Breast Disease Flashcards Preview

ESA 4 - Reproductive System > Breast Disease > Flashcards

Flashcards in Breast Disease Deck (206):
1

What do the breasts start off as embryologically?

Sweat glands

2

How are the breasts unusual amongst glands?

They are non-functional except during lactation

3

What are the histological features of the breast?

Lobules with acini and intralobular stroma
Double layer of cells - myoepithelial and epithelila

4

When do physiological breast changes occur?

Menarche
Menstrual cycle
Pregnancy
Cessation of lactation
Increasing age

5

Describe the histological features of the breast before puberty?

Few lobules - mainly just terminal ducts
Before puberty, male and female breasts are identical

6

What happens to the histology of the breast at puberty?

Increase in number of lobules, increased volume of interlobular stroma

7

How do the breasts change with the menstrual cycle?

Follicular phase lobules quiescent
After ovulation cell proliferation and stromal oedema
With menstruation see decrease in the size of lobules

8

What is the result of the decrease in size of lobules before mensturation?

Some women get pain or discomfort shortly before mensturation

9

What happens to the breasts in pregnancy?

Increase in size and number of lobules, decrease in stroma, secretory changes

10

What happens to the breast histology when there is cessation of lactation?

There is atrophy of lobules, but not to former levels

11

What happens to breast histology with increasing age?

Terminal duct lobular units (TLDUs) decrease in number and size
Interlobular stroma replaced by adipose tissue

12

What is the result of the interlobular tissue being replaced by adipose tissue in the ageing breast?

Mammograms are easier to interpret- when younger, very dense, so not much use

13

What are the clinical presentations of breast conditions?

Pain
Palpable mass
Nipple discharge
Skin changes
Lumpiness
Mammographic abnormalities

14

When may mammographic abnormalities be the presenting complaint in breast conditions?

Screening

15

What kind of pain indicates physiological changes?

Cyclical - with menstrual cycle
Diffuse - through most of both breastt

16

What kind of breast pain can indicate pathological change?

Non-cyclical
Focal

17

What can cause breast pain?

Ruptured cyst
Injury
Inflammation
Occasionally presenting complaint in breast cancer

18

What does a palpable mass in the breast indicate?

May represent normal nodularity
May be pathology

19

When are palpable breast masses most concerning?

When hard, craggy, fixed

20

What can cause a palpable breast mass?

Invasive carcinomas
Fibroadenomas
Cysts

21

What is true of all women when they have a palpable breast mass?

No woman should be allowed to have a lump in the breast without a firm diagnosis

22

When is nipple discharge most concerning?

If spontaneous (rather than occuring when nipple squeezed) and unilateral

23

What could cause a milky nipple discharge?

Endocrine disorders
Side effect of medication

24

Give an example of an endocrine disorder that might produce nipple discharge?

Pituitary adenoma

25

What medication could have nipple discharge as a side effect?

Oral contraceptive

26

What could cause a bloody or serous nipple discharge?

Benign lesions
Occasionally malignant lesions

27

What benign lesions could cause nipple discharge?

Papilloma
Duct ectasia

28

What is duct ectasia?

Enlargement or inflammation of duct

29

When are mammographic abnormalities found?

During mammographic screening

30

Who are mammographic abnormalities easier to detect in?

Older women

31

When are women screened with a mammograph?

When they are 47-73, every 3 years

32

Why are women 47-73 invited for mammographic screening?

More useful in older women
Malignancies more common

33

What are the worrying findings on mammographic screening?

Densities
Calcifications

34

What could cause a density on mammographic screening?

Invasive carcinomas
Fibroadenomas
Cysts

35

What could cause calcifications on mammographic screening?

Ductal carcinoma in situ (DCIS)
Benign changes

36

Are breast symptoms and signs common?

Yes

37

What is true of most breast symptoms and signs?

They will be benign

38

What is the most common benign breast tumour?

Fibroadenoma

39

How does breast cancer compare to other forms of cancer in terms of incidence?

It is the most common non-skin malignancy in women

40

What is the advantage of mammographic screening?

