booby conditions

Question 1

mastalgia

Answer 1

rarely assoc with malignancy unless palpable breast lump

cyclic
- diffus, most intense during premenstrual phase
- usually bilateral, can be uni
- heaviness, aching

non-cyclic
- localised, persistent, less responsive to treatment
- ensure pain from breast, not chest wall
- causes - meds (contraception), infection, pregnancy

Question 2

nipple discharge

Answer 2

physiologic - clear, yellow, watery
pathologic - bloody, from a singular duct

commonest cause - intraductal papilloma (benign)
rarely a sign of malignancy unless palpable

Ix - mammography, ultrasonography, surgical excision of dischargin ducts

Question 3

breast cysts

Answer 3

palpable common in late reproductive yrs
smooth discrete lump (may be fluctuant)
small increased risk of BC (esp in younger)
often tender esp before menstruation

Mx = aspirate
- blood stained or persistently refil -> biopsy/excise

Question 4

galactocele

Answer 4

palpable milk filled cyst
assoc with pregnancy or lactation

FNA can diagnose + drain

Question 5

lipoma

Answer 5

thin smooth border on mammography
can be palpable + reveals only adipose cells by biopsy

Question 6

causes of gynaecomastia

Answer 6

imbalance of oestrogen + androgen (testosterone)
- higher oestrogen, lower androg
- oest stimulates breast development, androg inhibits
- increase oes - puberty, obesity (aromatase in adipose converts androgens to oestrogen), Leydig cell testicular cancer, hyperthyroidism, liver disease
- decrease testosterone - old age, hypothalamus, klinefelter syndrome, orchitis (mumps), testicular damage

prolactin also stimulates glandular breast tissue + breast milk development
- raised prolactin -> gynaecomatia
- dopamine agonists (antipsychtics) block dopamine allowing prolactin to rise
–> gynaecomastia + galactorrhea

drugs
- steroids, antipsychotics
- digoxin, spirnolactone
- GnRH agonists (gosereline)
- opiates, cannabis, alcohol

Question 7

management of gynaecomastia

Answer 7

depends on cause

problematic cases (psycological distress)
- tamoxifen - selective oestrogen receptor modulator that reduces the effect of oestrogen on breast tissue
- surgery

Question 8

clinical features suggesting breast cancer

Answer 8

hard, irregular, painless or fixed in place
may be tether to skin or chest wall
nipple retraction
skin dim[ling or oedema

Question 9

who gets a 2wk referral

Answer 9

unexplained breast lump in patients >=30

unilateral nipple changes in patients >=50 - discharge, retraction or other changes

Question 10

fibrocystic change

Answer 10

women of menstruating age (majority 40-50)
- symptoms often improve post menopause
- V common

assoc with early menarche + late menopause
generalised lumpiness of breast, cyclical fluctuation

connective tissue (stroma), ducts + lobules respond to female hormone making fibrous + cystic

Question 11

presentation of fibrocystic change

Answer 11

smooth discrete lumps
mastalgia - cyclical
generalised lumpiness
fluctuation in breast size

symptoms start premenstrual, resolve during

cysts
- blue domed with pale fluid
- thin walled with fibrotic wall
- lined by apocrine epithelium

Question 12

management of fibrocystic pain

Answer 12

exclude malignancy (aspirate), reassure
manage cyclical breaast pain -
- wearing supportive bra
- NSAIDs
- apply heat to area

Question 13

harmartoma

Answer 13

circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution

Question 14

fibroadenoma

Answer 14

benign tumours of stromal/epithelial breast duct tissue - no increase in malignancy risk

common, palpable mass
usually solitary
commoner in african women
20-40yrs - peak 30s
usually found on screening

Question 15

fibroadenoma presentation

Answer 15

“breast mouse” - move around with breast tissue
painless, firm discrete small mobile mass
smooth round, well circumscribed, rubbery
grey/white colour

responds to female hormones - decrease after menopause
biphasic tumour/lesion - epithelium, stroma
30% shrink over 2yr period

Question 16

fibroadenoma investigation

Answer 16

US - solid
diagnosis = US core biopsy

not assoc with increase BC risk, complex ones with fam history of BC may indicate higher risk

Question 17

fibroadenoma mangement

Answer 17

diagnose, reassure
if >3cm surgical excision is usual
can decrease in size pproching menopause

Question 18

sclerosing lesions

Answer 18

sclerosing adenosis, radial scar/complex sclerosing lesion

benign, disorderly, proliferation of acini + stroma
can cause a mass or calcification, may MIMIC carcinoma

no increase BC risk

Question 19

sclerosing adenosis

Answer 19

benign, no increase BC risk

pain, tenderness
lumpiness/thickening
age 20-70

Question 20

radial scar

Answer 20

wide age range, common
incidental finding on screening
mimic carcinoma radiologically - shows epithelial proliferation

in situ or invasive carcinoma may occur with these lesion

Question 21

radial scar presentation + treatment

Answer 21

fibro-elastic scar
radiating fibrosis containing distorted ductules
fibrocystic change
epithelial proliferation

