the breast Flashcards
(114 cards)
1
Q
describe the general features of the anatomy of the breast
A
modified highly specialised sweat gland
no special capsule or sheath
duct system sits in adipose tissue
2
Q
do males haves breasts
A
rudimentary form
3
Q
where do the breast extend vertically and horizontally
A
vertical - 2/3rd rib to 6th rib
horizontal - 6th rib to mid-axillary line
4
Q
what fascia do the breasts lie in
A
deep pectoral
5
Q
what is the axillary tail (of seance) of the breast
A
small part of breast tissue may extend towards axillary fossa
(superolateral quadrant)
6
Q
what bursa give the breast some movement
A
retromammary bursa
7
Q
what 2 muscles does the breast lie on
A
2/3 - pectoralis minor
1/3 - serrates anterior
8
Q
what ligament firmly attaches the breast to the dermis
A
suspensory ligament of cooper
9
Q
what is the nipple and the areola
A
nipple - prominence of breast
areola- pigmented area around areola
10
Q
how many lobules of glandular tissue are contained in each breast (parenchyma)
A
15-20 lobules
11
Q
which duct drains each lobule of the breast
A
lactiferous duct
dilated portion - lactiferous sinus
12
Q
what splits the lobules in the breast
A
connective tissue septa
13
Q
what kinds of tissue is the nipple made up of
A
collagenous dense connective tissue
elastic fibres
bands of smooth muscle
14
Q
where is the nipple typically positioned
A
4th intercostal space
15
Q
what glands are contained in the areola and what do they secrete
A
sweat & sebaceous glands
- oily material provides protective lubricant for nipple and areola
16
Q
what are the 4 quadrants of the breast
A
superolateral
supermedial
inferolateral
inferomedial
17
Q
when do mammary crests/ buds appear in breast development
A
4th week - axillary to inguinal region but disappear everywhere apart from pectoral region
18
Q
what is gynaecomastia
A
postnatal development of rudimentary lactiferous ducts in males
increase in subareolar tissue
30-40% of adult men
19
Q
what is polymastia and polythelia
A
extra breast extra nipple (non functional)
20
Q
what is amastia/ aphelia
A
absence of breast
absence of nipple
21
Q
what occurs to the lactiferous ducts during puberty
A
they begin to branch
22
Q
what do breast alveoli look like
A
solid, spheroid masses of granular polyhedral cells
23
Q
what hormones cause the breasts to change in puberty
A
oestrogen
progesterone
24
Q
what happens to the breasts after menopause
A
progressive atrophy of lobules and ducts
fatty replacement of glandular tissue
25
list blood vessels that supply the breast
branches of axillary, internal thoracic, intercostal arteries
thoracic acromial artery, lateral thoracic artery, internal mammary artery
26
what nerves give sensation to the breast
anterior and lateral cutaneous branches of 4-6th intercostal nerves
27
does the breast receive sympathetic or parasympathetic innervation
sympathetic - from anterior and lateral cutaneous branches of 4-6th intercostal nerves
28
what group of lymph nodes mainly drain the breast
axilla
| 75% of lateral
29
what is virchows node
supraclavicular lymph node that breast cancer commonly drains to
30
what node is commonly biopsied to check for breast cancer (first draining node)
sentinel
| found by radio labelled colloid and blue dye
31
what its the risk of developing breast cancer in women
1 in 8
32
list signs of breast cancer
```
skin dimpling (peu d'orange)
hard lump / fixed
abnormal contours
oedema of skin
nipple retraction
deviation
```
33
list some benign examples of breast tumours
fibroadenomas
duct papillomas
adenomas
connective tissue tumours
34
what is pagets disease
erosion of the nipple resembling eczema
| associated with ductal or invasive carcinoma
35
what is the functional unit of the breast
terminal duct lobular unit - functional milk secretory component
36
what 2 layers line ducts and acini
luminal epithelial cells
| myoepithelial cells
37
what fluid is produced by the breast in pregnancy
colostrum - protein rich, rich in antibodies
38
what histological changes can be seen in a lactating breast
thin septa between lobules
| acini distended with milk
39
what hormones control milk production
prolactin and oxytocin
| pituitary
40
what is the gold standard practice triple assessment for investigating breast cancer
clinical examination
imaging
FNA cytology
41
what its the sensitivity and specificity of triple assessment for breast cancer
sensitivity -97-100%
| specificity - 98-100%
42
what 2 views are done for an mammography of breast cancer
ML oblique and craniocaudal
| additional - coned, magnification, true lateral, extended CC
43
when might mammography be offered to someone under 40
strong suspicion of cancer
| family history greater than 40%
44
what signs of disease are seen on a mammogram
```
dominant masses
asymmetry
architectural distortion (normal background pattern altered)
micro calcifications
soft tissue opacity
dense tissue
```
45
what is ultrasound used to differentiate between
cyst vs solid (benign or malignant)
46
what is the first line imaging for breast cancer in under 40s
ultrasound
47
how might you differentiate between benign or malignant breast tumours on ultrasound
benign - smooth outline, oval shape
| malignant -acoustic shadow, anterior halo, irregular outline
48
what is cytology
microscopic examination of a thin layer of cells on a slide
49
how is a cytology sample obtained
FNA
direct smear form nipple discharge
scrape of nipple with scalpel
core biopsy
50
how should safety be considered with FNA
```
wear gloves
handwashing
dispose needle safely
infection risk
chaperone?
