Benign breast conditions Flashcards
what three different classifications exist for benign breast conditions?
ANDIs (aberration of normal development and breast involution)
¥ Fibroadenoma
¥ Breast Cyst
¥ Duct Papilloma
Hormonale Changes
¥ Mastalgia
¥ Nipple Discharge
¥ Gynaecomastia
Infective Changes
¥ Abscess
¥ Periductal Mastitis
¥ Fat Necrosis
Tumours:
- phyllodes tumour
- intraduct papilloma
Fibroadenoma:
- Common?
- epidemiology?
- clinical features?
- pathology
- Treatment
Epidemiology
¥ Common (17% in autopsy studies)
¥ Usually solitary (10% multiple)
¥ Commoner in African women
Clinical features
¥ Peak incidence in 3rd decade (20-30yrs)
¥ Screening
¥ Painless, firm, discrete, mobile mass
¥ “Breast mouse” – escapes fingers on palpation
¥ Solid on ultrasound
Pathology ¥ Circumscribed ¥ Rubbery ¥ Grey-white colour ¥ Biphasic tumour/lesion containing both epithelium and stroma
Treatment
¥ Diagnose
¥ Reassure
¥ Excise - if unable to diagnose, increasing in size, deforming
Fibrocystic change:
- Epidemiology
- common?
- presentation?
- pathology
- microscopic pathology
- management
Women aged 20-50
Ð Majority 40-50
Very common
Clinical features: Ð Menstrual abnormalities Ð Early menarche Ð Late menopause (Often resolve or diminish after menopause)
Presentation: Ð Smooth discrete lumps Ð Sudden pain (as it ruptures) Ð Cyclical pain Ð Lumpiness Ð Incidental finding Ð Screening
Gross pathology Ð Cysts ¥ 1mm to several cm ¥ blue domed with pale (often greenish) fluid ¥ Usually multiple ¥ Associated with other benign changes
Microscopic pathology
Ð Cysts
¥ Thin walled but may have fibrotic wall
¥ Lined by apocrine epithelium
Management
Ð Exclude malignancy
Ð Reassure
Ð Excise if necessary
What is a hamartoma?
¥ Circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
What are sclerosing lesions?
¥ Benign, disorderly proliferation of acini and stroma
¥ Can cause a mass or calcification
¥ May mimic carcinoma
Two exist:
¥ Sclerosing adenosis
¥ Radial scar / Complex sclerosing lesion
What are the clinical features of sclerosing adenosis?
¥ Pain, tenderness or lumpiness/thickening
¥ Asymptomatic
¥ Age 20-70
¥ Benign
¥ Negligible risk of subsequent carcinoma
Radial scar:
- Common?
- Detected how?
- what is the difference between radial scar and complex sclerosing lesion?
- what is seen on pathology?
- what is seen on histology
- what is the pathology?
Common
Incidental/mammographic finding
Ð Radial Scar – 1-9mm
Ð Complex Sclerosing Lesion - >10mm (if larger)
Pathology: Ð Stellate architecture Ð central puckering Ð Radiating fibrosis Ð Mimic carcinoma radiologically Ð Probably not premalignant per se Ð Often show epithelial proliferation Ð In situ or invasive carcinoma may occur within these lesions
Histology: Ð Fibroelastotic core Ð Radiating fibrosis containing distorted ductules Ð Fibrocystic change Ð Epithelial proliferation
Treatment:
all used to be excised but now some monitored
Mastalgia can be cyclical or non-cyclical. For cyclical mastalgia:
- who does this affect?
- what are the symptoms?
- where is this felt?
¥ Premenopausal
¥ Average age 34
¥ Heightened awareness, discomfort, fullness, heaviness
¥ Classically – outer half of each breast, Can be unilateral
For non-cyclical mastalgia:
- who does this affect?
- what are the symptoms?
- where is this felt?
¥ Older women ¥ Average age 43 ¥ Pain can arise from chest wall, breast or outside breast ¥ Continuous/Random Burning/Drawing
What is the assessment for mastalgia?
¥ History
¥ Examination
¥ Imaging if necessary (e.g.unilateral mastalgia)
¥ Distinguish cyclical from non-cyclical
¥ Exclude non breast causes (e.g. chestwall tenderness, gall stones, lung disease, ect.)
What is the treatment for mild to moderate mastalgia?
Reassurance
Well-fitting bra
?topical NSAIDS
What is the treatment for severe mastalgia?
Reassurance
Consider drug treatment
What are the drug treatment options for mastalgia?
