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160 Cards in this Set

  • Front
  • Back

Normal reproductive system consists of?

  • Testis
  • Epididimys
  • Vas deferens
  • Seminal vesicles
  • Prostate glands
  • Penis
  • Urethra

Where does spermatogenesis occur

In the testes (situated in scrotum, suspecnded by spermatic cords and surrounded by membranes)

Exocrine portion

Seminiferous tubules (produce spermatozoa)



Endocrine portion

Intestinal cells of Leydig (produce testosterone)

Testicular disorders - (infections of the testes)

  • Epididymo-orchitis
  • Acute bacterial epididymo-orchitis
  • Viral orchitis
  • Tuberculous epididymo-orchitis

Epididymo-ochitis

Associated with infections that enter through the epididymis

Acute bacterial epididymo-orchitis


  • Due to gonococci and Chlamydia (STI) or Escherichia coli and other gram-negative bacilli
  • Infection spreads from urethra and lower urinary tract -> enlarged tender testes

May lead to permanent scarring of seminiferous tubules and epididymis, fertility impairment



Viral orchitis

Usually unilateral, the result of infection by mumps virus after puberty, in some bilateral, reduced fertility may occur

Tuberculous epididymo-orchitis

Bloodstream spread to epididymis during active pulmonary TB; Epididymis destroyed and infection spills over into testis

Intrascrotal lesions

  • Hydrocoele

  • Haemotocoele

  • Spermatocoele

  • Chlyocoele

  • Varicocoele

  • Inguinal Hernia

Hydrocoele


  • Increased serous fluid within the tunica vaginalis which becomes distended
  • Most common cause of scrotal enlargement
  • In infants - patent processus vaginalis
  • In adults - due to trauma, infection or tumour
  • Untreated condition causes organization of fluid, adhesions, atrophy of testis, infertility or sterility if bilateral

Haematocoele

  • Blood within the tunica vaginalis

  • Trauma, torsion of the testis, tumours, haemorrhagic diathesis; inflammatory response and organization

  • Atrophy of testis

Speramtocoele

Semen accumulates in spermatic cord due to dilation of ducts in the head of epididymis (epididymal cysts)




Congenital or may be acquired; Usually painless and in most cases it does not require any therapy

Chylocoele

Lymph in the tunica albuginea occuring with lymphatic obstruction in the region




Parasitic worm infestations (Wuchereria bancroftii) with resultant elephantiasis




Size of scrotum may become enormous -> atrophy of testis

Varicocoele

Varicose pampiniform venous plexus in the spermatic cord




A soft, elastic swelling, sometimes causes pain typically in left testis "Bag of worms" presentation 15-25 years




Congenital causes, Ca kidney; Can lead to thrombosis, intrascrotal pressure, infertility

Inguinal Hernia

Herniation where a loop of intestine enters the inguinal canal, sometimes filling the whole scrotal sac




Congenital patent vaginal process (~1% paediatric disorders) or acquired later when obliterated vaginal process opens due to excessive stress placed on it (lifting heavy weights, increased intra-abdominal pressure, after surgery)



Testicular tumours - Aetiology

Rising incidence, 15-45 years




Crytorchidism


Genetic factors


Hormonal effects


Tight clothing


Idiopathic





Main groups of testicular tumours

Germ cell tumours (95%)


Sex cord and stromal tumours (5%)



Germ cell turmours

Derived from multipotential germ cells lining the seminiferous tubules




Predisposed by maldescent or chromosome 12 abnormaility

Sex cord and stromal tumours

Derived from specialized and non-specialized support cells of the tesis

Germ cell tumours

Seminoma (classic)


Spermatocytic seminoma


Teratoma


Yolk sac tumour


Choriocarcinoma


Embryonal carcinoma

Seminoma

Totipotent germ cells differetiate to spermatocytic cell lines




Carcinoma of the seminiferous epithelium lining the testicular tubules




~30-45 years, painless enlargement of testis; bulging pale mass shows clear cells arranged in lobules




Direct or late blood spread; Treat by orchidectomy and radiotherapy; good prognosis ~85% 5-year survival

Spermatocytic seminoma

Totipotent germ cells differentiate to spermatocytic cell lines




Similar to classic seminoma but more prevalent in elderly men >60; Behaves in benign manner - does not metastasize



Teratoma

Primitive totipotent cells differentiate to various somatic embyronal tissues such as epithelium, cartilage, smooth, muscle, neural tissues etc (ie. contain tissues derived from ectoderm, mesoderm and endoderm)

Teratoma - mature somatic elements

Occur in young. Areas in skin, thyroid, bone, cartilage etc. = Organoid tumours




Good prognosis (behave in benign manner)



Terotoma - immature somatic elements

Peak age of incidence is 30 years. Highly malignant anaplastic tumours.




