Breast Flashcards
Triple Assessment
Clinical history and examination
Imaging- Mammography (look for mass/microcalcification) or USS (more useful in <35yrs).
Biopsy- Can be therapeutic for a known cysts (draining)/
Galactorrhoea-
Presentation
Causes
Copious, multi-ductal, milky secretions from both breasts, not related to pregnancy or breastfeeding (occurring 6-12 months after stopping BF).
Causes of hyperprolactinaemia- idiopathic, prolactinoma, hypothyroidism, drug induced (SSRIs etc), renal failure, liver failure etc.
Galactorrhoea-
Investigations
Management
Investigations include deranged LFTs/U+Es/TFTs. MRI head with contrast if suspect prolactinoma. Pregnancy test. Serum prolactin levels. Breast exam unremarkable.
Manage with treating underlying cause, idiopathic will self resolve. Transphenoidal surgery if tumour not controlled by dopamine agonists. If keeps occurring the bilateral total duct excision.
Mastalgia-
Breast pain is either cyclical- common, affecting both breast, in line with menstrual cycle.
Non cyclical- usually due to drugs.
Extramammary- shoulder pain, costochondritis.
Ask about breast pain, changes, discharge, lumps, menstrual cycle.
Give analgesia, usually NSAIDs (oral/topical)- work well with cyclical mastalgia. Otherwise if not subsiding refer to specialist.
Mastitis
Inflammation of the breast tissue; acute or chronic, caused by staph.aureus.
Lactational; occurring in breastfeeding women, usually with the first child (results in milk stasis).
Non lactational; RF is tobacco smoking.
Present with erythema, pain, tenderness, cracked nipples. Look for signs of abscess.
Manage with Abx and analgesia, continued breastfeeding is recommended.
Breast cysts
Diagnosed definitively with USS.
If symptomatic can drain the cyst; should disappear and fluid free of blood, if not send for cytology- can suggest cancer.
Increased risk of cancer and can lead to fibroadenosis.
Most self resolving, but can recur. Give analgesia.
Mammary duct ectasia
Dilation and shortening of major lactiferous ducts; get palpable mass, nipple retraction, yellow/green discharge. If blood conduct triple assessment.
Mammography shows calcified ducts.
Manage conservatively unless suggestive of cancer or recur- duct excision.
Fat necrosis
Palpable mass with history of trauma.
May mimic malignancy on mammogram, therefore biopsy for confirmation.
Treat with analgesia and reassurance.
Benign breast tumours types
Fibroadenoma- Most common, very motile and smooth bordered.
Adenoma- Of ductal cells, nodular, need triple A.
Lipoma-Benign tumour of fat cells, soft and mobile.
Papilloma- Between the ducts, bloody/clear discharge therefore biopsy.
Benign breast tumours
Investigations
Management
Investigate with triple A to rule out malignancy.
Reassure and regular monitor. If can’t confirm its not malignant, or has malignant potential then excise.
Gynaecomastia
Causes either physiological; more oestrogen than testosterone at puberty before the surge.
Pathological; decreased testosterone, increased oestrogen, medication or idiopathic.
Could be pseudoG- adipose with weight gain.
Gradual onset, firm rubbery mass. Examine for malignancy. Only investigate if cause unknown- LTFs, U+Es, hormone profile, testosterone.
Manage by reversing the cause, reassurance.
Carcinoma in situ
Malignancies contained in basement membrane.
Ductal CIN- Most common, incidental; mammogram shows microcalcification. Needs excision without residual remains, if multifocal/diffuse then mastectomy.
Lobular CIN- Less common but more potential to become invasive. Incidental finding on biopsy. Low grade needs monitoring, high grade and BRAC1/BRAC2
needs bilateral prophylactic mastectomy.
Invasive breast cancer
Invasive DC is more common than invasive LC (more in older women).
RF: Females, age, first degree relative, BRAC gene mutation, prolonged oestrogen exposure (early period/late menopause).
Investigate with triple assessment.
Screening for 50-70yrs a mammogram every 3yrs.
Paget’s disease
Either spread of malignant cells to the nipple or malignant cells arising from the nipple. Itching, redness, painful, flaking skin of nipple.
Differentials include eczema, dermatitis.
Need biopsy. Also USS, mammogram and MRI breast.
Manage with surgical removal of alveolar + nipple area.
Radiotherapy if underlying malignancy.
Treating breast cancer- Surgical
Surgical- Wide local excision (1cm around) in the case of localised tumour.
Mastectomy- Removal of all breast tissue if diffuse.
Sentinel nod biopsy- Remove only the nodes the breast first drains into.
Axillary clearance- Removal of all lymph nodes.
Can consider risk reducing mastectomy if pt has high chance of developing breast cancer.
