Breast

Question 1

Define benign breast disease

Answer 1

• Breast tissue changes ranging from normal to abnormal, either in development, cyclical change or involution (shrinking down of an organ in old age) phases. Includes:
  o Fibrocystic change
  o Breast cysts
  o Fibroadenomas - results from hypertrophy of abreast lobule

o Sclerosing adenosis - aberration of normal involution
o Intraductal papillomas - a small, benign tumour that forms in a milk duct

o Duct ectasia - when central ducts become dilated with ductal secretions. These secretions may leak into periductal tissues and cause an inflammatory reaction (periductal masititis)

o Periductal mastitis

o Fat necrosis

Question 2

Explain the aetiology/risk factors of benign breast diseas

Answer 2

• Related to changes in hormone levels
• Fat necrosis occurs secondary to TRAUMA
• Risk Factors
  (o May be less common in patients on the OCP
  o SMOKING is a risk factor for periductal mastitis)

Question 3

Summarise the epidemiology of benign breast disease

Answer 3

• VERY COMMON
• Diffuse fibrocystic changes are very common (60% of women)
• Fibroadenomas are more common in 15-35 yrs

Question 4

Recognise the presenting symptoms of benign breast disease

Answer 4

• History of breast discomfort or pain (may be cyclical)
• Swelling or lump
• Nipple discharge
  (o NOTE: if this is bloody, malignancy should be suspected )
• To assess risk factors for breast cancer, ask patient about:
  (o Family history
  o Exposure to oestrogen (age of menarche, menopause, number of kids, breastfeeding, use of OCP/HRT))

Question 5

Recognise the signs of benign breast disease on physical examination

Answer 5

• Focal or diffuse nodularity of breast
• Fibroadenoma - smooth, well circumscribed and mobile lumps (known as a ‘breast mouse’)
• Duct Ectasia (a condition in which central ducts become dilated with ductal secretion due to a blockage of the lactiferous ducts) - causes yellow/green discharge
• Features of malignancy will be ABSENT in benign breast disease:
  (o Dimpling
  o Peau d’orange
  o Enlarged axillary lymph nodes )

Question 6

Identify appropriate investigations for benign breast disease

Answer 6

• Patients usually undergo TRIPLE ASSESSMENT:
  o Clinical Examination
  o Imaging
  (* Mammography (two-view)
• NOTE: benign lumps are less likely to be calcified
• Ultrasound - in younger patients (< 35 yrs) )
  o Cytology/Histology
  (* Fine Needle Aspiration - sent for cytological analysis
• Excision Biopsy - sent for histological analysis )

Question 7

Generate a management plan for benign breast disease

Answer 7

• Conservative
  o Symptomatic treatment (e.g. analgesia for mastalgia)
  o Fibroadenomas may be treated conservatively
• Surgery
  o Removal or excision biopsy of a breast lump
  o Wide local incision if there is any suspicion of the lump not being benign
  o Microdochectomy (surgical removal of a lactiferous duct) - performed for intraductal papillomas
  o Hadfield’s Procedure (surgical removal of ALL lactiferous ducts under the nipple) - is used for duct ectasia

Question 8

Identify possible complications of benign breast disease

Answer 8

• Pain

* Recurrence

Question 9

Summarise the prognosis for patients with benign breast disease

Answer 9

• GOOD

* However, recurrence is common

Question 10

Define breast abscess

Answer 10

• Abscess formation in breast tissues.
  o TWO main forms:
• Lactational
• Non-Lactational

Question 11

Explain the aetiology/risk factors of breast abscess

Answer 11

• Caused by INFECTION
• Causative organisms defer based on whether the abscess is:
  o Lactational
• Staphylococcus aureus
  o Non-Lactational
• Staphylococcus aureus
• Anaerobes

* Risk Factors 
o Lactation 
o SMOKING 
o Mammary duct ectasia 
o Periductal mastitis 
o Wound infections (e.g. from breast surgery)

Question 12

Summarise the epidemiology of breast abscess

Answer 12

• Lactational breast abscess are COMMON and tend to occur soon after starting breast feeding or weaning
• Non-lactational breast abscesses are more common in 30-60 yo smokers

Question 13

Recognise the presenting symptoms of breast abscess

Answer 13

• Breast discomfort
• Painful swelling
• Generally unwell and feverish
• Non-lactational - tend to present with a history of previous infections with less pronounced systemic upset

Question 14

Recognise the signs of breast abscess on physical examination

Answer 14

• Local
  o Swollen, warm and tender area of the breast
  o Overlying skin may be inflamed
  o The nipple may be cracked
  o Non-Lactational
• Scars or tissue distortion from previous episodes
• Signs of duct ectasia (e.g. nipple retraction)
• Systemic
  o Pyrexia
  o Tachycardia

Question 15

Identify appropriate investigations for breast abscess

Answer 15

• Ultrasound

* MC&S of pus samples

Question 16

Generate a management plan for breast abscess

Answer 16

• Medical
  o Antibiotics
• Lactational: flucloxacillin
• Non-Lactational: flucloxacillin + metronidazole
• Surgical
  o Lactational: Incision and drainage
  o Non-Lactational: open drainage should be avoided. The involved duct system should be excised once the infection has settled

Question 17

Identify possible complications of breast abscess

Answer 17

• Mammary fistula

* Overlying skin may (rarely) undergo necrosi

Question 18

Summarise the prognosis for patients with breast abscess

Answer 18

• If untreated, a breast abscess may discharge onto the skin surface
• Non-lactational breast abscesses tend to recur