Spread to liver and lungs, late presentation. Poor prognosis. ~25% 5-year survival

Yolk sac tumour

Primitive totipotent germ cells differentiate into extraembryonic tissue such as the yolk sac




Most common testicular tumour <3yrs; Good prognosis - chemosensitive




alpha-fetoprotein secreted into blood, detected as a tumour marker

Choriocarcinoma

Primitive totipotent germ cells differentiate into extraembryonic tissue such as trophoblastic tissue




Rare, yet highly malignant, not very radiosensitive, seen in men 20-30 years; poor prognosis; HcG detected in blood as tumour marker

Embyronal carcinoma -

Primitive totipotent germ cells show no specific differentiation - just some epithelial pattern characteristics




~20-30yrs; Composed of immature large undifferentiated cells, resembling those of the early embryo - highly malignant




Early invasion of lymphatic and blood vessels. Responds well to cytotoxic chemotherapy

Sex cord and stromal tumours

Interstitial cell tumour




Sertoli cell tumour

Interstitial cell tumour

Cancer of Leydig cells; Sexual precocity associated with increased testosterone levels in children

Sertoli cell tumour

Well circumscribed, usually benign tumour

Prostate Gland

The prostate gland surrounds the urethra as it leaves the bladder, and is composed of 5 lobes of glandular tissue supported by a fibromuscular stroma




Acute prostatis


Chronic prostatitis


Benign Prostatic hyperplasia


Carcinoma of the prostate

Acute prostatitis

Common after surgery, instrumentation of the urethra. Also after acute infection in bladder/urethra




Escherichia coli, Enterococcus faecalis, Proteus spp (UTI)




Neisseria gonorrhoeae or Mycoplasma and Chlamydia, (STD)




Typical AI - leads to suppuration and abscess formation




Enlarged, painful prostate - when palpated by DRE (digital rectal exam) is very tender and soft





Chronic Prostatitis

Due to progressive acute prostatitis, TB (renal or epidydymal)




Hard, shrunken prostate, often containing calcified concretions; CI infiltrate and scarring

Benign Prostatic Hyperplasia (BPH)

Affects most men > 70 (80% > 80yo), Increased in cell number of glandular and stromal components




Caused by hormonal imbalances - raised oestrogen, lowered testosterone levels




Oestrogen may render cells more susceptible to the action of dihydrotestosterone - synthesized in prostate from circulating testosterone




Lateral and median lobes predominantly affected

BPH symptoms

Obstruction of urine flow causes progressive difficulty in micturition




Poor stream, frequency, nocturia, dysuria, predisposes to UTI, prostatitis

BPH Diagnosis

DRE reveals a firm rubbery gland, biopsy for confirmation

BPH Treatment

TURP (transurethral resection of prostate) or laser treatment to reduce size




Hormonal/drug treatment, esp. in elderly or debilitated men



BPH Prognosis

Good - does NOT predispose to prostatic carcinoma

Carcinoma of the prostate

Very common adenocarcinoma, frequency increases >55yr (80%> 80-90yrs)




Caused by genetic factors, exposure to cadmium, raised testosterone levls, decreased immunological surveillance




Posterior lobe predominately affected, asymptomatic initially as tumour slow growing

Prostate cancer symptoms

Late due to metastases in bone, include back pain, weight loss, anaemia



Prostate cancer diagnosis



Palpable mass (firm, nodular) detected by DRE, raised PSA levels, raised acid phosphatase, confirmed by biopsy

Prostate cancer treatment

Surgery, radiotherapy and hormonal therapy, anti-androgen therapy

Prostate cancer prognosis

Stage A


Stage B


Stage C


Stage D



Stage A - prostate cancer

Tumour confined to gland (80% 5 yr survival)



