Breast Flashcards
Fibroadenoma Ep Ax Sxs Mx [2] Prog
Ep: 20-30y/o
Ax: aberration in normal development
Sy/Si: painless, firm highly mobile lump
Mx:
- conservative if <40y/o or biopsy proven dx
- excision if >40y/o, >3cm or increasing size or pt choice
Pro: usually remain unchanged but 1/3 resolve spontaneously
Fibroadenoma
Ix: describe triple assessment and what you may find
Mammogram: well circumscribed oval mass
USS: well circumscribed round or ovoid mass
FNAC then biopsy
Breast cysts Ep Ax [2] Sxs [2] Mx
Ep: perimenopausal women
Ax: unknown but can be part of fibrocystic breast disease with cyclical mastalgia
Sy/Si: fluctuant or solid lump; may be tender or multiple
Mx: aspiration
Breast cysts
Ix: describe triple assessment and what you may find
- USS: anechoic signal, smooth walls, well circumscribed, underlying fat compression leads to halo sign
- FNAC: do cytology if fluid on aspiration bloody (should be straw coloured)
- Biopsy: if residual lump after aspiration
Phyllodes Tumour
Ax
Benign/malignant
Sxs [2]
Ax: fibro epithelial neoplasm; usually benign but can recur post-excision; some malignant but haematogenous metastasis uncommon
Sy/Si: firm lump, size may increase rapidly
Phyllodes Tumour
Ix: describe triple assessment and what you may find
Mx
Ix
• Mammogram: non-specific large oval or lobulated w/ smooth margins, may have radiolucent halo
• USS: non-specific, mimics fibro adenoma
• FNAC then biopsy
Mx: wide local excision or mastectomy in large tumours
Duct Papilloma Ep Ax Classification [2] Sxs [2] Cx
Ep: common, usually perimenopausal but can occur in younger women
Ax:
- benign neoplasm of sub areolar ducts
Categorised as central or peripheral
Sy/Si:
- single or multiple lumps
- with nipple single duct discharge (usually clear but may be bloody)
Cx: risk of later malignancy greater if peripheral
Duct Papilloma
Ix [4]
Mx
Ix: • Mammogram: normal • USS: well defined solid nodule or intra-ductal mass • Galactography: filling defect • FNAC then biopsy
Mx: no mx or surgical excision of duct (microdochectomy)
Fat necrosis Ax [2] Px Sxs What is one important thing in diagnosing fat necrosis
Ax:
- trauma e.g. seatbelt, implant removal
- prior reconstruction
Px:
- fat cell disruption causes inflammation and fibrosis
Sy/Si:
- firm painful lump, associated haematoma
- CANNOT clinically differentiate from carcinoma*
Fat necrosis
Ix [3]
Mx
- Mammogram: irregular spiculated mass area
- USS: hyper-echoic mass with well-defined margins +/- mural nodules
- FNAC then biopsy
Mx: conservative mx once dx proved by biopsy
Duct Ectasia Ep Ax [2] RF Sxs [2]
Ep: post-menopausal
Ax:
- normal chronic inflammatory fibrotic changes
- where ducts widen and shorten during breast involution in later life
RF: smoking
Sy/Si:
- lump
- nipple discharge (usually THICK AND GREEN; may be bloody)
- SYMMETRICAL slit-like nipple retraction
What is Mondor’s disease
Thrombophlebitis of a breast vein
Duct Ectasia
Ix [3]
Mx [2]
• Mammogram: dilated linear branching densities in sub areolar lesion with rod like calcifications
• USS: dilated fluid filled sub areolar ducts with moving debris
• FNAC then biopsy
Mx:
- conservative once dx proved by biopsy
- can do microdochectomy in young or total duct excision in old for excessive discharge
Lipoma Ax Sx Ix [3] Mx
Ax: benign neoplasm of adipose tissue
Sy/Si: lump
Ix: triple assessment
• Mammogram: fat composed lesion in subcutaneous plane with no calcification
• USS: rounded iso-echoic lesion
• FNAC then biopsy
Mx: conservative once dx proved by biopsy (surgical excision may be needed to confirm dx)
Sclerosing adenosis Prog Ax Px [3] Sxs [2] Ix [2] Mx
Prog: no increased malignancy risk Ax: disorder of involution Px: - distortion of distal lobular unit - without hyperplasia (hyperplasia in complex lesions) - radial scars Sy/Si: - breast lump or breast pain Ix: • Mammogram: can mimic carcinoma • FNAC then biopsy ***must be biopsied*** Mx: can be excised
Epithelial hyperplasia Ax Sx Ix Mx
Ax: increased cellularity of terminal lobular unit
Sy/Si: varies from lumpy breast to discrete lump
Ix: triple assessment
Mx: conservative unless atypical features or +ve FHx
Galactocele Ep Ax Sxs Ix Mx
Ep: women who have recently stopped breastfeeding
Ax: build-up of milk due to lactiferous duct occlusion
Sy/Si: smooth cystic lesion with no local or systemic signs of infection
Ix: not rqd
Mx: not rqd
Mastalgia: CYCLICAL Ep [2] Ax Symptoms [3] Signs [2]
Ep:
- pre-menopausal women, NOT associated with carcinoma
- mastalgia affects 70% of women in their lifetime
Ax: response to hormonal changes in menstrual cycle
Sy:
