Breast (2) (Benign conditions) Flashcards
Benign breast conditions
- Inflammatory disease
- Mastitis
- Breast cysts
- Mammary duct ectasia
- Fat necrosis
- Benign tumours
- Gynaecomastia
mastitis
Inflammation of breast tissue (can be acute or chronic). Classed by lactation status
lactational mastitis (most common)
- 1/3 of breastfeeding women- during first 3 months
- Associated with cracked nipples and milk stasis
- More common with first child
non-lactational mastitis
- In women with other conditions e.g. duct ectasia, as a peri-ductal mastitis
-
Tobacco smoking is an important RF
- Causes damaged to sub-areolar duct walls – predisposing to bacterial infection
causes of mastitis
- Infection e.g. S.Aureus
- Granulomatous
presentation of mastitis
- Tenderness
- Swelling/ induration
- Erythema
- Ensure there is no abscess formation
management of mastitis
- Systemic antibiotic therapy
- Simple analgesics
For lactational mastitis
- Continued milk drainage or feeding
- If persistent or multiple areas of infection
- Give Cabergoline (dopamine agonist) to cause cessation of breastfeeding
if persistent mastitis (lactational) what is the management
- Give Cabergoline (dopamine agonist) to cause cessation of breastfeeding
complication of mastitis
breast abscess
breast abscess
- Collection of pus within breast lined granulation tissue- most commonly developing from acute mastitis
presentation of breast abscess
Tender fluctuant and erythematous masses, with a punctum potentially present
- Systemic features inc fever and lethargy
investigations for breast abscess
US
management of breast abscess
- If caught early
- Prompt empirical antibiotics
- US-guided needle therapeutic aspiration
- If advanced
- Incision and drainage under local
complication of breast abscess
formation of mammary duct fistula
breast cysts
Cysts are epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage. Common cause of breast masses.
RF for breast cyst
- perimenopausal
presentation of breast cyst
- Singular or multiple lumps affecting one or both breasts
- Cysts:
- Smooth
- Distinct (non tethered)
- May be tender
investigations for breast cyst
- Mammography- halo shaped
- US offers definitive diagnosis
management of breast cysts
- Most require no further management and self resolve
- Persisting , symptomatic or undeterminable cystic masses may be aspirated à cancer may eb excluded if the fluid is free of blood or the lump disappears (otherwise send for cytology)
- Cyclical pain treated with high dose gamolenic acid (GLA) or danazol
complications of breast cysts
- 2% of patients with cysts have carcinoma at presentation
- Patient with cysts also have 2-3 times greater risk of developing breast cancer in the future
- Fibro adenosis (fibrocystic changes) caused by multiple small cysts and fibrotic area
- Tender and cause asymmetry
mammary duct ectasia
Duct ectasia is the dilation and shortening of the major lactiferous ducts.
RF for mammary duct ectasia
menopause
presentation of mammary duct ectasia
- Coloured green/yellow nipple discharge
- Any blood-stained discharge requires triple assessment
- Palpable mass
- Nipple retraction
nvestigations for mammary duct ectasia
- Mammography
- Dilated calcified ducts without any other features of malignancy
- If biopsied: multiple plasma cells on histology- plasma cell mastitis
management of mammary duct ectasia
- Managed conservatively
- Unless need to exclude malignancy
- Unremitting nipple discharge can be treated with duct excision
fat necrosis
Fat necrosis is a common condition caused by an acute inflammatory response in the breast, leading to ischaemic necrosis of fat lobules.
causes of fat necrosis
- Trauma (blunt)
- Previous surgical or radiological intervention
presentation of fat necrosis
- Asymptomatic or presents as a lump
- Less commonly
- Fluid discharge
- Skin dimpling
- Pain
- Nipple inversion
- Solid irregular lump (if acute inflammatory response persist- chronic fibrotic change)
investigation of fat necrosis
- Fat necrosis may be suggested by a positive traumatic history and/ or hyperechoic (fat content) mass on US
- More developed fibrotic lesions will mimic carcinoma on mammogram- as calcified irregular speculated masses and the solid irregular lump may feel suspicious on palpation
- Core biopsy- to rule out malignancy
management of fat necrosis
- Fat necrosis is self -limiting
- Analgesic management and reassurance
benign tumours
Differential diagnosis
- Send to Triple Assessment to distinguish between breast lumps
- Cysts
- Abscesses
- Malignant lesions
- If lump cannot be diagnosed as benign → lump excised and send to histology
what does triple assessment involve
- Examination
- Imaging
- Histology
breast screening programme for women aged
50-70 yrs
how often do women have mammogram after turning 50
every 3 years
aim of breast screening
- Aim is to detect small impalpable cancers and pre-invasive cancer (incidence of DCIS has increased from 5% of breast cancers to 25% in screened populations)
- Look for asymmetric densities, parenchymal deformities, calcifications
- Assess abnormalities using further imaging, core biopsy and FNAC
name some benign tumours
papilloma
adenoma
lipoma
fibroadenoma
phyllodes tumour
papilloma
Intraductal papilloma’s are a benign breast lesion -wart-like tumors that grow within the milk ducts of the breast.
