Breast Conditions Flashcards
Cyclical Mastalgia
Typically, cyclical pain affects both breasts, beginning a few days before the beginning of menstruation and subsiding at the end. It is caused by hormonal changes, therefore most cases come in those actively menstruating or using HRT
Pain is usually diffuse and bilateral (may be more severe in one breast). It varies in intensity according to the phase of the menstrual cycle
There may be generalised swelling and lumpiness but no specific lump found.
ex: benign fibrocystic breast disease
Cyclical Mastalgia treatment
- Women should be advised to wear a supportive bra.
- use paracetamol and/or ibuprofen, or a topical NSAID
- Conservative treatments include flax seed oil and evening primrose oil (not routinely given).
Non-cyclical Mastalgia
More likely to be unilateral or focal DDx - Mastitis - Breast trauma - Breast cysts - Benign breast tumours. - Breast cancer. - Medications: HRT, COCP, antidepressants (sertraline, venlafaxine, mirtazapine), haloperidol, digoxin, spiranolactone, metronidazole, ketoconazole
Mastalgia - extra-mammary causes
- MSK, eg costochondritis, Tietze’s syndrome, Cervical and thoracic spondylosis/radiculopathy, fibromyalgia
- Pregnancy
- Herpes zoster
- Coronary artery disease/angina, pericarditis, PE
- GORD, PUD
- Sickle cell anaemia
Nipple discharge - differentials and assessment
Clear: physiological, during breast feeding
Milky: Pregnancy/pituitary adenoma (hyperprolactinemia)
Brown/green: mammary duct ectasia
Bloody: Intraductal papilloma 90%, Cancer 10%
or infection
Assessment
- clinical examination (any mass lesion should undergo triple assessment)
- consider mammography
Mastitis - features
- Associated with lactation
- Skin becomes dry and cracked
- Usually staphylococcus
- Clinically: Erythema, tender, hot, patient unwell
- Need to rule out inflammatory breast cancer
If left untreated, mastitis may develop into a breast abscess. This generally requires incision and drainage.
Mastitis - management
The first-line management of mastitis is to continue breastfeeding.
The BNF advises treating ‘if systemically unwell, if nipple fissure present, if symptoms do not improve after 12-24 hours of effective milk removal of if culture indicates infection’.
The first-line antibiotic is flucloxacillin for 10-14 days, Breastfeeding should continue during treatment.
Breast Abscess
Lactational/non lactational
Periareolar/peripheral
Associated with smoking
Infection is usually with Staphylococcus aureus
Clinically: Erythematous, hot tender on palpation, swelling, fluctuant, patient may be systemically unwell
Management: Antibiotics, US guided aspiration. If any necrosis, may need excision of overlying skin
Duct Ectasia
Dilatation and shortening of the terminal breast ducts within 3cm of the nipple. It is common and the incidence increases with age. It typically presents with slit like retraction of the nipple and creamy nipple discharge.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
- May present with a tender lump around the areola
If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’
Patients with troublesome nipple discharge may be treated by microdochectomy (if young)(removal of lactiferous duct) or total duct excision (if older).
Benign breast conditions - ddx
- Fibroadenoma
- Breast cysts
- Fibrocystic disease
- Duct papilloma
- Epithelial hyperplasia
- Fat necrosis
Fibroadenoma
- Most common lesion of the breast
- Occurs in up to 25% of women between 15-35yrs
- Hormone dependent
- Composed of connective tissue and proliferating epithelium developing from a whole lobule
- Firm, non tender, highly mobile, single or multiple
- no increased risk of malignancy
Management
- Triple Assessment
- Conservative/surgical - if >4 cm excision is usual + core biopsy to rule out phyllodes tumour
Breast Cyst
Common over 35, often perimenopausal Fluctuates with menstrual cycle Smooth, well demarcated from surrounding tissue Firm, mobile, tender/non tender Small increase in risk of malignancy
Management
- Triple assessment - ‘halo appearance’ on mammography. US will confirm the fluid filled cyst
- Treat by Aspiration - if bloody fluid aspirated will need biopsy or if complete resolution not achieved may need surgical excision
- if purulent: send for culture and give abx
Fibrocystic disease (aka fibroadenosis or benign mammary dysplasia)
- Most common between ages 30- 50
- Loose association of cyst formation, breast nodularity, stromal proliferation, and epithelial hyperplasia
- A/w Imbalance of progesterone and estrogen
- Clinically -bilateral pain, usually cyclical, breast swelling /lumpy breast, palpable mass and heaviness
Management
- Triple Assessment
- Conservative management - supportive bra, pain relief
Duct Papilloma
- Local areas of epithelial proliferation in large mammary ducts: hyperplastic lesions rather than malignant or premalignant
- May present with blood stained nipple discharge
- Large papillomas may present with a mass
- No increase risk of malignancy
- Treatment –> Microdochectomy
Epithelial Hyperplasia
- Variable presentation ranging from generalised lumpiness through to discrete lump
- Disorder consists of increased cellularity of terminal lobular unit, atypical features may be present
- Atypical features and family history of breast cancer confers greatly increased risk of malignancy
Treatment
- no atypical features –> conservative, watchful wait
- atypical features –> close monitoring or surgical resection