Stage B - prostate cancer

Clinical manifestation evident (50% 5 yr survival)

Stage C - prostate

Invasion of surrounding organs, pelvic and para-aortic lymph nodes (35% 5 yr survival)

Stage D - prostate cancer

Vascular spread to bone, extra-pelvic metastases (20% 5 yr survival)




Overall prognosis; 25% 5 yr survival

Penile disorders

Hypospadias


Epispadias


Phirmosis


Urethritis


Balanitis


SCC of Penis

Hypospadias

Urethra opening on the ventral (underside) surface of penis, more common

Epispadias

Urethra opening on the dorsal (upperside) surface of penis




Both congenital malformations of the urethral canal

Phimosis

An abnormality of the foreskin leading to non-retractable or tight prepuce

Urethritis

Infections of penile urethra




Gonnococcal due to Neisseria gonorrhoeae (STD) - Urethral pain and a purulent discharge




Non-gonococcal due to Chlamydia trachomatis (STD) - purulent urethral dischage, may lead to Reiter's syndrome (arthritis, urethritis and conjuntivitis)

Balanitis

Infections of the glans and foreskin (e.g. Candida albicans, pyogenic and anaerobic bacteria)

SCC of Penis

Inadequate hygeine, precense of prepuce




SCC (warty, fungating mass) invades along the shaft of the penis, may spread to inguinal lymph nodes




Ulceration, deformity, urinary fistulae may form




Surgical amputation of the penis, block dissection of the groin




5 year survival > 95% (no lymph spread); if inguinal spread, 50-70% 5 year survival

Normal female reproductive system

Dependent on changing hormonal stimulation; comprises vulva, vagina, uterus, fallopian tubes, ovaries, breast



Gynaecologic pathology

Abnormalities of the female reproductive system

Obstetric pathology

Abnormalities related to conception, pregnancy or childbirth



Menarche

Beginning of menstruation ~12yrs




Menstrual cycle occurs on average every 28 days - antipates pregnancy by preparing uterus for implantation of fertilized ovum

Menopause

End of productive period ~50 years

Disease of the Vulva - SCC of vulva

Usually in elderly women



E.g. Verrucous carcinoma




Largely warty cauliflower-like growth that grows slowly, invading local tissues




Well-differentiated, confined to vulva and inguinal LNs - good prognosis




Invasion to bladder/rectum, spread to illiac LNs/bloodstream - bad prognosis


SCC of vulva - facts

Arise de novo, or in epithelium with severedysplasia & carcinoma in situ ie. vulval intraepithelial neoplasia (VIN) (see Figure 19.5)


VIN seen in younger women; HPV16demonstrated in 70-90% cases & show HPV warty change




Increased risk of SCC progression in young womenwho smoke cigarettes

Disease of the vagina

SCC of the vagina - Rare, much more common to see secondaries from cervix, endometrium and ovaries

Diseases of the Cervix

The ectocervix is lined by squamous epitheliuim and the endocervical canal by mucous secreting columnar epithelium




The squamocolumnar junction is the site where most diseases of cervix occur

Carcinoma of the Cervix

Accounts for 3-5% of female cancers, peak incidence ~50yrs




Death decreasing with earlier detection; HPV detected in >60% cases; HPV 16 and 18 most common




Gardasil vaccine protects against the 2 high-risk HPV types (16 and 18) and the 2 low-risk HPV types (6 and 11)




Linked with sexual activity, early age of 1st intercourse or pregnancy, pultiparity




Typically occurs at squamocolumnar junction at the region of the cervical OS




Metaplasia and dysplasia of epithelial may be seen; Nodular, polypoid of diffusely infiltrating mass seen on colposcopy




~95% cases are SCC ~5% adenocarcinoma

Carcinoma of the cervix - symptoms

Vaginal bleeding, esp. Postcoital due to ulceration of tumour




Bowel/urinary tract obstruction, rectovaginal/vesicovaginal fistulas, 2 degree infection -> purulent vaginal discharge

Carcinoma of the cervix - diagnosis

Pap smear test - cytological examination of cervical cells

Prognosis

Stage 0


Stage 1


Stage 2


Stage 3


Stage 4

Stage 0 - cervical cancer

Carcinoma in situ; 100% 5 yr survival

Stage 1 - CC

Microinvasive carcinoma, confined to cervix; 90% 5 year survival (with treatment)

