Benign Breast Flashcards
What are the types of benign breast lump?
Fibroadenoma Adenoma Duct papilloma Lipoma Phyllodes tumour Sclerosing adenosis
What are the inflammatory breast conditions?
Breast cystitis
Fat necrosis
Duct ectasia
Mastitis
What are the breast conditions associated with breastfeeding?
Blocked duct/galactocele
Nipple candidiasis
Engorgement
Raynaud’s disease of the nipple
What are the general features that differentiate benign and malignant breast lumps?
Benign: - more mobile - smooth borders - multiple masses Malignant - craggy surfaces - firm consistency - fixed to surrounding tissue - single mass
What is a fibroadenoma?
Proliferation of stroll epithelial tissue of duct lobules
What is the most common benign breast lump?
Fibroadenoma
What is a fibroadenoma also known as, and why?
‘Breast mouse’ because it is so mobile
Who most commonly present with fibroadenomas?
Women of reproductive age (peak in 3rd decade)
What is the presentation of fibroadenoma?
Painless
Smooth, firm, well-defined, rubbery, highly mobile
Most <5cm in diameter
Can be multiple and bilateral
What are the features of fibroadenoma on mammogram?
Oval or round
Circumscribed
May have coarse calcification
What are the features of fibroadenoma on biopsy?
Biphasic component - stroll and epithelial component
Circumscribed edge
What are the management options for fibroadenoma?
Routine follow up
Surgical excision
When are fibroadenomas routinely followed up?
Asymptomatic
If low malignant potential
Why can fibroadenomas just be routinely followed up?
Low malignant potential
30% will get smaller over 2 years
When are fibroadenomas excised?
> 3cm in diameter
Symptomatic
Increasing size of other changes
Patient choice
What is a breast adenoma?
Benign tumour of ductal glandular tissue
Who most commonly present with breast adenomas?
Older females
What is the presentation of breast adenomas?
Painless Slowly enlarging Well circumscribed, mobile Nodular Can mimic malignancy
What are intraductal papillomas?
Growth of papilloma in breast ductal tissue
What is the presentation of intraductal papillomas?
Clear or blood-stained discharge originating from a single duct
Lump or multiple lumps in subareolar region - usually <1cm away from nipple
What is included in triple assessment for breast lumps?
Clinical examination
Imaging - US or mammography
Biopsy
What is seen on biopsy in intraductal papillomas?
Papillary growth pattern
What is the management for intraductal papillomas, and why is it done?
Microdochectomy - surgical excision of duct
Done because of increased risk of breast cancer with multi-ductal papilloma
What is a lipoma?
Benign adipose tumour
What is the presentation of a breast lipoma?
Soft and mobile
Can feel under it on palpation
What are the features of breast lipoma on mammography?
Thin smooth border
What is seen on biopsy of breast lipoma?
Only adipose cells
What is the management of breast lipoma?
May require excision to confirm diagnosis
Excise if significantly enlarging, causing symptomatic compression or aesthetic issues
What is a phyllodes tumour?
Rare fibroepithelial tumours
Comprised of both epithelial and stromal tissue
What is the malignant potential of a phyllodes tumour?
Majority benign
1/3 have malignant potential
Who are most likely to present with a phyllodes tumour?
Older - 40-60
What is the presentation of a phyllodes tumour?
Larger Well delineated Unilateral Grow rapidly Firm lump
What is the management for phyllodes tumour?
Wide local excision
Mastectomy for larger tumours
What is sclerosing adenosis?
Includes radial scars and complex sclerosing lesions
Distortion of the distal lobular with or without hyperplasia
What is the difference between radial scars and complex sclerosing lesions?
Radial scars - distortion of the distal lobular unit without hyperplasia
Complex sclerosing lesions - if hyperplasia is present
What is the presentation of sclerosing adenosis?
Breast lump or breast pain
Asymptomatic incidental finding
What is the management of sclerosing adenosis?
Excision - but not mandatory
What are breast cysts?
Epithelial lined, fluid-filled cavities
Why do breast cysts form?
