2- Benign breast conditions Flashcards
Benign breast conditions
Inflammatory disease
- Mastitis
- Breast cysts
- Mammary duct ectasia
- Fat necrosis
Benign tumours
- Papilloma
- Lipoma
- Adenoma
- Fibroadenoma
- Phyllodes tumour
Gynaecomastia
- hormonal
- drug induced e.g. spironolacton
breast cysts background
Cysts are epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage. Common cause of breast masses.
breast cycst risk factors
perimenopausal
presentation of breast cysts
Singular or multiple lumps affecting one or both breasts
Cysts:
- Smooth
- Distinct (non tethered)
- May be tender
Investigation for breast cyst
- Mammography- halo shaped
- US offers definitive diagnosis
Management of breast cysts
- Most require no further management and self resolve
- Persisting , symptomatic or undeterminable cystic masses may be aspirated -> cancer may be excluded if the fluid is free of blood or the lump disappears (otherwise send for cytology)
Cyclical pain related to breast cysts treated with
high dose gamolenic acid (GLA) or danazol
Complications of breast cysts
- 2% of patients with cysts have carcinoma at presentation
o Patient with cysts also have 2-3 times greater risk of developing breast cancer in the future - Fibro adenosis (fibrocystic changes) caused by multiple small cysts and fibrotic area
o Tender and cause asymmetry
Mastitis
Inflammation of breast tissue (can be acute or chronic).
Classed by lactation status
- Lactational mastitis (most common)
- Non-lactational mastitis (less common)
Lactational mastitis (more common)
- 1/3 of breastfeeding women- during first 3 months
- Associated with cracked nipples and milk stasis
- More common with first child
Non-lactational mastitis (less common)
- In women with other conditions e.g. duct ectasia, as a peri-ductal mastitis
- Tobacco smoking is an important RF
- Causes damaged to sub-areolar duct walls – predisposing to bacterial infection
Cause of mastitis
- Infection e.g. S.Aureus
- Granulomatous
Presentation of mastitis
- Tenderness
- Swelling/ induration
- Erythema
- Ensure there is no abscess formation
management of lactational mastitis
Conservative
- Continued breastfeeding, expressing milk and breast massage.
- Heat packs, warm showers and simple analgesia can help symptoms
Medical- if infection suspected e..g high temp
- Flucloxacillin is first line, or erythromycin if allergic to penicillin. A sample of milk can be sent to the lab for culture and sensitivities. Fluconazole may be used for suspected candidal infections.
If persistent or multiple areas of infection
- Cabergoline (dopamine agonist) to cause cessation of breast feeding
complication of mastitis
Breast abscess
Breast abscess
Background
- Collection of pus within breast lined granulation tissue- most commonly developing from acute mastitis
Presentation
- Tender fluctuant and erythematous masses, with a punctum potentially present
- Systemic features inc fever and lethargy
Investigation- US
Management
If caught early
- Prompt empirical antibiotics
- US-guided needle therapeutic aspiration
If advanced
- Incision and drainage under local
Complication: formation of mammary duct fistula
Mammary duct ectasia
Duct ectasia is the dilation and shortening of the major lactiferous ducts.
RF mammary duct ectasia
- Menopausal women
Presentation of mammary duct ectasia
- Coloured green/yellow nipple discharge
o Any blood-stained discharge requires triple assessment - Palpable mass
- Nipple retraction
Investigation for mammary duct ectasia
- Mammography
o Dilated calcified ducts without any other features of malignancy - If biopsied: multiple plasma cells on histology- plasma cell mastitis
Management of mammary duct ectasia
- Managed conservatively
- Unless need to exclude malignancy
- Unremitting nipple discharge can be treated with duct excision
Fat necrosis
Fat necrosis is a common condition caused by an acute inflammatory response in the breast due to trauma, leading to ischaemic necrosis of fat lobules.
Causes
- Trauma (blunt) e.g. seatbelt
- Previous surgical or radiological intervention
Fat necrosis
Fat necrosis is a common condition caused by an acute inflammatory response in the breast due to trauma, leading to ischaemic necrosis of fat lobules.
Causes
- Trauma (blunt) e.g. seatbelt
- Previous surgical or radiological intervention
Presentation of fat necrosis
- Asymptomatic or presents as a lump
- Less commonly
o Fluid discharge
o Skin dimpling
o Pain
o Nipple inversion - Solid irregular lump (if acute inflammatory response persist- chronic fibrotic change)
Investigations for fat necrosis
- Fat necrosis may be suggested by a positive traumatic history and/ or hyperechoic (fat content) mass on US
- More developed fibrotic lesions will mimic carcinoma on mammogram- as calcified irregular speculated masses and the solid irregular lump may feel suspicious on palpation
o Core biopsy- to rule out malignancy
fat necrosis management
Management
- Fat necrosis is self -limiting
- Analgesic management and reassurance
Breast Screening Programmes
In the UK, the NHS breast cancer screening programme currently invites women aged 50-70yrs to have a mammogram every three years; any abnormalities identified will be referred to breast clinic for triple assessment.
* Aim is to detect small impalpable cancers and pre-invasive cancer (incidence of DCIS has increased from 5% of breast cancers to 25% in screened populations)
* Look for asymmetric densities, parenchymal deformities, calcifications
* Assess abnormalities using further imaging, core biopsy and FNAC
benign tumours differential diagnosis
- Send to Triple Assessment to distinguish between breast lumps
o Cysts
o Abscesses
o Malignant lesions - If lump cannot be diagnosed as benign -> lump excised and send to histology
types of benign breast tumours
- papilloma
- lipoma
- adenoma
- phyllodes
- fibroadenoma
papilloma background
a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge.
Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.
RF for papilloma
- 40-50yrs
presentation of papilloma
- Subareolar lesion (less than 1cm away from nipple)
- Bloody or clear nipple discharge
investigations for papilloma
Investigation
- Appear similar to ductal carcinomas on imaging therefore require biopsy
Management of papilloma
Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy
Most treat with Microdochectomy
A microdochectomy is a procedure to
remove one or more of the milk ducts from your breast.
Lipoma
Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.
lipoma presentation
On examination, lipomas are typically:
Soft
Painless
Mobile
Do not cause skin changes
management of lipoma
conservative
They have low malignant potential and are usually only removed if they are significantly enlarging or causing symptomatic compressive or aesthetic issues.
adenoma
A ductal adenoma is a benign glandular tumour
RF for adenoma
- Older women
adenoma presentation
Presentation
- Nodular
- Easily mimic malignancy
management of adenoma
- Triple assessment
phyllodes tumour
Phyllodes tumours are rare tumours of the connective tissue (stroma) of the breast, occurring most often between ages 40 and 50. They are large and fast-growing. They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.
investigation for phyllodes tumour
Investigations
- Hard to distinguish from fibroadenoma, however 1/3 have malignant potential
management for phyllodes tumour
Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal.
Chemotherapy may be used in malignant or metastatic tumours.
fibroadenoma
Most common benign growth. Proliferations of stromal and epithelial tissue of the duct lobules.
- Very low malignant potential and can be left in situ
- They are typically small and mobile within the breast tissue. They are sometimes called a “breast mouse”, as they move around within the breast tissue.
risk factors fibroadenoma
They are more common in younger women, aged between 20 and 40 years. They respond to the female hormones (oestrogen and progesterone), which is why they are more common in younger women and often regress after menopause.
presentation of fibroadenoma
- Painless
- Smooth- rubbery
- Round
- Well circumscribed (well-defined borders)
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
presentation of fibroadenoma
- Painless
- Smooth- rubbery
- Round
- Well circumscribed (well-defined borders)
- Firm
- Mobile (moves freely under the skin and above the chest wall)
- Usually up to 3cm diameter
management of fibroadenoma
- Excision if >3cm in diameter or patient preference
Fibrocystic Breast Changes
Fibrocystic breast changes were previously called fibrocystic breast disease. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a variation of normal and not a disease. The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.
It is a benign (non-cancerous) condition, although it can vary in severity and significantly affect the patient’s quality of life if severe. It is common in women of menstruating age. Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.
Presentation
Symptoms can affect different areas of the breast, or both breasts, with:
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:
* Wearing a supportive bra
* Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
* Avoiding caffeine is commonly recommended
* Applying heat to the area
* Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance
*
Gynaecomastia
A condition by which males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity.
- It is usually a benign disease but breast cancer can develop in about 1% of cases.
- It is a common condition with at least a third of men experiencing gynaecomastia in their lifetime and is usually an entirely reversible condition.
physiological causes of gynaecomastia
Adolescence
Due to delayed testosterone surge relative to oestrogen at puberty
Older population
Secondary to decreasing testosterone levels
pathological causes of gynaecomastia
*due to changes in oestrogen: androgen activity ratio. *
Variety of mechanisms
1) Lack of testosterone
- Causes include Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease
2) Increased oestrogen levels
- Causes include liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular tumours (e.g. Leydig’s cell tumours)
3) Medication*
- Common causative agents include digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids
4)Idiopathic
Presentation of gynaecomastia
- Insidious onset
- Rubbery or firm mass (typically <2cm) that starts from underneath the nipple and spreads outwards over the breast region
DD for gynaecomastia
- Pseudo gynaecomastia (associated with being overweight)
investigations for gynaecomastia
- Test are only necessary if cause is unknowns
- If malignancy suspected- triple assessment
- Cause of unknown
–> Liver and renal function
–> Hormone profile
–> investigate for leydig cell testis tumour
management of gynaecomastia
Depends on the causative factors and the phase of gynaecomastia
- Reversible underlying cause, then treatment or reversal of this should also allow for the resolution of the gynaecomastia as well.
- In most cases, reassurance may be enough for the patient
- Tamoxifen can also be used in cases to help alleviate symptoms, especially tenderness. In patients with later stages of fibrosis, surgery may be the only option if medical treatments have failed.
Hormone profile for gynaecomastia
- LH high and testosterone low = testicular failure
- LH low and testosterone low = increased oestrogen
- LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy
Paget’s disease of the nipple
A rare condition presents as a roughening, reddening, and slight ulceration of the nipple. The vast majority of Paget’s (97%) will also have an underlying neoplasm, either in situ or invasive disease, and it is associated with 1-4% of all cases of breast cancer.
- Involvement of epidermis by malignant ductal carcinoma cells
- Hypothesised that malignant cells migrate from the ducts to the nipple surface or the cells of the nipple themselves become malignant
DD for pagets disease of the nipple
eczema
Paget’s disease may affect your nipple, while eczema rarely affects your nipple.
presentation of pagets
- Itching or redness in the nipple
- Flaking and thickened skin around the nipple
- Painful and sensitive
- Flattened nipple
- With or without yellowish or bloody discharge
Investigation for pagets
- Biopsy
- Complete breast and axilla exam due to association with malignancy
