Benign Breast Disease Flashcards
1st
1st
Which breast is commonly larger?
The left
How does breast development start?
It may initially be unilateral therefore unilateral breast lump in 9/10 year old is likely a developing breast
Where do benign breast conditions arise from in the breast?
The terminal duct lobular unit - the glandular tissue
What are fibroadenomas classified as and what are they technically
Classified as benign neoplasms - best considered as aberrations of normal development
Where do fibroadenomas develop from?
Whole lobule not a single cell- under same hormonal control as the rest of the breast tissue
In women aged 20 what % of breast lumps are fibroadenomas
60%
Development of fibroadenomas over a 2 year period
1/10th increase in size, 1/3 get smaller or completely disappear and remainder stay the same
Fibroadenomas during pregnancy
Usually increase in size during pregnancy
Management of fibroadenomas
Imaging alone is acceptable if patient is young
What are breast cysts?
Distended and involuted lobules - epithelial origin
What % of discrete breast masses are cysts
15%
How do breast cysts present?
Smooth discrete breast lump that can be painful and is sometimes visible
How do cysts appear on imaging?
Characteristic halos on mammography
Diagnosed by ultrasonography
Management of breast cysts
Only symptomatic or interdeterminate cystic lesions should be aspirated (treatment) or biopsed
Risk with breast cyst
Slight increased risk of developing breast cancer
What is duct ectasia?
Subareolar ducts dilated with ductal secretions and shorten during involution that occurs with age - common in older women
If leakage occurs can cause periductal mastitis
What can happen (symptoms) with duct ectasia? x3
Some women with excessive dilatation and shortening present with nipple discharge (cheesy), nipple retraction (symmetrical and slit like) or a palpable mass
Drug which reduces gynaecomastia
Tamoxifen
What are duct papillomas?
Aberrations which show minimal malignant potential
Most common symptom of duct papilloma
Nipple discharge which is often bloodstained
Management of a papillary lesion
Core biopsy cannot readily differentiate between benign papilloma and papillary carcinoma - therefore excision usually performed
What is morphea?
Localised scleroderma of the breast - results in thickened white distorted area of skin - most frequently seen in women who have had radiotherapy after breast-conserving surgery for breast cancer - local creams can help
Which systemic conditions can cause breast symptoms? x4
Arteritis, sarcoidosis, keloids, wegeners granulomatosis
What is mastalgia?
Breast pain
What is the most common type of mastalgia?
Pain referred from the chest wall rather than true breast pain - even in women with cyclical breast pain
Signs which indicate that breast pain is actually referred from chest wall? x4
Unilateral
Brought on by activity
Very lateral or medial in the breast
Can be reproduced by pressure on a specific area of the chest wall
Examination of mastalgia
Palpate the breast and do it with woman on her side so that breast falls away and can palpate the chest wall
Management of mastalgia
NSAIDs are usually effective - can use topical agents Modify lifestyle (often recent changes of activity eg. with heavy lifting) Local injections of steroids if one specific point is very painful
Management of chronic breast pain following surgery
Exclude recurrence
Gabapentin, pregabalin or amitryptiline - recommended in all forms of neuropathic pain
What is true breast pain often associated with?