- pain mid-cycle to menstruation
- breast heaviness
- lumpiness
Si:
- breast tenderness of lateral half
check for signs of breast cancer (10-15%)
Cyclical breast pain conservative mx [4]
- reassurance
- better fitting day bra and soft support bra at night
- oral PARACETAMOL and IBUPROFEN
- continue these for 6m before secondary referral*
Cyclical breast pain Specialist mx [5]
- DANAZOL (anti-gonadotrophin; needs non-hormonal contraception as androgenic effects on fetus)
- TAMOXIFEN, GOSERELIN injections (inhibits gonadotrophin release; SE: vaginal dryness, flushes)
- BROMOCRIPTINE (SE: nausea, dizziness, postural hypotension, constipation)
- GESTRINONE (inhibits pituitary gonadotrophin)
- TOREMIFENE (SERM)
Non cyclical breast pain Ep [2] Ax Symptoms Ix Mx [4]
Ep: post-menopausal women, NOT associated with carcinoma
Ax: unknown (but can be referred pain from chest wall)
Sy: continuous or intermittent breast pain
Ix: CXR to excl. chest wall pain (chest wall arthritis, lung disease)
Mx: reassurance, better fitting day bra and soft support bra at night, oral PARACETAMOL and IBUPROFEN
Appearance of breast implant rupture US [3]
- Extracapsular rupture causes breast shape distortion
- and snowstorm appearance in breast
- and axilla die to silicone leakage
Nipple discharge: breastmilk [3]
- Physiological: breastfeeding
- Galactorrhoea: emotional events, histamine receptor antagonists
- Hyperprolactinaemia: pituitary adenoma
Nipple discharge:
- Green
- Carcinoma
- Intraductal papilloma
- Duct ectasia: green
- Carcinoma: blood stained with underlying mass or axilla lump
- Intraductal papilloma: younger patients with blood stained discharge and no palpable lump
Paget’s disease of the nipple [2]
Dx
- Eczematoid change of nipple (involves nipple primarily only laterally then spread to areolar)
- Associated with an underlying breast malignancy
Dx: punch biopsy, mammography, breast US
Mastitis
Ep [2]
Ax
Px [2]
Ep: post-partum or non-lactating women
Ax: usually staph aureus but can be mixed (anaerobic and recurrent most likely in smokers)
Px:
• Lactational: milk stasis or over production plus bacteria entering through traumatised nipple
• Non-lactational: duct ectasia causes squamous metaplasia of lactiferous ducts causing blockage and inflammation making more prone to infection
Mastitis
RF [9]
- > 30y/o
- poor breastfeeding technique, milk stasis
- lactation
- previous or prolonged mastitis, prior breast abscess
- shaving or plucking areolar hair
- anatomical breast defect
- mammoplasty or scar, nipple piercing, foreign body e.g. breast implants
- skin infection, immunosuppression
Mastitis
Symptoms [5]
Signs [3]
Sy: pain, tenderness, redness, flu-like symptoms, decreased milk outflow
Si: pyrexia, erythema, tenderness, fluctuance (abscess)
Mastitis
Ix: describe what a triple assessment, 3 other investigations
Complications [4]
• USS: hyperechoic lesion (abscess), may be well circumscribed, macrolobulated or irregular
• FNAC: drainage of purulent fluid indicates breast abscess (send for cytology and microbiology)
• MC&S: milk, aspirate, discharge or biopsy tissue
• Skin punch biopsy: if floridly inflamed (suspect inflammatory breast cancer)
• Bloods: cultures and FBC
• Pregnancy test: if not post-partum or knowingly pregnant
Complications:
- breastfeeding cessation, sepsis, scarring, fistula
Mastitis mx [5]
Mx of breast abscess or mammary duct fistula
SEPSIS 6 if signs of systemic infection
PCM, Ibuprofen
• Lactational: effective milk removal (breastfeeding or pumping); if symptoms persist beyond 12h or systemic signs, give empirical abx
• Non-lactational: FLUCLOXACILLIN 250-500mg x4/day (or CO-AMOVICLAV if smoker)
• Breast abscess or mammary duct fistula: aspiration or incision and drainage with LA under USS guidance
Gynaecomastia
Ep [3]
Ax [6]
Ep: males, puberty and old age Ax: • Drugs: spironolactone, digoxin, cimetidine, cannabis • Cirrhosis • Renal failure • Testicular tumours • Pseudo-gynaecomastia: obesity
Drugs that cause gynecomastia [4]
spironolactone, digoxin, cimetidine, cannabis
Gynaecomastia
RF [4]
Symptoms
Signs
RF: - anabolic steroids - prostate cancer - gender identity disorder - drugs Sy: soft lump that may be painful, symptoms of underlying cause Si; unilateral or bilateral soft lump
Gynaecomastia Mx [4]
Remove underlying cause
SERM eg Tamoxifen
Androgen therapy
Surgery: breast reduction
Androgen therapy
MOA [2]
SE [3]
DANAXOL inhibits pituitary gonadotrophins; combines androgenic activity with anti-oestrogenic and anti-progesterogenic activity SE: - impaired glucose tolerance - reduced spermatogenesis - facial oedema
