11 - Breast Disease Management

Question 1

What are some typical presenting features of breast disease?

Answer 1

• Swelling and tenderness
• Nodularity
• Mastalgia (cyclical and non-cyclical)
• Palpable breast lumps
• Nipple discharge (including galactorrhoea)
• Mastitis

Question 2

What type nipple discharge is a red flag?

Answer 2

Unilateral blood stained

Question 3

How can benign breast lumps be classified histologically?

Answer 3

- Non proliferative disorders: no increased risk of cancer

- Proliferative disorders: mild to moderate increased risk

- Atypical hyperplasia: increase in risk of 4.1-5.3

Question 4

Why is some physiological breast swelling that occurs in adolescence?

Answer 4

During puberty thelarche occurs and this can be unilateral or bilateral

Question 5

What are the two most common benign palpable breast lumps?

Answer 5

- Fibrocystic changes: presents with pain and nodularity in women 20-50. Responds to hormones so cyclical

- Fibroadenomas: breast mouse common in 20-30s. Made of fibrous and epithelial tissue. Firm, non tender, highly mobile lump. Hormones involved so HRT increases incidence

Question 6

What is nodularity of the breast and when is it abnormal?

Answer 6

• Lumpy glandular tissue often in upper outer quadrant of breast that is worst about a week before menstruation
• If bilaterally symmetrical rarely pathological but if there is asymmetry review after one or two menstrual cycles seeing her mid cycle and enquire about family history

Question 7

What is cyclical mastalgia and how do we treat it?

Answer 7

• Pain and nodularity that occurs in the breast in the premenstrual phase which rapidly resolves when menstruation starts
• Wear a supportive bra and analgesia

Question 8

What does a benign breast lump feel like?

Answer 8

• Smooth
• Mobile
• Regular borders
• Solid or cystic

Question 9

What are the 4 quadrants of the breast used to describe the location of breast pathology?

Answer 9

Question 10

How do you distinguish fibrocystic changes from a solid tumour?

Answer 10

• Can’t on examination so have to do fine needle aspiration biopsy but do not do this is you strongly suspect cancer as this provides a path for the cancer
• Often biopsy drains cyst and resolves it but may refill later

Question 11

How do we treat fibroadenomas?

Answer 11

Observe every 3 months with an ultrasounds

Question 12

What is a benign cause of bloody nipple discharge?

Answer 12

- Intraductal Papilloma and usually only unilateral

• Can often have pain as well as blocked milk duct
• Leaves patient susceptible to infection

Question 13

What is mammary duct ectasia and how does it present?

Answer 13

When a milk duct becomes dilated and filled with creamy secretions causing periductal inflammation

Question 14

What is mastitis and how do we treat it?

Answer 14

• Generalised cellulitis of the breast, often due to overfilling of the breasts from irregular nursing
• Cracks in the nipples can allow bacteria to get in and sometimes an abscess forms
• Treat with antibiotics and by expressing milk from unused breast

Question 15

What patients need to be referred via the 2 week wait for breast changes?

Answer 15

• Skin changes that suggest breast cancer
• >30 with unexplained lump in axilla
• Anyone under 30 with unexplained breast lump with or without pain can be a non-urgent referral

Question 16

What is the Kubler Ross change curve?

Answer 16

Last three changes can often be called acceptance

Question 17

What are some benign conditions causing nipple discharge?

Answer 17

• Duct ectasia
• Mastitis
• Intraductal Papilloma

Question 18

What is a radical mastectomy?

Answer 18

Surgical procedure involving the removal of breast, underlying chest muscle (including pectoralis major and pectoralis minor), and lymph nodes of the axilla