inform patient
```
51
what are complications of FNA
pain, haematoma, fainting, infection
52
why is core biopsy used for peri-operative classification
confirm invasion
tumour type and grading
histopathology
immunohistochemistry - receptor status
53
when is it indicated to take a nipple lesion biopsy
bloody discharge
54
what may be seen on a malignant sample of nipple cells
```
high cellularity - very irregular
loss of cohesion
crowding/ overlapping of cells
nuclear pleomorphism
hyperchromasia
absence of bipolar nuclei
```
55
is cytology good at diagnosising specific breast cancers
no - non-specific adenocarcinoma
| occasionally cytoplasmic vacuoles (lobular), cells arranged in tubes (tubular)
56
describe the cytology scoring system
```
C1 - unsatisfactory
C2 - benign
C3 - atypia (probably benign)
C4 - suspicious (probably malignant)
C5 - malignant
```
57
what are advantage of FNA
simple - can be done at clinic
well tolerated
inexpensive
58
what are disadvantage of FNA
lesions may be missed
| accuracy not 100% - false -ve, +ve
59
give indications for MRI in breast cancer investigations
recurrent disease
breast implants
indeterminate lesion from triple assessment
screening for high risk women
60
whta are disadvnatages of MRI for breast cancer investigation
```
poor specificity - picks up lots of unnecessary things
claustrophobic /noisy
lengthy
IV contrast
expensive
```
61
what nuclear medicine technique is used to investigate breast cancer
peritumoral injection of 99m Tc sulphur colloid +/- iso sulphan blue dye
62
what makes up the mesenchyme of breast tissue
fat and fibrous tissue
63
describe the breast cancer biopsy scale B1-B5b
```
B1 / B2
B3- benign but atypical
B4 - atypical
B5a - malignant in situ
B5b - malignant invasive
```
64
what is a fibroadenoma
circumscribed mobile nodule in reproductive age, has a proliferation with fibrous and epithelial component
65
how does duct ectasia normally present
nipple discharge
| - dilation of ducts, blockage of orifice by keratin
66
what is the most common breast tumour in adolescent and young adult women
fibroadenoma (peak age 3rd decade)
67
how may a fibroadenoma present
well circumscribed, freely mobile, painless mass
| can be cyclical pain with menustration
68
what is phyllodes tumour
```
fleshy tumour (leaf like patterns and cysts)
stormal component malignant, epithelial component benign
```
69
give risk factors for breast cancer
```
age
menstraul history - early menarche/ late menopause
delayed first pregnancy
radiation
previous benign breast disease
family history
hormonal treatment (HRT)
genetic factors
```
70
what % of breast cancers are attributed to inherited factors
5-10%
71
what 2 genes are most commonly attributed to breast cancer
```
BRAC 1 (20-40%)
BRAC 2 (10-30%)
```
72
what organs express the BRAC genes
breast, ovary, prostate, pancreas
73
what are the 2 non invasive and 2 invasive histological classifications of breast cancer
non invasive - ductal cancer in situ (DCIS), lobular cancer in situ (LCIS)
invasive - invasive ductal carcinoma, invasive lobular carcinoma
(special type - tubular, mucinous, medullary carcinoma)
74
what is meant by in-situ carcinoma
pre invasive
cells have malignant appearance but are contained in the basement membrane
cells do not form a palpable tumour and not detected
clinically
75
what is the risk of invasion of low and high grade DCIS
low - 30% in 15 years
| high - 50% in 8 years -
76
what is the risk of invasion by LCIS in 25 years
19% - bilateral
77
what radiological investigations can be done to investigate breast cancer
mammogram
ultrasound
MRI
78
which women are screened for breast cancer
50-70 every 3 years mammogram at GP
| uptake is 80%, 30% reduction in mortality
79
which members of staff may be present in a breast screening team
```
radiologist
radiographer
breast clinician
nurse
cytologist
surgeon
```
80
what types of breast cancer do the screening team want to pick up
symptomatic with palpable mass
diffuse thickening of nipple lesion - discharge/ eczema
DCIS stage
<15 mm
81
what are 2 of the most important mammopgraphic indicators of breast cancer
masses
| microcalcifications
82
what are micro calcifications (seen on mammograms)
tiny deposits of calcium - can appear anywhere and look like grains of salt
