Breast Disease

Question 1

Breast presentations

Answer 1

-Breast lump
-Pain
-Nipple discharge
-Skin changes (including nipple)
=Scaling (Paget’s disease of the breast, associated with in-situ or invasive carcinoma)
=Erythema (mastitis, abscess, fat necrosis, cancer)
=Puckering (invasion of the suspensory ligaments of the breast by an underlying malignancy that results in ligamentous contraction which draws the skin inwards)
=Dimpling (cutaneous lymphatic oedema, inflammatory breast cancer)
-Breast contour changes
-Axillary lump
-Infection
-Other

Question 2

Benign breast disease

Answer 2

-Fat necrosis
-Hamartoma
-Adenoma
-Lactational adenoma
-Nipple adenoma
-Sclerosing adenosis
-Radial scar / complex sclerosing lesion
-Ductal and lobular hyperplasia
-Lipoma

Question 3

Differentials for breast lump

Answer 3

-Cancer
-Abscess/ cyst
-Fibroadenoma
-Fibrocystic breast changes
-Fat necrosis
-Lipoma
-Galactocele
-Phyllodes tumour

Question 4

Differentials for breast pain (mastalgia)

Answer 4

-Cyclical breast pain
Cyclical breast pain is more common and is related to hormonal fluctuations during the menstrual cycle. The pain typically occurs during the two weeks before menstruation (the luteal phase) and settles during the menstrual period. There may be other symptoms of premenstrual syndrome, such as low mood, bloating, fatigue or headaches.
-Symptoms are typically:
=Bilateral and generalised
=Heaviness
=Aching

-Non-cyclical breast pain:
Non-cyclical breast pain is more common in women aged 40 – 50 years. It is more likely to be localised than cyclical breast pain. Often no cause is found.
=Medications (e.g., hormonal contraceptive medications)
=Infection (e.g., mastitis)
=Pregnancy
=The chest wall (e.g., costochondritis)
=The skin (e.g., shingles or post-herpetic neuralgia

Question 5

Diagnosis of breast pain

Answer 5

A breast pain diary can help diagnose cyclical breast pain.

The three main things to exclude when someone presents with breast pain are:

=Cancer (perform a thorough history and examination)
=Infection (mastitis)
=Pregnancy (perform a pregnancy test)

Question 6

Management of cyclical breast pain

Answer 6

-Wearing a supportive bra
-Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen (oral or topical)
-Avoiding caffeine is commonly recommended
-Applying heat to the area
-Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 7

Differentials for nipple discharge

Answer 7

-Physiological
=Yellow, milky or green discharge, often multiple ducts, not spontaneous.

-Duct ectasia
=Ducts can shorten and dilate perimenopausally.
=Discharge can be thick or watery, green or bloodstained. Slit-like nipple retraction.

-Intraductal papilloma
=Benign epithelial proliferation usually in ducts near nipples.
=Common cause of clear or bloody nipple discharge, single duct.
=May be a palpable lump.
=Excision advised to exclude any associated malignant disease

Question 8

Overview of mammary duct ectasia

Answer 8

-Benign condition where there is dilation of the large ducts in the breasts. Most common around menopause. Ectasia means dilation. There is inflammation in the ducts, leading to intermittent discharge from the nipple. The discharge may be white, grey or green.
=If ruptures may cause local inflammation, sometimes referred to as ‘plasma cell mastitis’

-Perimenopausal women, smoking, nipple discharge, tenderness r pain, nipple retraction or inversion, breast lump, incidental finding on mammogram

-Diagnosis: history, exam, USS, mammogram (microcalcifications), MRI, FNA, core biopsy.
=Ductography (contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct), Nipple discharge cytology (examining the cells in a sample of the nipple discharge), Ductoscopy – inserting a tiny endoscope (camera) into the duct

-Management:
=Reassurance after excluding cancer may be all that is required
=Symptomatic management of mastalgia (supportive bra and warm compresses)
=Antibiotics if infection is suspected or present
=Surgical excision of the affected duct (microdochectomy) may be required in problematic case

Question 9

Overview of Intraductal papilloma

Answer 9

-An intraductal papilloma is a warty lesion that grows within one of the ducts in the breast. It is the result of the proliferation of epithelial cells. The typical presentation is with clear or blood-stained nipple discharge. Intraductal papillomas are benign tumours; however, they can be associated with atypical hyperplasia or breast cancer.