¥ NO EVIDENCE for use of diuretics
¥ Evening Primrose Oil
¥ Gamolenic acid – up to 1000mg day. If effective treat for up to 6 months (better for cyclical, but nausea)
¥ If no response within 4 months, stop OCP [if on]
¥ Danazol 100mg od (better for cyclical) but wt gain, acne, hirsutism
¥ Bromocriptine (better for cyclical but nausea and dizziness)
¥ Tamoxifen
Nipple discharge:
- describe physiological discharge
- what would be worrying
Physiological:
¥ Common
¥ 2/3 of pre-menopausal women can produce nipple secretion by cleansing the nipple and applying suction
¥ Colour varies from white to yellow to green to blue/black
Worrying if bloodstained - 5-10% pts. underlying malignancy
What is the assessment and treatment of nipple discharge?
¥ History ¥ Examination ¥ Imaging ¥ If suspicious- Duct Excision ¥ If bilateral milky discharge (galactorrhoea)-Drug history, Prolaction levels (?pituitary tumour)
What can cause gynaecomastia?
¥ Puberty ¥ Idiopathic ¥ Drugs (cimetidine, digoxin, spironolactone,androgens, antioestrogens) ¥ Cirrhosis/Malnutrition ¥ Primary hypogonadism ¥ Testicular tumours ¥ Secondary hypogonadism ¥ Hyperthroidism ¥ Renal disease
What are the clinical features of gynaecomastia:
- who is affected
- does this resolve
- when to do triple assessment
¥ 30-60% boys aged 10-16y
¥ 80% resolves spontaneously within 2y
¥ Surgical referral for embarrassment/persistence
¥ Idiopathic- men 50-80y, in most not cases associated with an endocrine abnormality
¥ if suspicious- triple assessment
¥ Drug related - withdraw drug
What are the treatment options for gynaecomastia?
¥ Reassurance
¥ Address underlying cause
¥ Danazol or Tamoxifen can provide symptomatic improvement
¥ Surgery – in rare cases, not without risks
What is fat necrosis typically caused by?
¥ Local trauma
o Seat belt injury
o Frequently no history
¥ Warfarin therapy
What is the pathophysiology of fat necrosis?
¥ Damage and disruption of adipocytes
¥ Infiltration by acute inflammatory cells
¥ “foamy” macrophages
¥ Subsequent fibrosis and scarring
What is the management of fat necrosis?
- triple assessment
- self limiting
duct ectasia (periductal mastitis):
- clinical features?
- pathology
- management
Clinical features ¥ Affects sub-areolar ducts ¥ Pain ¥ Acute episodic inflammatory changes ¥ Bloody and/or purulent D/C ¥ Fistulation ¥ Nipple retraction and distortion
Pathology: ¥ Associated with smoking ¥ Sub-areolar duct dilatation ¥ Periductal inflammation ¥ Periductal fibrosis ¥ Scarring and distortion -mixed organisms/anaerobes
Management: ¥ Treat acute infections: antibiotics/aspiration/incision and drainage ¥ Exclude malignancy ¥ Stop smoking ¥ investigation for persistent lesions ¥ Excise ducts
Breast abscess:
- who is this common in?
- symptoms?
- what is the management?
¥ Common in lactating post partum women ¥ Pain, swelling, tenderness ¥ Encourage continued breast feeding ¥ Cytology/ bacteriology -staph. aureus/strep. pyogenes
¥ Flucloxacillin +/- aspiration
¥ Co-amoxicillin
¥ Persistent abscess – aspiration/incision & drainage
¥ Persistent – investigation for underlying pathology
Phyllodes tumour:
- what is this?
- who is affected?
- how is this treated?
This is a slow growing unilateral breast mass:
¥ Biphasic tumour
¥ Stromal overgrowth
¥ Behaviour depends on stromal features
¥ “Benign”, borderline, malignant (sarcomatous
Aged: 40-50
Treatment:
¥ Pathology helps to predict
¥ Prone to local recurrence if not adequately excised
¥ Rarely metastasize
Intraduct papilloma:
- what age is affected?
- what is seen clinically?
- what is pathology?
- what can this lead to?
¥ Age 35-60
¥ Nipple discharge +/- blood
¥ Asymptomatic at screening
Ð Nodules
Ð Calcification
¥ Pathology:
Ð Sub-areolar ducts
Ð 2-20 mm diameter
Ð Papillary fronds containing a fibrovascular core
Ð covered by myoepithelium and epithelium
Ð Epithelium may show proliferative activity
¥ Can lead to epithelial proliferation Ð None Ð Usual type hyperplasia Ð Atypical ductal hyperplasia Ð Ductal carcinoma in situ
