcinoma

148

What is Paget's disease of the breast?

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

149

How does Paget's disease of the breast present?

Unilateral red crusting nipple (like eczema)

150

Describe the neoplasm seen in invasive breast carcinoma.

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

151

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

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

152

What is peau D'orange?

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

153

What is the most common type of invasive breast carcinoma?

Invasive ductal carcinoma, no special type

154

What is the 10 yr survival rate for IDC NST?

35-50%

155

How do well differentiated IDC NST appear histologically?

Tubules line with atypical cells

156

How do poorly differentiated IDC NST appear histologically?

Sheets of pleomorphic cells

157

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

Under influence of substances released by malignancy

158

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

Invasive lobular carcinoma

159

How does invasive lobular carcinoma appear histiologically?

Infiltrating line of single file cells lacking E-cadherin

160

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

Tubular and mucinous

161

Which population are mucinous breast carcinomas more commonly seen in?

Older women

162

How do mucinous breast carcinomas appear histologically?

Lacked of mucin with epithelial cells floating within

163

How can invasive breast carcinoma metastasise?

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

164

What is gene expression profiling, used in breast carcinoma?

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

165

How can breast carcinomas be profiled molecularly?

By oestrogen receptor then by Her2 receptor

166

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

Oestrogen receptor -ve

167

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

70 y.o.

168

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

50 y.o.

169

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

Oestrogen receptor -ve, Her2 -ve

170

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

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

171

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

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

172

Why should axillary dissection be avoided where possible?

Risk of oedema and Fibroadenoma

173

What is sentinel lymph node biopsy?

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

174

What systemic control approaches can be used in breast carcinoma?

Chemotherapy, including neoadjuvant; hormonal Tx; Herceptin

175

What proportion of breast carcinomas are oestrogen receptor +ve?

80%

176

What proportion of breast carcinomas are Her2 +ve?

20%

177

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

This is where the receptors are located

178

What stains darker in a Her2 receptor +ve tumour?

CSM

179

What is Herceptin?

Monoclonal antibody against Her2 protein

180

What is Her2?

Human epidermal growth factor encoding transmembrane tyrosine kinase receptor

181

What improves survival of breast carcinoma?

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