Benign Breast disease

Question 1

How do we class mastitis (inflammation of the breast tissue)?

Answer 1

By lactation status:

• lactational mastitis (more common) - 1/3 breastfeeding, cracked nipples, milk stasis, poor feeding technique
• non-lactational more common with duct ectasia/ peri-ductal mastitis/ smokers

Question 2

Management of mastitis

Answer 2

Systemic antibiotic therapy (typically s.Aureus, can granulomatous) & simple Analgesics

Lactational - continued milk drainage/ feeding (cessation of breastfeeding dopamine agonists e.g. cabergoline persistent infection)

Question 3

A woman with acute mastitis presents with a tender fluctuant & erythematous mass with a puncutum, fever & lethargy.
How can you confirm the suspected diagnosis if unsure? How would you manage it?

Answer 3

Breast abscess

USS
Initially fully reversible - US guided needle therapeutic aspiration + empirical antibiotics (more advance - incision & drainage)

Complication non-lactational abscess - mammary duct fistula (often recur)

Question 4

How do breasts cysts form?
How common are they?
How do you diagnose them?

Answer 4

Lobules become distended due to blockage (perimenopausal group) - epithelial lined fluid filled cavities

15% palpable breast masses, 7% women lifetime

Halo shape mammography
Definitely diagnosed USS

Persisting/ symptomatic/ undeterminable cystic masses - aspirated (cancer excluded if free of blood or lump disappears if not -> cytology)

Question 5

Management of Breast cysts

Answer 5

Once diagnosed usually self resolve
Larger aspirated

2% carcinoma at presentation
2/3X greater risk breast ca
Fibroadenosis- tenderness/ asymmetry

Analgesia cyclical pain - gamolenic acid/ Danazol

Question 6

What is memory duct ectasia and how does it present?

Answer 6

Dilation & shortening of major lactoferri s ducts

Common peri-menopausal woman
40% significant duct dilation 70yrs

Features: green/ yellow nipple discharge, palpable mass, nipple retraction

Mammography - dilated calcified ducts
Biopsied - multiple plasma cells (plasma cell mastitis)

✅conservative unless can’t exclude malignancy
Nipple discharge doesn’t go - duct excision

Question 7

Explain fat necrosis and its cause

How does it present?

Answer 7

Common condition - acute inflammatory response in breast -> ischaemic necrosis fat lobules

Traumatic fat necrosis - association with trauma (blunt 40% cases, 60% surgical/ radiological)

Presentation: usually asymptomatic or lump, CN discharge/ skin dimpling/ pain/ nipple inversion
Can persist -> chronic fibrotic change -> solid irregular lump

Question 8

How can fat necrosis be investigated & managed?

Answer 8

Positive traumatic history &/or hyperechoic mass USS
Mire developed - mimic carcinoma mammogram
Core biopsy

✅self-limiting
Analgesia

Question 9

List the 5 most common benign tumours of the breast

Describe how they feel

Answer 9

• fibroadenomas (most common) reproductive age, proliferation’s stromal & epithelial tissues of duct lobules, mobile, well defined, rubbery, <5cm, routine follow up over 2yrs - low malignant poential
• adenoma glandular, older, nodular, mimic malignancy - triple assessment
• papilloma intraductal 40-50yrs, subareolar, bloody/ clear discharge/ mass, similar ductal carcinomas imaging - biopsy ✅microdochectomy
• lipoma soft, mobile, adipose, low malignant potential
• phyllodes tumours rare fibroepithelial, older, epithelial & stromal, 1/3 malignant potential ✅widely excisised

Question 10

What is the triple assessment for suspicious breast lesions?

Answer 10

Examination
Imagining
Histology

Question 11

What is atypical ductal hyperplasia?

Answer 11

Infers a greater risk of breast cancer (5X)

Histological similar in situ cancer

Question 12

What is gynaecomastia ?

Answer 12

Males develop breast tissue due imbalanced ratio oestrogen: androgen
Breast cancer 1% cases
1/3 men lifetime
Usually reversible

Rubbery/ firm mass
From under nipples
+ testicular exam

Question 13

Pathophysiology behind gynaecomastia

Answer 13

Physiological - adolescence, delayed testosterone surge or older decreasing testosterone

Pathological:

• lack testosterone e.g. Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, renal disease
• increased oestrogen e.g. liver disease, hyperthyroidism, obesity, adrenal tumour, testicular subtypes (Leydig cell tumours)
• medication (25%) e.g. digoxin, metronidazole, spironolactone, chemoT, goserelin, antipsychotics, anabolic steroids
• idiopathic

Question 14

What’s the main differential for gynaecomastia?

Answer 14

Pseudogynaecomastia
Adipose associated overweight
Pinch see disc breast tissue
Imaging/ hisiotogy