booby conditions Flashcards
mastalgia
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
nipple discharge
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
breast cysts
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
galactocele
palpable milk filled cyst
assoc with pregnancy or lactation
FNA can diagnose + drain
lipoma
thin smooth border on mammography
can be palpable + reveals only adipose cells by biopsy
causes of gynaecomastia
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
management of gynaecomastia
depends on cause
problematic cases (psycological distress)
- tamoxifen - selective oestrogen receptor modulator that reduces the effect of oestrogen on breast tissue
- surgery
clinical features suggesting breast cancer
hard, irregular, painless or fixed in place
may be tether to skin or chest wall
nipple retraction
skin dim[ling or oedema
who gets a 2wk referral
unexplained breast lump in patients >=30
unilateral nipple changes in patients >=50 - discharge, retraction or other changes
fibrocystic change
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
presentation of fibrocystic change
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
management of fibrocystic pain
exclude malignancy (aspirate), reassure
manage cyclical breaast pain -
- wearing supportive bra
- NSAIDs
- apply heat to area
harmartoma
circumscribed lesion composed of cell types normal to the breast but present in an abnormal proportion or distribution
fibroadenoma
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
fibroadenoma presentation
“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
fibroadenoma investigation
US - solid
diagnosis = US core biopsy
not assoc with increase BC risk, complex ones with fam history of BC may indicate higher risk
fibroadenoma mangement
diagnose, reassure
if >3cm surgical excision is usual
can decrease in size pproching menopause
sclerosing lesions
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
sclerosing adenosis
benign, no increase BC risk
pain, tenderness
lumpiness/thickening
age 20-70
radial scar
wide age range, common
incidental finding on screening
mimic carcinoma radiologically - shows epithelial proliferation
in situ or invasive carcinoma may occur with these lesion
radial scar presentation + treatment
fibro-elastic scar
radiating fibrosis containing distorted ductules
fibrocystic change
epithelial proliferation
Mx = excise or sample extensively by vacuum biopsy/excision (no atypia)
examples of inflammatory lessions
fat necrosis
duct ectasia
acute mastitis/abscess
fat necrosis
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
pathophysio + presentation of fat necrosis
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
investigation of fat necrosis
imaging + core biopsy, confirm Dx + exclude malignancy
US or mammograme can show similar appear to breast cancer
- histology (FNA/core biopsy)
duct ectasia
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
duct ectasia presentation
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)
investigation + management of duct ectasia
triple assessment - microcalcifications
ductography - contrast injected
nipple discharge cytology
ductoscopy
Mx
- treat acute infections
- stop smoking
- excise ducts
mastitis
inflammation of breast tissue
assoc with breastfeeding - 1 in 10 women
painful, tender, red hot breast
fever + general malaise may be present
mangement of mastitis
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
2 main causes of acutem mastitis/abscess
duct ectasia - mixed organisms, anaerobes
lactation - staph aureus, strep pyogenes
abscess management
aspiration with 18gauge needle using local anaesthetic
- sent for microbiological analysis
- may have to be repeated
phyllodes tumour
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
phyllodes tumour presentation + management
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
intraduct papilloma
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
intraduct papilloma presentation
age 35-60
nipple discharge +/- blood
palpable lump
tenderness or pain
intraductal investigation + management
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
