Breast Flashcards by Sebastian Henry Ritchie

What is the breast triple assessment?

A hospital-based assessment clinic that allows for the early and rapid detection of cancer.

Components:
History/examination
Investigation
Histology

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Imaging in the triple assessment?

Mammography

Ultrasound scanning

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What is the scoring system in the triple assessment?

Exam score starts with P, imagine score starts with M or U, and histology score starts with B.

There is then a number that denotes the result of each component.
1 = Normal
2 = Benign
3 = Uncertain/likely benign
4 = Suspicious of malignancy
5 = Malignant

So e.g.
P1/M1/B1 would be a normal finding

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When to use mammography or ultrasound?

Ultrasound is more useful in women <35 and in men.

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What is mastitis?

Inflammation of the breast tissue, usually due to infection (s. aureus)

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How can we classify mastitis?

Lactational mastitis (more common)
Non-lactational mastitis

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What are the clinical features of mastitis?

Tenderness
Swelling
Induration
Erythema

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How do you manage mastitis?

Simple analgesics
Abx
If lactational, continued milk drainage/feeding is recommended

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What is a breast abscess?

A collection of pus within the breast lined granulation tissue, most commonly developing from acute mastitis

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How does a breast abscess present?

A tender fluctuant and erythematous mass, with potentially a punctum present

They can also have systemic symptoms, including:
Fever
Lethargy

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How can we diagnose a breast abscess?

Ultrasound

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How do we manage breast abscesses?

Initial phase - prompt empirical abx and US guided needle therapeutic aspiration
Advanced - incision and drainage under local anaesthetic

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Complications of a breast abscess?

If non-lactational, it can cause formation of a mammary duct fistula (communication between the skin and subareolar breast duct)

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What is a breast cyst?

An epithelial lined fluid-filled cavity which occurs when lobules become distended due to blockage, usually in the perimenopausal age group

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Features of a breast cyst?

Can be singular or with multiple lumps
May affect one or both breasts
On palpation they appear as distinct smooth masses

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How can we investigate a breast cyst?

Mammography - halo shape
Ultrasound
Aspiration (freehand or with US) and cytology

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Management of a breast cyst?

No treatment, they self resolve

Larger cysts can be aspirated for aesthetic reasons

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Does previous cysts affect your likelihood to have cancer in the future?

Yes. Patients with cysts are 2-3 times more likely to develop breast cancer in the future

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What is mammary duct ectasia?

Dilation and shortening of the major lactiferous ducts

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How does mammary duct ectasia present?

Yellow/green nipple discharge
Palpable mass
Nipple retraction

How do we investigate mammary duct ectasia?

Mammography - dilated, calcified ducts seen with no features of malignancy

How do we manage mammary duct ectasia?

Conservatively

Unremitting nipple discharge can be managed with duct excision

What is fat necrosis?

A common condition caused by an acute inflammatory response in the breast, leading to ischaemic necrosis of fat lobules

Often associated with trauma

Fat necrosis clinical features

Asymptomatic

Lump
Fluid discharge
Skin dimpling
Pain
Nipple inversion

If the inflammation persists, can cause a chronic fibrotic change leading to a solid irregular lump

Investigating fat necrosis

A hyperechoic mass on ultrasound If they're more developed they often feel a bit more irregular and as a result are more suspicious of cancer. Core biopsy will often be taken to rule out malignancy

Management of fat necrosis

Self-limiting Analgesia Reassurance

What is a fibroadenoma?

The most common benign growth. They are proliferations of stromal and epithelial tissue of duct lobules Usually found in women of reproductive age

What are the examination findings of a fibroadenoma?

``` Highly defined Mobile Rubbery Less than 5cm usually They can be multiple and bilateral ```

Management of fibroadenoma

Left in situ with routine follow up appointments | Main indications for excision are >3cm in diameter or patient preference

What is a ductal adenoma?

A benign glandular tumour that typically occurs in the older female population

What are the features of a ductal adenoma?

Nodular | Mimic malignancy

Management of ductal adenoma?

As they are nodular and mimic malignancy, most cases undergo triple assessment

What is an intraductal papilloma?

A benign breast lesion that usually occurs in women in their 40/50s, mostly in the subareolar region

How does an intraductal papilloma present?

Clear or bloody nipple discharge | Sometimes as a mass

How do we treat intraductal papillomas?

As they can appear similar to a ductal carcinoma on imaging, they usually require biopsy If multi-ductal papilloma, microdochectomy

What is a lipoma?

A soft and mobile benign adipose tumour | We don't usually remove, but can if it's causing symptomatic compression/aesthetic reasons

What are Phyllodes tumours?

These are rare fibroepithelial tumours composed of both epithelial and stromal tissue

What are the features of Phyllodes tumours?

Older age Rapid growth Often difficult to differentiate from fibroadenomas

Are Phyllodes tumours malignant?

10% have malignant potential | As a result they are usually widely excised (or mastectomy)

What causes gynaecomastia?

An imbalanced ratio of oestrogen and androgen activity

What are physiological causes of gynaecomastia?

Delayed testosterone surge relative to oestrogen during puberty Older age - secondary to decreasing testosterone levels w/age

What are pathological gynaecomastia causes?

``` Lack of testosterone: Klinefelter's Androgen insensitivity Testicular atrophy Renal disease ``` ``` Increased oestrogen levels: Liver disease Hyperthyroid Obesity Adrenal tumours Leydig cell tumours ``` ``` Medication: Digoxin Metronidazole Spironolactone Chemo Anabolic steroids Antipsychotics ``` Idiopathic

Examination findings in gynaecomastia?

Rubbery/firm mass (>2cm in diameter) starting from underneath the nipple and expanding outward

Differentials of gynaecomastia?

Pseudogynaecomastia (basically they're overweight)

Investigations in gynaecomastia?

To investigate the cause If expecting malignancy, triple assessment If unknown cause - check liver/renal function and hormone profile

Hormone profile results interpretation (gynaecomastia)?

LH high + low testosterone - testicular failure LH low and testosterone low - increased ostrogen LH high and testosterone high - androgen resistance or gonadotrophin secreting malignancy

How do we manage gynaecomastia?

Depnds on the causative factors In many cases, just reassurance Tamoxifen can alleviate symptoms (tenderness)

Paget's disease of the nipple

Eczematous change of the nipple associated with invasive ductal carcinoma

Complications of axillary node clearance

Lymphoedema and functional arm impairment