Stage 2 - CC

Direct spread of tumour, invasion of vagina; 82% 5-year (with treatment)

Stage 3 - CC

Lymphatic spread, spread to pelvic wall, lower vagina or ureters 35% 5-year survival (with treatment)

Stage 4

Haemotogenous spread, rectum, bladder wall and outside pelvis; 10% 5-year survival (with treatment

Treatment of CC

Cauterization, laser therapy, removal by biopsy (dysplasis, stage 0)




Conization of cervix (stage 1); Hysterectomy and radiotherapy (stages 2-3); Chemotherapy (stages 3-4)

Diseases of the Uterus

The endometrium lines the uterus, responding to cyclical hormonal stimulation during the menstrual cycle




The myometrium is composed of smooth muscle cells and supporting stromal and vascular tissue

Endometriosis

Ectopic endometrium develops outside uterine cavity (myometrium, ovaries, fallopian tubes, less common in interstinal wall, bladder)




Very common 1 in 15 (~7%) of women of reproductive age -> infertility in 30% cases




Macroscopically, foci ofendometriosis appear as cystic and solid spaces; Histologically, endometrial glands and stroma seen;




Fibrosis may occur with repeated inflammation and organization

Endometriosis interna/Adenomyosis

Endometrial tissue in myometrium

Endometriosis externa

Endometrium tissue outside of uterine wall

Endometriosis - Aetiology

Poorly understood, but 3 theories




Retrograde menstruation


Metaplasia theory


Metastatic theory

Retrograde menstruation

Reflux of shedding endometrium during menstruation, through fallopian tubes into the peritoneum



Metaplasia theory

Metaplasia of peritoneal epithelium may cause differentiation into endometrial tissue

Metastatic theory

Endometrium spreads to distant sites (nodes, pleura, lungs, umbilicus) via lymphatics or blood vessels

Endometriosis - symptomalogy

Asymptomatic or slight pain, discomfort during menstruation




In severe cases, dysmenorrhoea; dyspareunia; dyschezia; dysuria; menorrhagia; haemochezia; haematuria, diarrhoea; constipation; premenstrual tension (PMT), depression, marked mood swings; insomnia; low energy, fatigue, infertility, rupture of chocolate cysts in the ovary

Treatment of endometriosis

Endocrine manipulation of endometrial growth is usually effective or surgically removed (via laparoscopy)

Carcinoma of endometrium

Account for ~7% of female cancers; most common malignant tumour of female genital tract




Nearly all are adenocarcinomas. Divided into two main groups:



  • Those that occur close to menopause (due to endometrial hyperplasia, oestrogen stimulation) - most common, good prognosis)
  • Those that occur in older post-menopausal women (not associated with hyperplasia or oestrogen stimulation) - poor prognosis

Carcinoma of endometrium - aetiology

Causes of hyperoestrinism (hyperplasia/tumours), obesity, infertility/nulliparty, genetic factors



Carcinoma of endometrium - Symptoms

Unusual bleeding, leukorrhoea; painful, tender unterus if pyometra occurs (due to obstruction and 2 degree infections)

Carcinoma of endometrium - Treatment

Surgical excision or hysterectomy; radiotherapy and/or chermotherapy

Carcinoma of endometrium - Prognosis

Very good due to usual detection in the early stages (better than cervical and ovarian)


Stage 1-4

Carcinoma of endometrium - stage 1

Corpus of uterus only; 90% 5-yr survival (with treatment)

Carcinoma of endometrium - stage 2

Corpus and cervix; 50% 5-yr survival (with treatment)

Stage 3

Invasion confined to pelvis; 30% 5 yr survival (with tt)

Stage 4

Invasion outside pelvis or involves bladder/rectum; 10% 5-yr survival (with treatment)

Fibroleiomyoma of the Uterus

Fibroid; most common benign tumour of female genital tract




Oestrogen-dependent tumour of smooth muscle cells and fibroblasts; NOT premalignant




Arise at a young age, anywhere in myometrium, becoming symptomatic in decade before menopause