majority benign - small percentage may be in precancerous/ cancerous tissue
83
what perentage of beast cancers are ductal and lobular
70% ductal, 20% lobular
84
what fraction of breast cancers are positive for the oestrogen/ progesterone receptor (ER/PR)
2/3
| strong predictors of response to hormonal therapy
85
describe the local, lymphatic and blood spread of breast cancer
local - skin, pectoral muscle
lymphatic - axillary, internal mammary nodes
blood - bone, lungs, liver, brain
86
where does breast cancer commonly metastasise to
bone, lungs, liver, brain
87
what does the prognosis of breast cancer depend on
```
node status - best prognostic indicator
tumour size
histological type
grade 1-3
age
genes - ER/ PR, HER-2
```
88
what does the Nottingham prognostic index (NPI) for breast cancer base itself on
tumour size
grade
nodal status
89
what is the overall 5Y survival for breast cancer
64%
90
what drug works well with breast cancer patients that are HER 2 +VE
trastuzumab (herceptin)
| 20-30%
91
what 5 subtypes of breast cancer does gene expression give
```
luminal A (55%)- ER/PR/ HER 2 -ve, low Ki67
luminal B (15%) - ER/PR/ HER 2 +/-ve, high Ki67
triple negative (10-15%) - negative for everything
HER 2 (10-20%) HER 2+Ve
normal breast
```
92
what are symptoms and signs of pagets disease
pain, itching, sling, redness (mistaken for eczema)
| ulceration, crusting, serous/ bloody discharge
93
how common is male breast cancer
<1%
94
why does male breast cancer present at a higher stage
no protective underlying tissue so pectoral muscle is involved
95
what things is gynaecomastia associated with
```
hyperthyroidism
cirrhosis of liver,
chronic renal failure
COPD
hypogonadism
use of hormones - oestrogen's, androgens
drugs - cimetidine, spinoroloactone, marihuana, TCA
```
96
what anti - hormonal therapy is given to manage breast cancer
tamoxifen
97
do histological 'special type' cancers have a better or worse prognosis
better
| tubular - 100% survival
98
what are the sensitivities of clinical examination, mammography, ultrasound and FNA cytology
clinical examination - 88%
mammography- 93%
ultrasound -88%
FNA cytology - 94%
99
what are the 5 principles in the management of breast cancer
1. establish the diagnosis
2. assess the severity
3. treat underlying cause
4. general measures
5. specific measure
100
what are the 3 levels of axilla spread
level 1- below and lateral to pec minor
level 2- behind pec minor
level 3 - above and medial to pec minor
101
what lifestyle factors can increase your risk of breast cancer
obesity - fat cells produce oestrogen
alcohol
oral contraceptive
HRT
102
how is breast cancer investigated
history and exam
radiology - mammogram, ultrasound, MRI
cytology - FNAc, core biopsy
open surgical biopsy
103
what system is used to stage breast cancer
TNM
T1-4 <2cm, 2-5, >5, fixed to skin
N0-2- none, nodes in axilla, large or fixed nodes
M0-1 non to metastatic
104
what are the 2 options for breast cancer surgery
breast conservation surgery
| mastectomy (remove whole)
105
what is involved in breast conservation surgery
lump + 1mm healthy breast tissue
| wide local excision, quadrantectomy, segmentectomy
106
what patients are suitable for breast conservation surgery
tumour size <4cm
suitable for radiotherapy
single tumours
minimal in situ component
107
why does a tumour >2cm get radiotherapy when undergoing breast conservation surgery
high probability of more disease
108
what does it mean if the sentinel lymph node is clear of tumour
no further treatment required - skip lesions don't occy
109
list complications of axilla surgery
decreased ROM of shoulder
nerve damage
lymphedema
vascular damage
110
is presence of ER/PR and HER2 good or bad for prognosis
ER/PR - good
| HER 2 - bad (growth)
111
how long is hormonal therapy (tamoxifen) given in the treatment of breast cancer
5 years premenopausal
5 years if good prognosis postmenopausal
if bad - aromatase inhibitor (anastrozole) for 5-10 years
112
how are micro metastases treated
hormonal therapy
chemotherapy
targeted therapy
113
what is the targeted therapy to HER-2 gene
trastuzumab (perception)
| monoclonal antibody against her-2 receptor
114
what is the follow up care for breast cancer
clinical examination every 6 months for 3-5 years
| mammogram every 10 years