It increases detection of small invasive tumours and in situ carcinomas

41

At what age can fibroadenomas occur?

At any age during the reproductive period, often <30 years

42

At what age do most Phyllodes tumours present?

In the 6th decade

43

At what age is breast cancer rare?

Before 25 years (except for in some familial cases)

44

What happens to the incidence of breast cancer with age?

It rises

45

What % of breast cancers occur in women >50 years?

77%

46

What is the average age of breast cancer diagnosis?

64

47

Give 6 pathological conditions of the breast

Disorders of development
Inflammatory conditions
Benign epithelial lesions
Stromal tumours
Gynaecomastia
Breast carcinoma

48

Give an example of a disorder of breast development?

Milk line remnants

49

What conditions can arise from milk line remnants?

Polythelia - third nipple
Accessory axillary breast tissue

50

Where on the body can polythelia occur?

Anywhere along the milk line - from axilla to vulva

51

Give two inflammatory conditions of the breast

Acute mastitis
Fat necrosis

52

What is acute mastitis?

Acute inflammation of the breast

53

When does acute mastitis occur?

Almost always during lactation or pregnancy

54

What causes acute mastitis?

Usually S. Aureus infection from nipple cracks and fissues

55

What are nipple cracks and fissures usually secondary to?

Breastfeeding

56

What are the symptoms of acute mastitis?

Erythematous painful breast
Pyrexia

57

What complications can arise from acute mastitis?

Breast abscesses

58

How is acute mastitis treated?

Expressing milk
Antibiotics

59

How does fat necrosis present?

Mass
Skin changes
Mammographic abnormality

60

How does the mass feel in fat necrosis of the breast?

Craggy, fixed feeling - similar to malignancy

61

What is there often a history of in fat necrosis of the breast?

Trauma
Surgery

62

What can fat necrosis mimic clinically and mammographically?

Carcinoma

63

Give a benign epithelial lesion of the breast

Fibrocystic change

64

How common is fibrocystic change

In autopsy, virtually all women have fibrocystic change

65

How may fibrocystic change present?

Mass or mammographic abnormality

66

What often happens to the mass on investigations?

Mass often disappears after fine needle aspiration

67

How does fibrocystic change appear histologically?

Cyst formation
Fibrosis
Apocrine metaplasia

68

What can fibrocystic change mimic clinically and mammographically?

Carcinoma

69

Give 5 examples of stromal tumours of the breast

Fibroadenoma
Phyllodes tumours
Lipoma
Leiomyoma
Hamartoma

70

How do fibroadenomas present?

Mass - usually mobile
Mammographic abnormality

71

What is the mass termed in fibroadenomas?

Breast mouse

72

Why is the mass termed a 'breast mouse' in fibroadenomas?

Mobile and elusive

73

How many fibroadenomas is a person likely to have?

May be multiple and bilateral

74

How do fibroadenomas appear macroscopically?

Well circumscribed
Rubbery
Greyish/white

75

How do fibroadenomas present histologically?

Composed of a mixture of stromal and epithelial elements

76

What can fibroadenomas mimic clinically and mammographically?

Carcinoma

77

Are fibroadenomas true neoplasms?

No, they are localised hyperplasia

78

How do Phyllodes tumours present?

Masses
Mammographic abnormalities

79

What are the different types of Phyllodes tumours?

Benign
Borderline
Malignant

80

What is meant by a borderline Phyllodes tumour?

Grows quicker than benign, and can metastasise

81

How big are Phyllodes tumours?

Can be very large and involve entire breast

82

What are the histological features of Phyllodes tumours?

Nodules of proliferating stroma covered by epithelium
Stroma more cellular and atypical than in fibroadenomas

83

How are Phyllodes tumours?

Need to be excised with wide margin

84

Why do Phyllodes tumours need to be excised with wide margin?

Otherwise they reoccur, and come back further along the line towards malignancy

85

What is gynaecomastia?

Enlargement of the male breast

86

Is gynaecomastia unilateral or bilateral?

Can be either

87

Is gynaecomastia more concerning when it is unilateral or bilateral?

Unilateral (because breast cancers are unilateral)

88

When is gynaecomastia often seen?