Typically rounded, rubbery, pale nodule (whorled appearance on cut surface) and well demarcated by a fibrous capsule




Require oestrogen for growth so often regress after menopause; Common cause of infertility, may complicate pregnancy

Fibroleiomyoma of uterus
Symptoms
Treatment

Symptoms - Dysmenorrhoea, menorrhagia, discomfort, obstruction or pressure effects on bowerl and bladder




Treatment - Surgery excision or hysterectomy

Ovaries

Paired organs located in the ovarian fossa, one on each side of the uterus




Comprise surface 'germinal' epithelium, stroma (produces steroid hormones), & follicles (contain germ cells)




Secrete oestrogen and progesterone and are dependent on pituitary gonadotrophic hormones

Non-neoplastic cyst

Extremely common, the majority arising from the development of Graafian follicles, others derived from surface epithelium,




Stein-Leventhal syndrome

Stein-Leventhal syndrome

Characterised by formation of multiple ovarian follicular cysts (polycystic ovarian syndrome); Three theories




1. Defect in hypothalamic pituitary axis -> increased ­FSH -> Increased ­ovarian follicles - >don’t rupture due to no LH surge -> increased ­ovarian androgens




2. Defect in ovarian steroidogenesis mayfavour androgen production




3. Insulin resistance in peripheraltissues (detected in obese patients), may divert metabolic pathways to androgensynthesisPresents 20-30yrs, associated withobesity, hirsutism, irregular periods or amenorrhoea (reduced fertility)

Stein-Leventhal syndrome - Treatment

Exogenous hormone administration to correct imbalance -> normal pregnancy




Ovaries show thickening of the capsule and multiple follicular cysts with stromal hyperplasia

Neoplasms of the ovary

Epithelial tumours


Sex cord and stromal tumours


Germ cell tumours

Epithelial tumours

Derived from surface epithelium which in turn derived from embryonic coelomic epithelium, therefore differentiate into many tissues

Epithelial tumours - tubule differentiation

Serous ovarian tumours (cystadenomata, cystadenocarcinomata - most common ovarian Ca)



Overall 20% 5-year survival rate; Invade locally then through serosa into peritoneal cavity

Endocervical differentiation

Mucinous ovarian tumours (mucinous cystadenoma, mucinous cystadenocarcinoma)




Benign or malignant; 35% 10-yr survival (better than malignant serous)

Endometrial differentiation

Endometriod or clear-cell ovarian tumours; rarely benign; Overall, 40% 5yr survival



Transitional differentiation

Brenner ovarian tumours; cells resemble transitional cell epithelium of urinary tract




Benign or malignant, good prognosis

Sex cord and stromal tumours

10% of ovarian tumours; May secrete oestrogen, giving rise to endometrial hyperplasia and predisposing to endometrial carcinoma




Fibromas


Thecomas


Granulosa cell

Fibromas

Benign, mainly seen in postmenopausal women may see ascites



Thecomas

Usually benign seen in young women, solid and usually produce oestrogen

Granulosa cell cell

Usually benign, >50% occur post-menopause, also seen in young girls (precocious puberty, early menarche)




75% secrete oestrogen, excellent prognosis if confined to ovary

Germ cell tumours

Teratomas


Yolk sac


Choriocarcinoma

Teratomas - GCT

~ 10% of ovarian tumours; Mostly benign cystic tumour of ovarian germ cells


Extremely well-differentiated with a variety of tissue types (teeth, bone, respiratory tract tissue, hair)


alpha-foetoprotein positive 25-50% of cases

Yolk sac - GCT

Rare, highly malignant, usually in women <30yrs; secrete alpha-fetoprotein (tumour marker)

Choriocarcinoma - GCT

Rare, highly malignant, composed of trophoplastic cells; secret hCG (tumour marker)

GCT - Aetiology

Each year, more than 1200 Australian women are diagnosed with ovarian cancer, ~800 will die from the disease

GCT - Symptamology

Presents when tumour enlarges, causing pressure effects and accidental complications




Pain, discomfort, GIT complaints, urinary frequency, abdominal distension, acute abdomen

GCT - Diagnosis

Rare early, usually on routine pelvic examination; No current good tumour marker or screening test

GCT - Prognosis and staging

Similar for all malignancies of the ovaries; Due to late diagnosis, average 5yr survival ~40%

