30. Breasts and Lumps

Question 1

What are the main breast differentials for a lump?

Answer 1

Fibroadenoma
Fibrocystic disease
Cyst
Cancer

Question 2

How would a fibroadenoma present?

Answer 2

A non-tender lump that is mobile, smooth.

Often in those <30

Question 3

How do we treat and manage a fibroadenoma?

Answer 3

USS, rescan 3-6 months for growth.
Biopsy if large.

<4cm then leave it (shrink on own)
>4cm or rapidly enlarging then surgical excision

Question 4

How does fibrocystic disease present?

Answer 4

Lumpy breasts that are painful.
Changes with menstrual cycle - worse pre-menstruation.
Child-bearing age
May be discharge

Question 5

How do we manage fibrocystic disease?

Answer 5

Supportive - educate, supportive bra, reduce sodium and caffeine
Analgesia

If breast pain severe then hormonal therapy e.g. tamoxifen

Question 6

How would a breast cyst present?

Answer 6

Child-bearing age
Well circumscribed mass
Sudden enlargement
Fluctuant

Question 7

Management of cyst?

Answer 7

Large and painful? USS guided aspiration

Question 8

What are the main differentials for breast discharge?

Answer 8

Duct ectasia
Ductal papilloma
Cancer

Question 9

What is duct ectasia and how does it present?

Answer 9

Dilation of breast ducts that become blocked, fluid builds up.
Perimenopausal women.
Nipple has slit-like retraction
Tender lump around areola +/- green discharge

Question 10

How do we manage duct ectasia?

Answer 10

Conservative - warm compress and abx

Surgical - microdochetomy, total duct excision

Question 11

How would a ductal papilloma present?

Answer 11

Clear or blood-stained discharge, rarely a lump

Question 12

Investigations for a ductal papilloma?

Answer 12

Imaging - MMG, USS
Galactogram - dye injected into the nipple duct + x-ray
Biopsy

Question 13

Management of a ductal papilloma?

Answer 13

Depends on size, number, associated sinister findings

Surgery - microdochectomy

Question 14

Differentials for breast erythema/pain?

Answer 14

Mastitis

Breast abscess

Question 15

What is mastitis and presentations?

Answer 15

Inflammation of the breast. 
Coryzal symptoms
Nipple discharge
Red/tender breast
Possible abscess

Question 16

How to treat mastitis?

Answer 16

Non-severe - warm compress and analgesia

Severe (nipple fissure, not improving, breast milk culture +ve) - flucloxacillin and analgesia

Question 17

How does a breast abscess present and how do we treat it?

Answer 17

Localised area of infection, walled off with pus.
May be associated with mastitis

Managed with drainage, culture, abx and analgesia

Question 18

Five main types of breast cancer?

Answer 18

Invasive ductal carcinoma
Invasive lobular carcinoma
Ductal carcinoma in-situ (stays in ducts)
Lobular carcinoma in-situ (stays in lobes)
Paget’s disease of the nipple

Question 19

Paget’s disease of breast presentation?

Answer 19

Itching/burning/pain in or around nipple
Flattening
Discharge
Lump
Only one breast

Often alongside breast cancer

Question 20

How would we manage breast cancer?

Answer 20

Node clearance if axillary lymphadenopathy
Mastectomy if central/large/pt preferred/multifocal
Wide local excision for solitary/peripheral/small lesion
Radiotherapy adjuvant
Biologics

Question 21

What biologics can we give to breast cancer patients depending on their hormonal receptors?

Answer 21

ER +ve

• pre/peri menopausal - tamoxifen
• post-menopausal - anastrazole, letrozole

Her2 +ve
- Trastuzumab

Question 22

How often and who do we screen for breast cancer?

Answer 22

50-70 y/o

Mammogram every 3 years