Benign Breast Disease

Question 1

Patient Pathway in breast disease

Answer 1

Notice a problem–> GP referral –> One-stop clinic –> Multi-disciplinary meeting (MDM) –> Results clinic

Question 2

Triple assessment of breast lumps

Answer 2

(1) Clinical assessment of the lump
(2) Radiological assessment (Mammography, USS, MRI
(3) Tissue diagnosis (needle biopsy, FNA or core)

Question 3

Diagnostic Grading like the bi-rad

Answer 3

Multiple methods (exam, mammography, USS, cytology or biopsy) all graded 1-5
1--> Normal
2--> Benign
3--> Probably benign
4--> Suspicious
5--> Malignant

Question 4

Cytological Diagnosis

Answer 4

C1--> Acellular or insufficient
C2--> Benign
C3--> Probably Benign
C4--> Suspicious
C5--> Malignant

Question 5

Mastalgia

Answer 5

Breast pain –> can be cyclic (related to menstruation) or non-cyclic (rarer)
Common (70% will have it) most people seek help due to fear of breast cancer–> low risk if only symptom

Question 6

Cyclic mastalgia

Answer 6

Normal or physiological breast pain for 1-4 days is premenstral and can have swelling and lumpiness. More severe pain for >7 days is cyclic mastaglia which effects 10-20% of women. Tends to be dull/heavy and diffuse, bilateral and upper, outer quadrant but can be more severe in one breast

Question 7

Causes of Cyclic Mastalgia

Answer 7

Often related to Sleep, work or stress problems

More common in younger women who have had previous investigations

Question 8

Non-cyclic Mastalgia

Answer 8

1/3 of breast pain –> usually unilateral & localized

presents in 40s/50s or post-menopause

Question 9

Causes of non-cyclic Mastalgia

Answer 9

Usually idiopathic–> more likely anatomical than hormonal –> can be related to Drugs
Can be due to pregnancy, mastitis, trauma, thrombophelbitis, cysts, tumours or cancer

Question 10

Drugs associated with Non-cyclic mastalgia

Answer 10

16-32% of women report mastalgia with oestrogen containing hormonal therapies
Antidepressants including venlafaxine & mirtazapine
Cardio drugs including diogoxin & spirolactone
Metronidazole and cimetidine

Question 11

Extramammary breast pain

Answer 11

Is usually felt in the breast but from chest wall or skeletal –> Tietze’ syndrome (costo-chondritis)

Question 12

Breast Lumps

Answer 12

Most likely to be benign Fibroadenoma or cysts. If smooth and mobile, with regular borders and is solid or cystic–> benign. If firm, irregular and fixed to underlying tissue. May be skin changes or nipple retraction–>malignant

Question 13

Management of Cyclic mastalgia

Answer 13

Reassurance is usually enough–> check bra fit (soft sleeping bra) and analgesia is 1st line
Topical NSAIDs, particularly Diclofenac
If severe consider changing from COC
20-30% spontaneously resolve but 60% recurrence

Question 14

Management of severe mastaglia

Answer 14

Danazol (anti-gonadotropin)
Tamoxifen (oestrogen receptor blocker)
Goserelin injections (blocks gonadotropin release)
Ormeloxifene (selective oestrogen receptor modulator

Question 15

Management of non-cyclic mastaglia

Answer 15

Resolves spontaneously in 50% of women
Chest wall pain often responds to NSAIDs
Trigger spots can respond to LA or steroid injections
Better bras can help or acupuncture

Question 16

Breast Cysts

Answer 16

Can be simple or complex
The diagnosis is clinical (examination) with radio-logical confirmation–> can treat by aspirating fluid and if suspicious or fail to aspirate send to cytology

Question 17

Fibroadenoma (FA)

Answer 17

A benign tumor (20% multifocal) which is common in young women
Complex or multiple FA double breast cancer risk
Hyperplasia of single terminal duct unit–> usually stop at 2-3cm but can get bigger, and regress at the rate of 10%/yr or after menopause
Occur in 50% of women given Ciclosporin after renal transplant

Question 18

Management of FA

Answer 18

USS in younger patients, or mammogram if >50yrs
Biopsy or excision is often used for peace of mind
Pt should be advised to check regularly and note changes–> may need excision or aspiration

Question 19

Phyllodes Tumour (also known as Brodie’s disease)

Answer 19

A rare tumour effecting women 40-50, can be benign or malignant
Treat with wide excision–> benign tumour may re-appear after excision and become malignant
Should have 2-yearly mammograms afterwards

Question 20

Intraductal papilloma

Answer 20

A benign, warty lesion behind the areola
Notice a small lump or bloody discharge (70%)
Young women may have multiple lesions, and 40yos just 1–> Aspiration or biopsy can be used

Question 21

Atypical Hyperplasia

Answer 21

Benign hyperplasia can occur in ducts or lobes–> may lead to carcinoma–> do not need excision but require annual mammograms
Risk is higher if there is family history

Question 22

Sclerosing adenosis

Answer 22

A benign condition causing sclerosis within lobules
May cause a lump, pain or be an incidental finding
Hard to exclude malignancy so biopsy is needed

Question 23

Fat necrosis

Answer 23

Usually following trauma in large, fatty, obese breasts –> usually painless, with red, bruised or dimpled skin. Biopsy to confirm diagnosis but no further management is required

Question 24

Mastitis

Answer 24

An infection of the breasts usually associated with lactation but can occur without it

Question 25

Mastitis with lactation

Answer 25

Duct ectasia

Question 26

Mastitis without lactation

Answer 26

Can be due to Complicated duct ectasia
Periductal mastitis
Mammary fistula

Question 27

Features of pathological nipple Discharge

Answer 27

Spontaneous
Unilateral
Related to a single duct
Bloody

Question 28

Common causes of nipple discharge

Answer 28

Intra-ductal papilloma
Duct ectasia
FCC (fibrocystic change)
Cancer

Question 29

Cancer risk associated with nipple discharge

Answer 29

about 5% (usually DCIS if it is)

Question 30

DCIS

Answer 30

Ductal carcinoma in situ

Question 31

Male breast disorders

Answer 31

True or pseudo gynaecomastia
Benign breast lumps
Benign lumps on the chest wall (lipoma, fibroma, epidermal cysts)