GCT - Stage 1

Tumour is confined to ovary with or without ascites (good prognosis)



GCT - Stage 2

Growth involves one or both ovaries with pelvic extensions

GCT - Stage 3

Intraperitoneal metastases outside pelvis with/without growth in retroperitoneal nodes

GCT - Stage 4

Distant metastases present - liver, lungs (grave prognosis)

GCT - Treatment

Usually, surgery, radiotherapy and chemotherapy all used in combination

Disorders of pregnancy

Pre-eclampsia of Pregnancy


Eclampsia of pregnancy


Ectopic pregnancy


Placental Abruption


Placental Previa


Congenital diseases

Pre-eclampsia of pregnancy

~10% prenancies; Associated with multiple pregnancies, primigravidae > 35 years




Characterised by increased BP, proteinuria & peripheral oedema




Develops from ~ week 20 of pregnancy and continues to end of 1st week post partum




Rarely fatal to mother; reduced placental blood flow and foetal hypoxia; if BP not controlled and proteinuria appears, delivery of foetus




Delivery improves condition dramatically; full recovery

Eclampsia of pregnancy

Rare; Pre-eclampsia symptoms and any or all of the following: Frontal headaches; fits; DIC; Kidney and liver failer; Coma




May follow pre-eclampsia or may develop de novo. If untreated, may be fatal to mother, foetus or both

Ectopia pregnancy

Fertilized ovum implants outside uterine cavity




Most commonly in fallopian tube due to previous tubal damage (Chlamydia infections, tubal surgery for contraception purposes, endometriosis) but also in peritoneal cavity, ovary, cervix




In tubal pregnancies, embyro grows normally for 2-6 weeks -> 'acute abdomen' presentation -> tube may rupture




An intra-abdominal pregnancy is carried to full term and delivered via laparotomy




In rare cases, embryo may die from poor placental attachment; necrotic embyro may calcify via dystrophic calcification (lithopaedion)

Placental abruption

Prematureseparation of a normally located placenta; Abdominal pain, antepartumhaemorrhage; May cause stillbirth, maternal death



Idiopathic, but more likely to occur inwomen with history of abruption, many previous pregnancies or hypertension

Placental Previa

Implantationof the placenta low in the uterus so that it encroaches on the lower segment




May lead to antepartum haemorrhage or anobstructed labour. Four grades of placenta previa are recognized



Grade 1 - PPrevia

Edge of placenta enroaches on the lower segment, but does not reach the internal os

Grade 2 - PPrevia

Placenta occupies the lower segment, with its edge reaching the internal os but not covering it

Grade 3-4 - PPrevia

Placenta implanted in the lower segment and either party (grade 3) or completely (grade 4) covers internal os

Congenital disease

Infectious agents or exposure toharmful environmental agents (chemicals, radiation) cancomplicate a pregnancy/delivery




There is maximalsensitivity to congenital defects in first 3 months of foetal development


Infections may be transmitted viaplacenta, however an infected birth canal during childbirth can also lead tocomplications




Rubella virus


Listeria monocytogenes


N.Gonorrhoea


Treponema pallidum


Toxoplasma


HIV


M.Tuberculosis

Rubella Virus

Crosses placenta; ~25% babies born to mothers with rubella in first 4 months pregnancy develop congenital malformations



Listeria monocytogenes

Crosses placenta, causes spontaneous abortion or babies die ~2-3 days old due to widespread necrosis of internal organs

N. Gonorrhoea

An infected birth canal during childbirth may cause opthalmia neonatorum

Treponema pallidum

Crosses placenta; causes spontaneous abortion or congenital syphilis (if not treated before 5th month)

Toxoplasma gondii

Crosses placenta; causes spontaneous abortion or still birth; surviving babies may have microcephaly/hydrocephaly

HIV

Crosses placenta oracquired during birth/lactation; Causes development of AIDS

M.Tuberculosis

Crosses placenta; Causesfoetal tuberculosis

Normal adult female breast

Composed of lobules of glandularepithelial tissue (small ducts terminating in terminal ductules or acini)




Theselink by branching to larger ducts that eventually converge and drain at thenipple




Within lobules, between the epithelialtissue is a cellular, specialized hormone-responsive stroma (intralobularstroma)