-P: any age but 35-55, asymptomatic, nipple discharge (clear or blood-stained), tenderness or pain, palpable lump. Hyperplastic lesions rather than malignant or premalignant

-D: triple assessment, core biopsy or vacuum-assisted biopsy, ductography ( injecting contrast into the abnormal duct and performing mammograms to visualise that duct. Area does not fill)

-M: Intraductal papillomas require complete surgical excision. After removal, the tissue is examined for atypical hyperplasia or cancer that may not have been picked up on the biopsy

Question 10

Breast disease by age

Answer 10

-Cancer increases (85% >60)
-Cyst peak 41-50 (30%)
-Localised benign peak 31-40 (60%) then decrease
-Fibroadenoma peak <20 (60%) then decrease
-Abscess decrease over time (10%)

Question 11

Breast history

Answer 11

-History of presenting complaint
=SOCRATES
=Soft/hard, smooth/irregular, pain
=Is size or discomfort related to menstrual cycle?
=Duration of symptoms, associated skin changes, nipple discharge or bleeding (mastitis, cancer), axillary and neck lumps (cancer, abscess)
=Nipple inversion (cancer), erythema (abscess, mastitis, cancer), ulceration (cancer), dimpling/ peau d’orange (cancer), fever (abscess), weight loss, malaise, bone pain (metastatic cancer)

-Systemic
=SOB (lung mets), abdo pain, N&V (bowel obstruction), confusion (brain mets), back pain (spinal mets)

-Risk factors for breast cancer
=Family history of breast or ovarian cancer, HRT use, alcohol, smoking, obesity, nulliparity, early menarche and late menopause

-General fitness
=Past medical history, medications, allergies

Question 12

Breast Examination

Answer 12

-Chaperone, pain

-Inspection
=Lumps, skin changes (dimpling, scaling, erythema), puckering, nipple inversion cancer, abscess, mammary duct ectasia, mastitis) and discharge, (scars, radiotherapy dots), asymmetry, masses

-Examination: hands pushing into hips
=Repeat inspection: if mass visible suggests tethering to underlying tissue (invasive), accentuate puckering of invading suspensory ligaments of breast
=Arms above head whilst leaning forward: exaggeration
=Benign nipple inversion
=Nipple retraction
=Nipple eczema
=Paget’s disease of the nipple (erythematous scaly rash resembling eczema)

-Palpation: 45 degrees, hand behind head
=Start with asymptomatic side
=Describe location of abnormality in terms of clock face (i.e. 1-12 o’clock). Examine each hour from outside towards nipple
=Masses: location, size, shape, consistency, mobility, fluctuance, overlying skin changes
=Ask patient to elicit nipple discharge if present
=Examine axillae and supra/infraclavicular fossae for ymph nodes
(E1: normal, E2: benign, E3: indeterminate, E4: suspicious, E5: malignant)

Question 13

Breast ultrasound

Answer 13

-Indication
=Any palpable lump
=It should not used in pain, and not as screening
=U1: normal, U2: benign, U3: indeterminate, U4: suspicious, U5: malignant

Question 14

Indications of mammography

Answer 14

-Breast abnormalities in ages >40 years.
-National screening program >50 years.
-Early Screening (age < 50years if strong family history)
-Follow up in diagnosed breast cancer

Question 15

Other breast imaging

Answer 15

-Tomosynthesis
-MRI

Question 16

Breast pathology techniques

Answer 16

-FNA (can confirm the presence of malignancy but gives limited other information, often used in axillary lymph nodes)
-Core biopsy (standard investigation for new breast lump, for cancers, gives information on tumour type, grade, endocrine receptor and HER2 receptor status) B1 (normal), B2 (benign), B3 (indeterminate), B4 (suspicious), B5a (malignant in situ), B5b (malignant invasive)

