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REGUB Path - Benign Breast Disease (i) (Breast anatomy (mammary gland…
REGUB Path - Benign Breast Disease (i)
Breast embryology
derived from skin
modified sweat gland
breast tissue (+pathology) can develop anywhere along milk line (ant axillary line to perineum)
Breast anatomy
specialised glandular tissue
epithelium (glands + ducts)
stroma (specialised stroma + fibrofatty tissue)
major ductal system orginates @ nipple (6-10 lactiferous ducts)
mammary gland composed of 10 lobes
lobe = single lactiferous duct + its branches - ducts + lobules (think bunch of grapes, the brunch is a lobe + each grape is a lobule)
lobule = glandular acini
terminal duct lobular unit (TDLU) = the functional unit
terminal branches of ducts, lobules + surrounding connective tissue
most cancers arise from TDLU
Breast histology
ducts + lobules - 2 cell layer thickness
superficial layer = epithelial cells
deep cell layer = myoepithelial cells - this layer is lost in breast cancer
BM separates ducts, ductules + acini from the intralobular + interlobular connective tissue (stroma)
Breast physiology
not fully formed @ birth
pre-pubertal: branching ducts connected to nipple, no glandular component (same as male breast)
post-pubertal: terminal ducts give rise to lobules, formation of interlobular connective tissue (fibrous + adipose tissue)
reproductive life: cyclic changes through mestrual cycles
follicular phase - epithelial prolif
luteal phase - increase no. of acini, stroma, oedema
during menstruation - disappearance of stromal oedema, apoptosis + regression in the size of lobules
pregnancy + lactation - fully developed
menopause - involution
galactorrhoea
milk production outside of lactation
not a symptom of breast cancer
caused by nipple stim, prolactinoma (ant pit), drugs
Supernumerary nipples/breasts
most common congenital anomaly
heterotrophic glands along the milk line outside of normal location
may be a/w pathologic process (e.g. breast carc in axilla)
Clinical presentations of breast disease
breast pain (mastalgia)
palpable mass
discrete lump or diffuse lumpiness?
age?
other symptoms (pain, discharge, skin changes)
solid or cystic?
smooth or irregular?
hard or firm?
mobile or tethered/fixed?
single or multiple?
bilat or cyclical?
new lump or new in pre-existing nodularity?
persistent asymmetrical nodularity
unresolving inflamm
lumps a/w other features
lump remains following cyst aspiration
family hx
nipple discharge
mammographic abnormality
peau d'orange - oedema due to lymphatic obstruction
nipple retraction
Clinical assessment
Hx + exam
inspection
palpation
examine axilla
US: cysts, outlines mass lesions, young patients, guided bx
mammography
difficult in younger women + women on HRT because breast tissue is more dense
sensitivity + specificity increase with age
only do in young women who are high risk - prior cancer, strong family hx
signs of malignancies
densities
calcifications: small, irregular, clustered, linear, branching
architectural distortion
asymmetry
if abnormality detected: clinical exam, additional mammography, US
only a small no need to proceed with bx (pathological dx) + even fewer require MRI
MRI
high sensitivity but low specificity (false +ves)
image implants
staging of lobular carc if conservative surgery indicated
evaluation of high risk patients
monitoring following neoadjuvant chemo
Triple assessment
clinical, radiological, pathological
if all 3 benign leave lump (reduces no of bx's)
allows pre-op tx planning
may require intra-op confirmation of carc by frozen section (exceptional)
BreastCheck
Screening programme est in 1988
initially provided free mammograms to 50-64 y/os every 2 yrs
in 2015 extended to 69
quality assurance in place to ensure programme standards (based on international guidelines)
to detect small non-palpable asylum great carc @ earlier stage - reduces mortality by 20%
Overview of breast diseases
inflamm: acute a/w lactation, chronic a/w trauma or distended ducts
fibrocystic change: common in pre + perimenopasual
fibroadenoma: common lesion in young women
breast carc: most important, 1 in 10 lifetime risk