abnormal breast pathology

Question 1

what is lactational mastitis?

Answer 1

• Inflammation of breast tissue and common complication of breast feeding
  can be an infection

Question 2

what is the pathophys of lactational mastitis?

Answer 2

obstruction in duct and accumulation of milk  regularly expressing breast milk can prevent this from happening
- Can be caused by infection – bacteria can enter nipple and back-track into ducts causing infection and inflammation – staph.a

Question 3

how does lactational mastitis present?

Answer 3

• Breast pain and tenderness (unilateral)
• Erythema in focal area of breast tissue
• Local warmth and inflammation
• Nipple discharge
• Fever

Question 4

what is conservative management of lactational mastitis?

Answer 4

Conservative: continue to breastfeed, breast massage, express milk, heat pack, warm shower, simple analgesia

Question 5

what medication can be used within lactational mastitis?

Answer 5

• Flucloxacillin, Erythromycin if pen allergic
  fluconazole if candida infection

Question 6

what complication can arise from lactational mastitis?

Answer 6

: breast abscess is rare complication – may need incision and drainage

Question 7

when would candida of the nipple likely occur?

Answer 7

can occur after a course of Abx

Question 8

what can candida of the nipple lead to?

Answer 8

can occur after a course of Abx  can lead to recurrent mastitis

Question 9

how does candida of nipple lead to recurrent mastitis?

Answer 9

• Skin will crust and crack on nipple  entrance for infection

Question 10

what conditions in baby are linked to candida of nipple?

Answer 10

• Linked to oral thrush and candidal nappy rash in infant

Question 11

how does candida of nipple present?

Answer 11

• Nipple tenderness and itching
• Cracked, flaky/ shiny areola

Question 12

what are symptoms of candida in nipple in baby?

Answer 12

• Symptoms in baby: white patches in mouth/ tongue, candidal nappy rash

Question 13

how do you manage candida of nipple?

Answer 13

topical miconazole 2% to each nipple after each breastfeed, baby – nystatin

Question 14

what is galactorrhoea?

Answer 14

refers to break milk production not associated with preg/ breastfeeding

Question 15

what hormone triggers galactorrheoa?

Answer 15

prolactin

Question 16

where is prolactin produced?

Answer 16

: prolactin is produced in anterior pituitary  can be made in breast and prostate

Question 17

how does dopamine affect prolactin?

Answer 17

• Dopamine blocks secretion of prolactin: dopamine antagonists (antipsychotics) can increase prolactin = galactorrhoea

Question 18

how does milk production in breast feeding occur?

Answer 18

Breast feeding: milk production may only start in small amounts during second/ third trimester and small amounts may leak  oestrogen and progesterone inhibit secretion of prolactin, oxytocin stimulates breast milk excretion
- Breast milk production will taper and stop once breastfeeding stops

Question 19

what can cause hyperprolactinaemia?

Answer 19

Hyperprolactinaemia: raised prolactin level
- Idiopathic
- Prolactinomas – hormone secreting pituitary tumours
- Endocrine disorders: hypothyroidism and polycystic ovarian syndrome
- Medications: dopamine antagonists eg antipsychotics

Question 20

if prolactin is suppressed by GRH, what other symptoms can be seen?

Answer 20

• Menstrual irregularities eg amenorrhoea
• Reduced libido
• Erectile dysfunction
• Gynaecomastia

Question 21

why might prolactin suppressed by GRH by hypothalamus have other features?

Answer 21

Prolactin suppressed gonadotrophin-releasing hormone by hypothalamus leading to reduced LH and FSH

Question 22

how do you manage galactorrhoea?

Answer 22

find underlying cause
- Dopamine agonists eg bromocriptine and cabergoline can help treat symptoms  blocks prolactin
- Trans-sphenoidal surgical removal of pituitary tumour: definitive management of prolactinoma

Question 23

what can cause non-milk discharge?

Answer 23

• Mammary duct ectasia
• Duct papilloma
• Pus from breast abscess

Question 24

what is mammary duct ectasia?

Answer 24

benign condition where there is dilation of large ducts in breasts
- Ectasia means dilation: inflame in ducts leading to intermittent discharge from nipple  may be white, grey, green

Question 25

who does mammary duct ectasia occur most freq in?

Answer 25

Occurs most freq in perimenopausal women

Question 26

what is a big RF for mammary duct ectasia?

Answer 26

smoking

Question 27

how does mammary duct ectasia present?

Answer 27

• Nipple discharge
• Tenderness/ pain
• Nipple retraction/ inversion
• Breast lump – pressure on lump may produce nipple discharge

Question 28

what investigations are needed for mammary duct ectasia?

Answer 28

2WW: triple assessment  clinical assess, imaging (US/ mammography/ MRI) and histology with fine needle aspiration
ductography
nipple discharge cytology
ductoscopy

Question 29

what key finding are seen on mammography for mammary duct ectasia?

Answer 29

calcifications

Question 30

what is ductography?

Answer 30

• Ductogrpahy: contrast injected into abnormal duct and mammogram then performed

Question 31

what is ductoscopy?

Answer 31

• Ductoscopy: inserting tiny endoscope into duct

Question 32

how do you manage mammary duct ectasia?

Answer 32

Management: may resolve on its own – no association to higher cancer risk
- Reassurance: after excluding cancer
- Symptomatic management of mastalgia: supportive bra and warm compresses
- Abx: if infection suspected
- Surgical excision of affected duct – microdochectomy

Question 33

what is intraductal papilloma?

Answer 33

Intraductal papilloma: warty lesion that grows within one of the ducts
- It is a result of proliferation of epithelial cells
- Clear/ blood stained nipple discharge

Question 34

has intraductal papilloma link to cancer?

Answer 34

They are benign tumours: but are associated with atypical hyperplasia/ breast cancer

Question 35

how does intraductal papilloma present?

Answer 35

Presentation: can occur at any age, most often 35-55yrs
- Often asymptomatic – picked up incidentally on mammograms/ US
- Nipple discharge: clear/ blood stained
- Tenderness/ pain
- Palpable lump

Question 36

how do you diagnose intraductal papilloma?

Answer 36

Diagnosis: 2WW: triple assessment: clinical assess, imaging (US/ mammography/ MRI) and histology with fine needle aspiration
- Ductography: contrast injected into abnormal duct and mammogram then performed

Question 37

how do you manage intraductal papillomas?

Answer 37

Management: intraductal papilloma’s require complete surgical excision
- After removal, tissue is examined for atypical hyperplasia that may have not be picked up on biopsy