papilloma RF
40-50 yrs
papilloma presentation
- Subareolar lesion (less than 1cm away from nipple)
- Bloody or clear nipple discharge
investigation for papilloma
- Appear similar to ductal carcinomas on imaging therefore require biopsy
management of papilloma
Risk of breast cancer is only increased with multi-ductal papilloma and most are treated with microdochectomy.
adenoma
A ductal adenoma is a benign glandular tumour
RF
- Older women
Presentation
- Nodular
- Easily mimic malignancy
Management
- Triple assessment
fibroadenoma
Most common benign growth. Proliferations of stromal and epithelial tissue of the duct lobules.
- Very low malignant potential and can be left in situ
fibroadenoma rf
- Women of a reproductive age
fibroadenoma presentation
- Highly mobile (breast mouse)
- Well defined
- Rubbery
- <5cn
- Can be multiple or bilateral
management of fibroadenoma
- Excision if >3cm in diameter or patient preference
Lipoma
Benign adipose tumour
Presentation
- Soft and mobile normally otherwise asymptomatic.
Management
They have low malignant potential and are usually only removed if they are significantly enlarging or causing symptomatic compressive or aesthetic issues.
phyllodes tumour
Rare fibroepithelial tumour. Comprise both epithelial and stromal tissue. Grow rapidly.
RF
- Older age group
Investigations
- Hard to distinguish from fibroadenoma, however 1/3 have malignant potential
Management
- Should be widely excised or mastectomy if lesion is large
Gynaecomastia
A condition by which males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity.
- It is usually a benign disease but breast cancer can develop in about 1% of cases.
- It is a common condition with at least a third of men experiencing gynaecomastia in their lifetime and is usually an entirely reversible condition.
pathophysiology of gynaecomastia: physiological
- Adolescence
- Due to delayed testosterone surge relative to oestrogen at puberty
- Older population
- Secondary to decreasing testosterone levels
pathophysiology of gynaecomastia: pathological
- due to changes in oestrogen: androgen activity ratio. Variety of mechanisms
- Lack of testosterone
- Causes include Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease
- Increased oestrogen levels
- Causes include liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular tumours (e.g. Leydig’s cell tumours)
- Medication*
- Common causative agents include digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids
- Idiopathic
presentation of gynaecomastia
- Insidious onset
- Rubbery or firm mass (typically <2cm) that starts from underneath the nipple and spreads outwards over the breast region
DD for gynaecosmastia
- Pseudo gynaecomastia (associated with being overweight)
investigations of gynaecomastia
- Test are only necessary if cause is unknowns
- If malignancy suspected- triple assessment
- Cause of unknown
- Liver and renal function
- Hormone profile
management of gynaecomastia
Depends on the causative factors and the phase of gynaecomastia
- Reversible underlying cause, then treatment or reversal of this should also allow for the resolution of the gynaecomastia as well.
- In most cases, reassurance may be enough for the patient
- Tamoxifen can also be used in cases to help alleviate symptoms, especially tenderness. In patients with later stages of fibrosis, surgery may be the only option if medical treatments have failed.
hormone profile for gynaecomastia
- LH high and testosterone low = testicular failure
- LH low and testosterone low = increased oestrogen
- LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy
pagets disease of the nipple
A rare condition presents as a roughening, reddening, and slight ulceration of the nipple. The vast majority of Paget’s (97%) will also have an underlying neoplasm (ductal), either in situ or invasive disease, and it is associated with 1-4% of all cases of breast cancer.
- Involvement of epidermis by malignant ductal carcinoma cells
- Hypothesised that malignant cells migrate from the ducts to the nipple surface or the cells of the nipple themselves become malignant
presentation of pagets disease of nipple
- Itching or redness in the nipple
- Flaking and thickened skin around the nipple
- Painful and sensitive
- Flattened nipple
- With or without yellowish or bloody discharge
investigations for pagets
- Biopsy
- Complete breast and axilla exam due to association with malignancy