Puberty
Elderly

89

What causes gynaecomastia?

Relative decrease in the androgen effect
Increase in oestrogen effect

90

What can gynaecomastia mimic?

Male breast cancer, especially if unilateral

91

Does gynaecomastia cause an increase risk of cancer?

No

92

Why does gynaecomastia occur in most neonates?

Secondary to circulating maternal and placental oestrogens and progesterone

93

How common is transient gyanecomatia in puberty?

Affects more than half of boys

94

What causes transient gynaecomastia in puberty?

Oestrogen production peaks earlier than testosterone

95

What are the pathological causes of gynaecomastia?

Klinefelter's syndrome
Oestrogen excess
Gonadotrophin excess
Drug related

96

What are the pathological causes of oestrogen excess?

Cirrhosis of the liver

97

Why does cirrhosis of the liver cause oestrogen excess?

Oestrogen is not metabolised effectively

98

What can cause gonadotrophin excess?

Functioning testicular tumours, e.g. Leydig and Sertoli cell tumours
Testicular germ cell tumours

99

What drugs can cause gynaecomastia?

Spironolactone
Chlorpromazine
Digitalis
Cimetidine
Alcohol
Marijuana
Heroin
Anabolic steroid

100

What % of malignancies in women are accounted for by breast cancer?

About 30%

101

What proportion of women develop breast cancer at some point in their life?

1 in 12

102

What % of breast cancer cases are in males?

1%

103

What is the problem with male breast cancer?

It tends to present later

104

Why does male breast cancer tend to present later?

Don't think they can get it
Embarassed

105

What increases the risk of male breast cancer?

Klinefelter's syndrome
Male to female transexuals
Men treated with oestrogen for prostate cancer

106

What % of breast cancers are adenomcarcinomas?

95%

107

Give an example of a rare malignant tumour of the breast

Primary sarcomas such as angiosarcoma

108

Where are breast cancers most common?

Upper outer quadrant, towards axilla

109

What % of breast cancers occur in the upper outer quadrant?

Approx 50%

110

What are the major risk factors for breast cancer related to?

Hormone exposure

111

What are the risk factors for breast cancer?

Gender
Uninterrupted menses
Early menarche
Late menopause
Reproductive history
Breast-feeding
Obesity and high fat diet
Exogenous androgens
Geographic influence
Atypical changes on previous biopsy
Previous breast cancer
Radiation
Genes

112

When will a woman have uninterrupted menses?

Very few or no pregnancies
Didn't breast feed

113

Why does uninterrupted menses increase in risk of breast cancer?

During menstrual cycle, turnover of cels - more mitoses and mutations

114

What age of menarche increases risk of breast cancer?

<11 years

115

What aspects of reproductive history are related to risk of breast cancer?

Parity
Age at first full term pregnancy

116

Why does obesity and a high fat diet increase risk of breast cancer?

Androgens are converted to oestrogens in peripheral adipose tissue

117

Where may exogenous oestrogens come from?

HRT slightly increases risk
Long term users of OCP possibly have an increased risk

118

By how much is risk of breast cancer increased with HRT?

1.2-1.7 times

119

What countries have a higher incidence of breast cancer?

US and Europe

120

What are the possible explantations for the geographical influence of breast cancer?

Diet
Physical activity
Breast-feeding
Environmental factors

121

By how much does atypical changes in previous biopsy increase the risk of breast cancer?

4-5 times

122

By how much does previous breast cancer increase the risk of breast cancer?

10x

123

How is radiation related to breast cancer risk?

Increased risk with previous exposure to therapeutic radiation, especially in childhood and adolesence

124

Give an example of when radiation may increase risk of breast cancer?

Mantle radiation for Hodgkin's lymphoma

125

What % of breast cancers are hereditary?

10%

126

What % of breast cancers are attributed to BRCA1 and BRCA1 genes?

3% of all, 25% of familial

127

What do BRCA1 and BRCA2 do?

Tumour suppressor genes - their proteins repair damaged DNA

128

What % of the population have BRCA1 germline mutations?

0.1%

129

What is the lifetime risk of breast cancer of female carriers of BRCA1 or 2 genes?