When lobules become distended due to blockage
Are breast cysts common?
Yes
Who are breast cysts most common in?
Peri-menopausal women
What is the presentation of breast cysts?
Breast lumps May be painful and tender - pain often cyclical, worse before menstruation Single or multiple, can be bilateral Character of masses: - distinct - smooth - fluctuant or solid - mobile
What investigation gives the definitive diagnosis for breast cysts?
USS
What sign of beast cysts is seen on mammogram?
Halo shape
What is the management of breast cysts?
FNA of persisting, symptomatic or undeterminable lumps
Otherwise none needed
What may need to be done post-aspiration of breast cysts?
Cytology if aspirated fluid is bloody
Biopsy if any residual lump left after aspiration
What is the prognosis of breast cysts?
Risk of recurrence
Small increased risk of breast cancer in the future
What is fat necrosis?
Acute inflammatory response leading to ischaemic necrosis of fat lobules
What is the pathophysiology of fat necrosis?
Damage and disruption of adipocytes
Infiltration of acute inflammatory cells
‘Foamy’ macrophages
Subsequent fibrosis and scarring
Who are most likely to present with fat necrosis?
Obese women with large breasts
What is the common cause of fat necrosis?
Trauma to breast - blunt trauma, previous surgical o radiological intervention, seatbelts in RTA
What is the presentation of fat necrosis?
Firm lump May have associated haematoma Fluid discharge Nipple pain and inversion Skin dimpling If fibrotic change - solid, irregular lump
What are the investigation findings in fat necrosis?
USS - hyper echoic mass
Mammogram - can mimic carcinoma - core biopsy needed to rule out malignancy
What is the management of fat necrosis?
Self-limiting, usually resolves spontaneously
Conservative - reassurance, analgesia
What is duct ectasia?
The dilation and shortening of the major lactiferous ducts
A normal change occurring during breast involution
Followed by periductal inflammation, fibrosis, scarring and distortion
Which breast ducts does duct ectasia affect?
Sub-areolar ducts
Which benign breast condition is associated with smoking?
Duct ectasia
What is the presentation of duct ectasia?
Lump
Nipple discharge (brown-green/yellow/creamy)
Nipple retraction (slit-like)
Pain - accentuated by acute episodic inflammatory changes
Fistulation
What is seen on investigation of duct ectasia?
Mammogram - dilated calcify ducts without any other features of malignancy
Biopsy - mass typically containing plasma cells
If bloody nipple discharge is seen in a presentation of duct ectasia, what is needed?
Triple assessment
What is the management of duct ectasia?
Conservative
Surgical excision if excessive, unremitting nipple discharge
Treat acute infection
What is mastitis?
Inflammation of breast tissue
What are the classifications of mastitis?
Acute vs chronic
Lactational vs non-lactational
What is the presentation of mastitis?
Pain Tenderness Swelling Erythema Pyrexia Lump
What feature on presentation of mastitis suggests abscess?
Fluctuant mass
What is more common, lactational or non-lactational mastitis?
Lactational mastitis
What organism is most common in lactational mastitis?
Staph aureus
Who are affected by lactational mastitis?
Breastfeeding women - usually in the first 3 months or during weaning
What is lactational mastitis often caused by?
Poor feeding technique
What is the features presentation of mastitis is specific to lactational mastitis?
Cracked nipples and milk stasis
What general measures should be taken in lactational mastitis?
Continue breastfeeding
Express milk
Massage breast
When should breastfeeding be stopped in lactational mastitis, and how should this be done?
If persistent or multiple areas of infection
Cessation of breastfeeding by cabergoline (a dopamine agonist)
When should antibiotics be given in lactational mastitis, and which one?
If:
- systemically unwell
- nipple fissure
- positive culture
- symptoms not improving after 12-24 hours of effective milk removal
If nipple fissure infected - topical fusidic acid
Flucloxacillin
Who most commonly get non-lactational mastitis?
Smokers
Association with duct ectasia, periductal mastitis
How does smoking predispose to non-lactational mastitis?
Damage to sub-areolar duct walls
And predisposes to bacterial infection
What is the management of non-lactational mastitis?