Between lobules, there isnon-specialized fibrocollagenous tissue and prominent adipose tissue(extralobular stroma)




Developmental changes occur in response to hormonalchanges from puberty to maturity, through pregnancy and menopause

Tumours of the breast

Fibroadenoma


Carcinoma of the breast



Fibroadenoma

Most commonbenign breast lump, typically 25-35yrs; Firm, rubbery, well-circumscribedlesions




Comprise localized proliferation of branchingduct-like structures (epithelial component) and abundant fibrous tissue(stroma)




Presents as ahighly mobile smooth solitary lump, typically 1-4cm diameter

Carcinoma of the breast

Very common, ~20% of all malignanciesin women, affects up to 1 in 10 women




Incidence ­s steeply through the reproductiveyears, and then less so from the age of menopause (~50yrs)




Main aetiological factors are oestrogen exposure and geneticpredisposition (eg. gene mutations in BRCA1, BRCA2, p53)




Also, geographical & dietaryfactors, epithelial hyperplasia, early menarche, nulliparity, late menopause,exogenous hormones





Four ways breast cancer presents

1.Palpable lump in the breast


2. Abnormality detected on mammography


3. Incidental histological finding inbreast tissue removed for another reason


4. Detection of metastatic deposits inother organs

Types of Breast cancer

  1. Non-invasive ductal carcinoma in situ (DCIS)
  2. Non-invasive lobular carcinoma in situ (LCIS)
  3. Invasive ductal carcinoma
  4. Invasive lobular carcinoma
  5. Tubular carcinoma
  6. Mucoid carcinoma
  7. Medullary carcinoma

Non-invasive DCIS

Usually detected as a palpable lump ormammographic abnormality



Histologically, atypical cells fill anddistend small & medium-sized ducts



  1. Paget'sdisease of the nipple is a pattern of spread of DCIS to the skin
  2. Reddening,thickening, scaling of nipple & areola skin, resembles eczema

Non-invasive LCIS

Usually detected as a mammographicabnormality not as a palpable lump




Histologically, atypical cells fill themammary lobules; ­­risk of invasive carcinoma




Most breast cancers are invasiveadenocarcinomas

Invasive ductal carcinoma

Most common type of breast cancer; islands of cells, dense fibrous stroma



Invasive lobular carcinoma

2nd most common type; narrow cords of cells, dense fibrous stroma

Tubular carcinoma

Composed of cells that form regular tubular structures (resemble small ducts). Well differentiated

Mucoid carcinoma

Composed of cells that secrete mucin into stroma -> soft, slimy texture; Well differentiated

Medullary carcinoma

Composed of well-circumscribed masses -> soft and fleshy texture; Dense lymphocytic infiltrate

Spread

Local


Lymphatic


Vascular

Local spread

Into adjacent breast, overlying skin (nipple retraction/discharge), pectoral muscles (deep fixation)

Lympathic

Into regional lymph nodes -> may affect lymphatic drainage of skin, causing a peau d'orange appearnace



Vascular

To bone (pathological fractures, hypercalcaemia, leukoerythroblastic anaemia, spinal-cord compression)




To lung (breathlessness), pleura (effusion of breathlessness), and ovary

Diagnosis of breast cancer

Breast self examination (BSE); Mammography; biopsy; needle or lumpectomy

Treatment

Lumpectomy


Mastectomy


Radical mastectomy


Radiotherapy


Chemotherapy


Hormone therapy

Staging and prognosis

Stage 1: Confinedto breast (~80-90%, 5yr survival)


Stage2: Confined to breast & LNs (~60-80%, 5yrsurvival)


Stage3: Deep tissue fixation (~25%, 5yr survival)


Stage4: Distant metastases (~10%, 5yr survival)


Grade of tumour assessed by looking at degree of glandformation, pleomorphism, numbers of mitoses


Grade I: 85%, 10yr survival GradeII: 60%,10yr survival


GradeIII: 45%,10yr survival


Molecular classification of breast cancer alsotaken into account (see Figure 20.16)


Gene profilingallows identification of carcinoma subtypes related to prognosis based onexpression ofER (oestrogen receptor) and HER-2 (human epidermal growth factor receptor 2)