Breast Differentials

Question 1

What is gynaecomastia?

Answer 1

Development of breast tissue in males due to imbalance of oestrogen and androgen activity.

Question 2

What is the relationship between gynaecomastia and breast cancer?

Answer 2

1% of gynaecomastis cases develop into breast cancer

Question 3

What is the epidemiology of gynaecomastia?

Answer 3

Common condition - atleast 1/3 of men - usually entirely reversible.
Often confused with pseudogynaecomastia (breast growth due to adipose tissue in obestiy)

Question 4

What are the common causes of physiological gynaecomastia?

Answer 4

Adolescene most common - delayed testosterone surge during puberty
Older population - decrease testosterone

Question 5

What are the potential causes of pathological gynecomastia?

Answer 5

Changes in oestorgen:androgen activity
Lack of testosterone - renal disease, testicular atrophy, Klinefelter syndrome, androgen insensitivity
Increased oestrogen - liver disease, hyperthyroidism, obsetiy, adrenal tumours or testicular tumours.
Medication - digoxin, metronidazole, spironolcatone, chemo, gosereline, antipsychotics, anabolic steroids
Idiopathic

Question 6

What are the clinical features of gynaecomastia?

Answer 6

Insidious
Rubbery or firm mass norm >2cm starting underneath the nipple and spread outwards

Question 7

What investigations should be taken for gynaecomastia?

Answer 7

Screen for malignancy, triple assessment (weight loss, FIT test etc)
Liver and renal function (U&Es, LFTs)
Hormone profile - LH and testosterone

Question 8

How does analysisng LH and testosterone level results suggest the cause of gynaecomastia is?

Answer 8

High LH and low testotserone - testicular failure
Low LH and low testosterone - increased oesotrogen
High LH and high testosterone - androgen resistance or gonadotrophin-secreting malignancy.

Question 9

What are the different types of benign tumours that can be found in the breast?

Answer 9

Fibroadenoma - glandula and stromal tissue
Adenoma - epithelial tissue
Papilloma - norm derived from epidermis
Lipoma - adipose tissue
Phyllodes tumour - stromal tissue

Question 10

What are the common features of fibroadenoma?

Answer 10

Most common benign growth
Women of reporductive age
Proliferation of stromal and epithelial tissue of duct lobules
Highly mobile, well-defined and rubbery
Multiple and bilateral (can be)
Very low malignant potential, some get smaller over years.

Question 11

What are some common non-cancerous breast lumps?

Answer 11

Fibroadenoma
Fibrocystic changes
Breast cyst
Galactocele
Breast abscess

Question 12

At what age are certain breast lumps the most common?

Answer 12

15-30 fibroadenoma (decline with age)
30-45 - fibrocystic changes
45-55 - breast cyst (peak at menopause)
55+ cancer most likely (post-menopause)
Absecc - may occur in 20s then rate declines

Question 12

What is a fibroadenoma?
What are its key features?

Answer 12

Benign breast tumour made of fibrous tissue arising from breast lobules
Most common in young women 20-40years.
Is sensitive to oestrogen, so varies in size during menstraul cycle, grows during pregnancy and regress after menopause.
NOT associated with an increased risk of breast cancer

Question 13

What are the clinical features of a fibroadenoma?

Answer 13

Well defined/circumscribed
Smooth, mobile mass
Non-tender
Usually solitary
Solid mass

Question 14

What is the management for a fibroadenoma?

Answer 14

Observation
Excision considered if very large, uncertain diagnosis or psychological reasons.

Question 15

What is meant by fibrocystic changes in the breast?
What are the most common features?

Answer 15

Increased tissue fibrosity and density with cystic changes results in “generalised lumpiness to the breast”
Normal variation
Related to increased hormonal sensitivity - fluctuate with the menstraul cycle
Common in menstruating age
Usually improves or resolves after menopause.

Question 16

What are the symptoms of a fibrocystic change within the breast?

Answer 16

Lumpiness
Mastalgia (pain/tenderness)
Fluctuation of breast size

Question 17

What is the management of fibrocystic changes in the breast?

Answer 17

Exclude cancer
Manage symptoms aka analgesia, supportive bra, heat compress

Question 18

What is a breast cyst?
What are its common features?

Answer 18

Benign, single lump, fluid filled
Common in women aged 30-50yrs. (perimenopausal), less common post menopausal.

Question 19

What are the features of a breast cyst on examination?

Answer 19

Smooth
Well-circumscribed/defined
Mobile
May be tender

Question 20

How can you differentiate between a fibroadenoma and a breast cysts?

Answer 20

USS - determine if solid or fluid filled

Question 21

What is the management for a breast cyst?

Answer 21

Monitor
Exclude cancer
If very large/painful consider aspiration

Question 22

What is a galactocele?

Answer 22

Breast cyst filled with breast milk
Occurs when the lactiferous duct is blocked
Therefore occurs exclusively in lactating patients.

Question 23

How does a galactocele typically present on examination?

Answer 23

Firm
Mobile
Usually painless
Often around the areolar area

Question 24

What is the typical management of a galactocele?

Answer 24

Observe - usually resolve without any treatment
Can be aspirated
If becomes infected adminster antibiotics

Question 25

What is a breast abscess?
What are its common features?

Answer 25

Contain collections of pus
Common in lactating women
Can be caused by trauma (e.g piercings) or a result of underlying breast disease e.g invasive cancer.

Question 26

What are the features of a breast abscess on clinical examination?

Answer 26

Acute onset
Tender lump
Localised swelling
Warm
Erythema
Nipple discharge
+/- systemic features (fever)