Antibiotics (flucloxacillin/clindamycin)
Simple analgesia
Aspiration, incision, drainage of abscess
What is the complication of non-lactational mastitis, and how is it treated?
Mammary duct fistula - communication between skin and scubareolar duct
Surgical excision
What is a blocked duct/galactocele?
Milk bleb - little milk blister on nipple
Who most commonly get a blocked duct/galactocele?
Recent cessation of breastfeeding
What is the presentation of a blocked duct/galactocele?
Visible milk bleb
Pain when breastfeeding
What is the management of a blocked duct/galactocele?
Diagnosis and drainage by FNA
Continue breastfeeding, massage breast
What is nipple candidiasis?
Fungal infection of the nipple
Candida albicans
What is the presentation of nipple candiasis?
Pain when breastfeeding
What is the treatment for nipple candidiasis?
Miconazole cream for mother
Nystatin suspension for the baby
What is engorgement?
When milk isn’t fully removed front he breast
Who most commonly presents with engorgement?
Breastfeeding women, usually in the first few days after baby born
What is the presentation of engorgement?
Bilateral erythema
Breast pain, typically worse just before a feed
Fever may be present, styles within 24 hours
Milk doesn’t flow well - infant finds it difficult to attach and suckle
What is the management of engorgement?
Moist heat on breasts before feed
Cold compresses after feed to reduce swelling
Gently massage and compress the breasts during breastfeeding when baby pauses between sucks
What complications of engorgement can occur?
Blocked ducts
Mastitis
What is the presentation of Raynaud’s disease of the nipple?
Nipples blanch, followed by cyanosis or erythema
Pain during and immediately after feeding
Nipple pain resolves when it returns to normal colour
What is the management of Raynaud’s disease of the nipple?
Advise to minimise cold exposure
Head packs following breastfeeding
Lifestyle changes - avoid caffeine, stop smoking
What is mastalgia?
Breast pain
What is the management of mastalgia not associated with a breast lump?
Reassurance
Recommend better fitting bra or soft-support bra at night
Simple analgesia
Medications to stop (or reduce): COCP, antidepressants, anti-psychotics
What is galactorrhoea?
Copious bilateral multi-ductal milky discharge
Not associated with pregnancy or lactation
What is the normal physiology of breastfeeding?
Regulated by prolactin
Polypeptide hormone is produced and secreted by the anterior pituitary gland
Inhibited by dopamine
Stimulated by oestrogen and TRH (thyrotropin releasing hormone)
What are the causes of hyperprolactinaemic galactorrhoea?
Idiopathic
Prolactinoma
Hypothyroidism
Neurological conditions lowering dopamine - spinal cord injury, varicella zoster
Drugs - SSRIs, antipsychotics, H2 antagonists
What is done for investigation of galactorrhoea?
Exclude pregnancy Serum prolactin (>1000 in absence of drug cause is suggestive of prolactinoma - do MRI head with contrast) Further endocrine blood tests
What is the management of galactorrhoea?
Treat underlying cause
Pituitary tumors
- dopamine agonists - cabergoline, bromocriptine
- neurosurgery - trans-sphenoidal surgery
What is gynaecomastia?
Benign breast tissue growth in males
What are causes of gynaecomastia?
Physiological - delay in testosterone surge relative to oestrogen at puberty, decreasing testosterone with age
Idiopathic
Medications - digoxin, spironolactone, H2 antagonist, metronizadole, chemotherapy, gosterelin, antipsychotics, anabolic steroids
Lack of testosterone - Klinefelter’s, androgen insensitivity, testicular atrophy, renal disease
Increased oestrogen - liver disease, hyperthyroidism, obesity, adrenal tumours, Lydia cell tumour
What is the presentation of gynaecomastia?
Insidious onset of rubbery or firm mass
Starts from underneath nipple and spreads outwards over breast region
Uni or bilateral
What is the management of gynaecomastia?
Treat underlying cause
Medication - tamoxifen (relieves symptoms), danazol
Surgery if later stages and medical treatments have failed
