9.9 Breast Flashcards
Two factors that changes benign breast tumour conditions
Age
- developmental (15-25 years)
- cyclical activity (25-45 y)
- involution (35-55 y)
Hormonal
- pregnancy
- breast feeding
What is ANDI
Aberration of Normal Development and Involution
ANDI includes all benign changes that take place in breast with age
Fibroadenoma / new fibroadenomata
- Benign
- normal until 25
- new common 15-25 years
- Rare at any other age and MUST be biopsied if a new mass feeling like a fibroadenoma appears after 25
- Cellular proliferation of stroma and glands
- May have cyclical changes in size on a monthly basis and will increase markedly during pregnancy (goes back to original or even smaller size after pregnancy)
- Well-circumscribed, non-encapsulated (does not infiltrate the adjacent breast parenchyma)
- One fibroadenoma or many fibroadenomas (fibroadenomata)
- Not associated with malignancy BUT may be misdaignosed
- Non-tender, mobile and solitary
Cysts / Fibrocystic changes
- Fibrosis in breast tissue development and subsequent failure in the continuous process of the lobule and terminal ductule formation. Associated with shrinkage of the lobes of breast (involution)
- Fluid filled
- Incidental discovery in some cases. Micro (<1cm) or macro cysts (>1cm and generally palpable)
- Common in 40’s
- May be tender (cyclic mastalgia)
- If untreated: usually disappear after menopause
- If on hormone replacement therapy (HRT): may continue to get cysts
- Must not be assumed on examination alone that breast cyst is benign as patient may have a cystic cancer
- Can be papillary cancer
- If aspirate and get blood = stop and send blood to cytology
Ductal ectasia
- The terminal ducts become wider as they approach the nipple (wall become thin)
- Inflammatory changes can develop around the terminal ducts causing scarring and inversion of the nipple
- > 35 years or after menopause
Peri-ductal mastitis
- Inflammatory condition of the nipple and retro-areolar area often due to ductal ectasia
- Commonly causes small abscesses, scarring, purulent drainage from nipple
- May result in an inverted nipple
Nipple inversion
General
Seen with
Pagent’s disease
- 10 to 20% prevalence
- Affects men and women
- Bilateral and sometimes familial
- If new - cause for concern (if nipple changes)
- If longstanding - often a developmental abnormality
Seen with:
- congenital maldevelopment
- traumatic fat necrosis
- infections (acute mastitis, , tuberculosis)
- duct ectasia
- sudden weight loss
- surgical procedures on the breast
Paget’s disease of the breast.
- malignancy (due to infiltration of the lactiferous ducts)
Eczema
- Very itchy
- Common if patient has eczema elsewhere
- Must distinguish from Paget’s Disease
Eczema starts on the areola and spreads to the nipple
Nipple changes
General
3 Types
- relatively common
- problematic during breastfeeding
1. Cracked nipples
- common in breastfeeding (cause pain)
- can result in mastitis or an abscess
2. Nipple polyps
- Abnormal, but non-cancerous growth from the wall of a duct (fibro-epithelial stromal polyp)
- Relatively common
- Slow growing and pedunculated
- Rubbery, nodular or cauliflower-like appearance
- remove before breastfeeding
3. Keratin pearls
- Small yellow bead which appear on the nipple (wart-like)
- Hyperkeratosis can include nipple, areola or both
- No known etiology (some cases related to medication – estrogens, spironolactone)
Nipple discharge
Definition
Types
- Spontaneous discharge from the breast is uncommon except in late pregnancy or in the post-partum period
- Seeing discharge with mechanical stimulation is normal
Types:
- Milky
- Multicoloured gummous
- Purulent
- Watery
- Serous
-Serosanguinous
- Bloody
There is always a pathological cause for BLOODY discharge: usually papilloma but malignancy must be excluded
Bloody / watery is problematic (unilateral); also if the discharge is dripping from nipple
Infections of breast - Cellulitis
Causes
Lactation infection organisms
Non-breastfeeding infection
Cellulitis - no collections
Abcess - collection of puss
Infections of the breast causes:
- Associated with lactation
- Not associated with lactation but due to breast changes
- Associated with systemic disease
- Benign conditions mimicking infections
Lactation infections:
- Staph Aureus (breastfeeding abscesses)
- Candidal infections also seen
- General infection = mastitis
Non-Breastfeeding infections:
- Immune system causes (TB and HIV)
- Malignancy (can cause blockage leading to infection)
- Inflammatory breast cancer can mimic an infection
- Increased risk of infection in Diabetes
- Common pathogen = Streptoccus or Staphylococcus
- smoking strongly associated with abscesses
Gynecomastia
- Common in younger men (15-30 years) and older men (60-75 years)
- Involves the tissue behind the NAC
- There is usually no specific cause
- It may be caused by certain drugs (ARV)
Pre invasive MALIGNANT BREAST CONDITIONS
Pathogenesis
Common forms
Other types of malignancies
- Slow growing (with local complications)
- Fast growing (spread)
- Commonest form is DCIS (ductal carcinoma in situ)
- LCIS less common (lobular carcinoma in situ)
Other types of malignancy include:
- Inflammatory
- Tubular
- Papillary
- Colloid
- Mucinous
- Paget’s disease
- Malignant phyllodes tumour
- Medullary carcinoma
Risk factors for breast cancer
- In 90% of cases, the cause is unknown
- Gender (female > men)
- Age (advanced age increases risk)
- Family history (5% of women have a gene abnormality - Breast Cancer-BRCA type 1 or 2 mutation)
- History of breast cancer
- History of atypical ductal hyperplasia or a new fibroadenoma (age >40)
- Exogenous hormone use
- Reproductive risk factors (onset of menarche < age 12, nulliparity, menopause > age 55, first live childbirth > age 30)
- Living in a first world country (increased life expectancy)
- Obesity
- ⬆️ alcohol intake
Signs and symptoms of breast cancer
- A lump that is not clearly defined.
- Thickening of the breast
- Skin dimpling
- Redness of the skin
- Peau d’orange skin changes
- Nipple changes: either bloody discharge, inversion of the nipple or Paget’s disease