85%

130

What happens to the median age of diagnosis when a woman has a mutation in BRCA1 or 2?

It decreases by 20 years

131

What may carriers of the BRCA1 or 2 gene choose to do?

Undergo prophylatic bilateral mastectomies

132

Other than BRCA genes, what other gene is involved in hereditary breast cancer?

P53 (Li-Fraumeni syndrome)

133

What are breast carcinomas classified into?

In situ
Invasive

134

Where can breast carcinomas involve?

Ducts
Lobules

135

What happens in an in situ carcinoma?

Neoplastic population of cells limited to ducts and lobules by basement membrane, and so myoepithelial cells are preserved

136

What is the result of the limitation of neoplastic cells in in situ breast carcinoma?

It does not invade into vessels, and therefore cannot metastasise and kill

137

How does ductal carcinoma in situ most often present?

As mammographic calcifications, but can present as mass

138

How to the mammographic calcifications appear with DCIS?

Clusters or linear and branching

139

How extensive is DCIS?

Can spread through ducts and lobules, and be very extensive

140

How does DCIS appear histologically?

Often shows central (comedo) necrosis with calcification

141

What % of DCIS become invasive cancer?

50%

142

What is Paget's disease?

Condition related to DCIS, where cells can extend to the nipple skin without crossing the BM

143

What are the symptoms of Paget's disease?

Unilateral red and crusting nipple

144

What should be done when a patient presents with eczematous or inflammatory conditions of the nipple?

Should be regarded as suspicious and a biopsy performed to exclude Paget's disease

145

What is the difference between DCIS and an invasive carcinoma?

Invasive has invaded beyond BM into stroma, and can invade into vessels

146

What is the result of invasive carcinoma being able to invade into vessels?

Can metastasise to lymph nodes and other sides

147

How does invasive breast carcinoma usually present?

Mammographic abnormality or mass

148

What is the problem with detection of invasive breast carcinoma with a mass?

By the time a cancer is palpable, more than half of patients will have axillary lymph node mets

149

What is peau d'orange?

The involvement of the lymphatic drainage of the skin in invasive carcinoma

150

What happens in peau d'orange?

There is disruption of lymphatic drainage, and so the skin becomes oedematous, so swells, but the hair follicles are tethered and pulled down into the breast

151

What causes a retracted nipple in invasive carcinoma?

The tumour causes tethering

152

What are the types of invasive breast carcinoma?

Invasive ductal carcinoma, no special type (IDC NST)
Invasive lobular carcinoma
Tubular
Mucinous

153

What % of invasive breast carcinomas are IDC NST?

70-80%

154

What are the different types of IDC NST?

Well-differentiated type
Poorly differentiated type

155

What is the histological appearance of the well differentiated type of IDC NST?

Tubules lined by atypical cells

156

What is the histological appearance of the poorly differentiated type of IDC NST?

Sheets of pleomorphic cels

157

What is the 10 year survival of IDC NST?

35-50%

158

What % of invasive carcinomas are invasive lobular carcinoma?

5-15%

159

What is the histological appearance of invasive lobular carcinoma?

Infiltrating cells in a single file, cells lack cohesion

160

Why do cells lack cohesion in invasive lobular carcinoma?

No longer have E-cadherin, so have lost links

161

What is the 10 year survival of invasive lobular carcinoma?

Similar to IDC NST

162

What % of invasive breast carcinomas are tubular?

1-2%

163

What is the prognosis of tubular invasive carcinoma?

Excellent

164

What % of invasive breast carcinomas are mucinous?

1-6%

165

What is the prognosis of mucinous breast carcinoma?

Excellent

166

Who is often affected by mucinous breast carcinoma?

Older women

167

Where may breast cancer metastasise to?

Lymph nodes via lymphatics
Distant metastases via blood vessels
Invasive lobular carcinoma can spread to odd sites

168

Where does breast cancer usually spread by lymphatics?

To the ipsilateral (same side) axilla

169

Where does breast cancer metastasise by blood vessels?