Mx = excise or sample extensively by vacuum biopsy/excision (no atypia)

Question 22

examples of inflammatory lessions

Answer 22

fat necrosis
duct ectasia
acute mastitis/abscess

Question 23

fat necrosis

Answer 23

benign lump formed by localised degeneration + scarring of fat tissue in the breast
- may be assoc with oil cyst (eggshell)

physical feature mimic carcinoma - no increase risk tho
mass may increase in size initially

**commonly triggered by localised traume, radiotherapy or surgery
- inflammatory reaction resulting in fibrosis + necrosis of fat tissue

causes
- 40% due to local traume - seat belt injury, falls
- warfarin therapy

Question 24

pathophysio + presentation of fat necrosis

Answer 24

damage + disruption of adipocytes
infiltration by acute inflammatory
“foamy” macrophages/histocytes
subsequent fibrosis + scarring
calcification, ghost adipocytes - “oil cyst”

presentation
- painless, firm, irregular lump
- fixed to local structures
- may be skin dimpling or nipple inversion

Question 25

investigation of fat necrosis

Answer 25

imaging + core biopsy, confirm Dx + exclude malignancy

US or mammograme can show similar appear to breast cancer
- histology (FNA/core biopsy)

Question 26

duct ectasia

Answer 26

benign condition where there is dilation of large ducts in breasts, shortening of terminal ducts
- there is inflammation in ducts, leading to intermittent discharge from nipple - creamy
ectasia = dilation

affect sub areolar ducts
commonest in PERImenopausal
assoc with smoking

Question 27

duct ectasia presentation

Answer 27

creamy nipple discharge
nipple retraction
tenderness or pain
lump - pressure on lump may produce discharge

periductal inflammation
periductal fibrosis
scarring + distortion

microcalcification on mammogram (not specific to duct ectasia)

Question 28

investigation + management of duct ectasia

Answer 28

triple assessment - microcalcifications
ductography - contrast injected
nipple discharge cytology
ductoscopy

Mx
- treat acute infections
- stop smoking
- excise ducts

Question 29

mastitis

Answer 29

inflammation of breast tissue
assoc with breastfeeding - 1 in 10 women

painful, tender, red hot breast
fever + general malaise may be present

Question 30

mangement of mastitis

Answer 30

continue breast feeding
analgesia, warm compress

if systemically unwell, niiple fissure, symptoms not improve after 12-24hrs of effective milk removal -> indicates infection
- oral flucloxacillin for 10-14days
–> staph aureus
- examined every 3days to check response + no abscess

if left -> breast abscess -> incision + drainage

unresponsive to antibiotic + spread over whole breast -> inflammatory carcinoma

Question 31

2 main causes of acutem mastitis/abscess

Answer 31

duct ectasia - mixed organisms, anaerobes

lactation - staph aureus, strep pyogenes

Question 32

abscess management

Answer 32

aspiration with 18gauge needle using local anaesthetic
- sent for microbiological analysis
- may have to be repeated

Question 33

phyllodes tumour

Answer 33

rare tumour of connective tissue (stroma) of breast
commonest age 40-50yrs
can resemble fibroadenomas but larger + fast growing
–> older women (fibroadenoma 20-40)

biphasic tumour
stromal overgrowth

behaviour depends on stromal features
- benign (50%)
- bordeline (25%)
- malignant (25%) - sarcomatous, can metastasize

Question 34

phyllodes tumour presentation + management

Answer 34

pres
- age 40-50
- slow growing unilateral breast lump
- prone to recurrence if not properly excised

treatment
- surgical removal of tumour + surrounding tissue -> wide excision - prone to recurrence if not properly excised
- chemo may be used in malignant or metastatic tumour

Question 35

intraduct papilloma

Answer 35

warty lesion that grows within one of ducts in the breast
- result of proliferation of epithelial cells in large mammary ducts
- can occur within a cyst

benign - can be assoc with atypical hyperplasia or BC

Question 36

intraduct papilloma presentation

Answer 36

age 35-60
nipple discharge +/- blood
palpable lump
tenderness or pain

Question 37

intraductal investigation + management

Answer 37

triple assessment
ductography - inject contrast, papilloma wont fill (filling defect)

management = vacuum excision, mirodochestomy

• if the rare intracystic carcinoma is susspected when fluid is grossly bloody or residual mass after aspiration