Cyclical swelling and nodularity - worse week before menstruation and better with onset - therefore believed to be related to hormones - also alters with hormonal treatment
Management of true breast pain
Reassurance
Evening primrose oil (gammalinoleic acid)
Soft supportive bra to help pain at night
Danazol (gonadotrophin supressor prevents LH surge and inhibits ovarian steroid formation)(luteal phase)
Tamoxifen (luteal phase)
What age group does breast infection commonly affect
Between 18 and 50
Two types of breast infection
Lactational and non-lactational (non-puerperal) infection
4 guiding principles in treating breast infection
Antibiotics given early to reduce likelihood of abscess development
Hospital referral if infection does not settle rapidly following antibiotics course
Suspected abscess should be confirmed by ultrasonography, aspiration or both before surgical drainage considered
Breast cancer should be excluded in patients with inflammatory lesion if it is solid on ultrasonography
Management of breast abscess
Repeated aspiration (every 2-3 days is required for larger abscesses) or incision and drainage
Most common organism in breast infection
Staph aureus in lactational and in non-lactational its staph aureus or anaerobes
How do you reduce risk of lactating infection
Maternal and infant hygiene
When is lactating infection most commonly seen
Following first child and within first 6 weeks of breastfeeding
Presentation of lactating infection
Pain, swelling and tenderness - usually a history of cracked nipple or skin abrasion
Treatment of lactating infection
Promotion of milk drainage and early antibiotic therapy (flucloxacillin)
Ice packs and cabbage leaves help
Surgical - daily needle aspiration, formal incision and drainage for abscesses larger than 5cm - wound can be left open with daily packing or primary closure
Breastfeeding continue with other breast
Which antibiotics should not be used to treat lactating infection
Tetracycline, ciprofloxacin and chloramphenicol - as they will enter the breast milk and can harm the baby
Treatment of multiple areas of lactating breast infection
Stopping milk production with cabergoline 2.5mcg BD for 2 days
Two types of non-lactating infections
Those that occur centrally in periareolar region and those that affect peripheral breast tissue
In whom is periareolar infection most commonly seen
In young women mean age 32
What occurs histologically with periareolar infection - periductal mastitis
Active inflammation around NON-DILATED subareolar breast ducts (as opposed to duct ectasia where there is duct dilatation)
What is an important risk factor for periductal mastitis
Smoking - abscesses often recur because patients carry on smoking
Associated features of periductal mastitis x3
Central breast pain, nipple retraction at site of diseased duct and nipple discharge
Management of periductal mastitis
Antibiotics - flucloxacillin and metronidazole (for anaerobes)
Drainage of abscess
Avoid open drainage - carried out through small incision
What is a mammary duct fistula?
Communication between the skin and subareolar breast duct after periductal mastitis abscess drainage
What can peripheral non-lactating breast abscesses be associated with?
Underlying can condition such as diabetes, RA, steroid treatment etc, but majority have no underlying cause
In whom are skin breast infections common
Overweight women with large breasts or poor hygiene - typically affects lower 1/2 of breast
Role of fungi and antifungals in breast infection
No role has been proven therefore should not be used
What is polymastia
Accessory breast tissue due to incomplete involution of the mammary ridge
What is polythelia?
Accessory nipples
What is amastia
Absence of breast development
What is Poland syndrome?
Unilateral hypoplasia of breast, hemithorax and pectoral muscles
What is Tietze’s syndrome?
Costo-chondritis - cause of non-cyclical mastalgia
Difference between fibroadenoma and fibrocystic breast change
Fibroadenoma is a defined, singular mobile mass- made of glandular and fibrous tissue - more common in women younger than 30 - painless and well-circumscribed
Fibrocystic is more “lumpy breasts” pain which varies with menstrual cycle - changes in breast epithelium - fluid filled and more common women 30-50
Aetiology of lactational breast abscess
Milk stasis associated with staph a infection
Systemic features of breast abscess
Tachycardia and pyrexia - less common in non-lactational abscess
Investigations of breast abscess
Ultrasound + aspiration for microscopy, culture and sensitivity of pus samples
Cellular morphology of fat necrosis
Irregular and necrotic adipocytes, amorphous material and inflammatory cells (including foreign body giant cells)
What is sclerosing adenosis?
Aberration of normal involution - proliferative lesion of cells within breast lobules - usually benign - can cause pain or small lump
Association of benign breast disease and OCP
Less common with OCP
Relationship with breast cysts and age
More common 40-50 and usually disappear after menopause unless on HRT
What is Hadfield’s or Adairs operation
Surgical removal of all lactational ducts below the nipple in duct ectasia