Bones (most frequent site)
Lungs
Liver
Brain

170

What sites can invasive lobular carcinoma spread to>

Peritoneum
Retroperitoneum
Leptomeninges
Gastrointestinal tract
Ovaries
Uterus

171

What factors determine prognosis in breast cancer?

In situ disease of invasive carcinoma
Histological subtype
Tumour grade
Tumour stage
Gene expression profile

172

What histological subtype of breast cancer has the poorest prognosis?

IDC NST

173

What factors are considered in tumour stage?

Size
Locally advanced disease
Lymph node metastases
Distant mets

174

What is meant by locally advanced disease in cancer?

Invading into skin or skeletal muscle

175

How are gene expression patterns useful in breast cancer?

Microarrays have been used to examine the expression patterns of some 25,000 genes in tissues from breast cancer patients.
Computer cluster analysis of the patterns led to the identification of about 17 marker genes that can correctly identify about 90% of women who would eventually develop mets, and therefore guides what treatment they should get

176

How is breast cancer investigated?

Clinically
Radiographic imaging
Pathology

177

How is breast cancer investigated clinically?

History
Family history
Examination

178

How is breast cancer investigated radiographically?

Mammogram
Ultrasound scan

179

How is breast cancer investigated by pathology?

Fine needle aspiration cytology
Core biopsy

180

When was mammographic screening started in the UK?

Late 1980s

181

What happens in the mammographic screening programme in the UK?

Women 47-73 have 2 view mammograms every 3 years

182

What is the aim of mammographic screening?

Detect small impalpable cancers and pre-invasive cancer

183

How has mammographic screening changed the incidence of DCIS?

Increased from 5% of breast cancers to 25% in screened populations

184

What is looked for on mammographic screening?

Asymmetrical densities
Parenchymal deformities
Calcifications

185

What happens when an abnormality is found on breast cancer screening?

Assessed with further imaging - FNAC and core biopsy

186

What are the therapeutical approaches in breast cancer?

Local and regional control
Systemic control

187

How is breast cancer controlled locally and regionally?

Breast surgery
Axillary surgery
Post-operative radiotherapy

188

What are the types of breast surgery in control of cancer?

Mastectomy
Breast conserving therapy

189

What does the decision regarding mastectomy or breast conserving surgery depend on?

Patient choice
Size and site of tumour
Number of tumours
Size of breast

190

What does the extent of axillary surgery depend on in breast cancer?

Whether there are involved nodes

191

What are the types of axillary surgery in the control of breast cancer?

Sentinel node sampling
Axillary dissection

192

What is the advantage of sentinel lymph node biopsy?

Reduces risk of postoperative morbidity

193

What happens in a sentinel lymph node biopsy?

Intraoperative lymphatic mapping with dye and/or radioactivity of the draining or 'sentinel' lymph node(s) - the one most likely to contain breast cancer mets/
If sentinel node is negative, axillary dissection can be avoided

194

How is systemic control of breast cancer achieved?

Chemotherapy
Hormonal treatment
Herceptin treatment

195

When is chemotherapy given as a neoadjuvant (before surgery)

If the benefits outweigh the risks

196

Give an example of a hormonal treatment for breast cancer?

Tamoxifen

197

What does hormonal treatment for breast cancer depend on?

Oestrogen receptor status

198

What % of breast cancers are ER positive, and so can have endocrine therapy?

80%

199

What does herceptin treatment depend on?

Her2 receptor status

200

What % of cancers are Her2 positive?

20%

201

What is Her2?

A member of the human epidermal growth factor receptor family that encodes a transmembrane tyrosine kinase receptor

202

What is herceptin?

Humanised monoclonal antibodies against the Her2 protein

203

How can survival from breast cancer be improved?

Early detection
Neoadjuvant chemotherapy
Use of newer therapies e.g. Herceptin
Gene expression profiles
Prevention of familial cases

204

How can early detection of breast cancer be achieved?

Awareness of disease
Importance of family history
Self-examination
Mammographic screening

205

What is the purpose of neoadjuvant chemotherapy?

Early treatment of metastatic disease

206

How can familial cases of breast cancer be prevented?

Genetic screening
Prophylactic mastectomies