Question 17

Overview of breast cancer

Answer 17

-Triple assessment of a breast lump is standard practice to exclude or diagnose cancer. This involves:
=Clinical assessment (history and examination)
=Imaging (ultrasound or mammography)
=Histology (fine needle aspiration or core biopsy)

-Clinical features that may suggest breast cancer are:
=Lumps that are hard, irregular, painless or fixed in place
=Lumps may be tethered to the skin or the chest wall
=Nipple retraction
=Skin dimpling or oedema (peau d’orange)

-2 week wait referral for suspected breast cancer for:
=An unexplained breast lump in patients aged 30 or above
=Unilateral nipple changes in patients aged 50 or above (discharge, retraction or other changes)
=An unexplained lump in the axilla in patients aged 30 or above
=Skin changes suggestive of breast cancer
-The NICE guidelines suggest considering non-urgent referral for unexplained breast lumps in patients under 30 years.

Question 18

Describe fibroadenoma

Answer 18

-Benign breast tumour formed by proliferation of both stromal and epithelial components of the breast duct tissue.
-Firm or rubbery, smooth, mobile (moves freely under the skin and above chest wall), painless, round, well-circumscribed, usually up to 3cm diameter
-Presentation usually 20-35yrs of age, respond to female hormones (oestrogen and progesterone) so regress after menopause
-Account for 13% of all palpable breast lesions
-In 18-25 year olds account for 60% of all palpable breast lesions.
-Core biopsy to confirm diagnosis. Complex fibroadenomas and a positive family history of breast cancer may indicate a higher risk.
-Excise if >3cm

Question 19

Describe breast cysts

Answer 19

-Breast cysts are benign, individual, fluid-filled lumps. They are the most common cause of breast lumps and occur most often between ages 30 and 50, more so in the perimenopausal period. They can be painful and may fluctuate in size over the menstrual cycle.
-15% of all palpable breast lumps.
-Most are impalpable, asymptomatic, and are found incidentally.
-Caused by distended involuted lobules.
-Palpable cysts are smooth, soft or firm, may be painful. Well-circumscribed, mobile, possibly fluctuant.
-May appear rapidly.
-Diagnose with ultrasound / mammogram + aspiration
-Ensure complete aspiration and no residual solid nodules within cyst
-Having a breast cyst may slightly increase the risk of breast cancer.

Question 20

Describe gynaecomastia

Answer 20

-Benign enlargement of the male breast resulting from the glandular component of the breast (compare with pseudogynaecomastia)
-Common
-Rarely associated with significant pathology
-Often a manifestation of a systemic condition
-Rubbery or firm mass extending concentrically from the nipples.
-Usually bilateral

Question 21

Aetiology of gynaecomastia

Answer 21

-Age (puberty / old age)
-Drugs (opiates, cannabis, alcohol, steroids, digoxin, spironolactone, captopril, enalapril, amiodarone, nifedipine, verapamil, cimetidine, ranitidine, omeprazole, ketoconazole, metronidazole, minocycline, diazepam, allopurinol, domperidone, metaclopramide, penicillamine, phenytoin, theophylline, goserelin)
-Liver disease
-Tumours (pituitary, testicle, lung)

Question 22

Investigation of gynaecomastia

Answer 22

-General examination / breasts / axilla / liver / testes
-Mammograms aged >40
-Ultrasound if discrete lump present
-Core biopsy any discrete lesion
-Bloods only in those aged 18-60 without obvious cause from history and examination and significant enlargement of breast tissue (U+Es, LFTs, LH, FSH, testosterone, prolactin, alpha-fetoprotein and beta HCG)

Question 23

Management of gynaecomastia

Answer 23

-Identify and treat any underlying cause.
-Pubertal gynaecomastia usually resolves spontaneously (within 6 months to 2years) and therefore no intervention required.
-For idiopathic gynaecomastia, or residual gynaecomastia after treatment of underlying cause, medical or surgical treatment may be considered (and tried early).

Question 24

Overview of breast abscess

Answer 24

-A breast abscess is a collection of pus within an area of the breast, usually caused by a bacterial infection. This may be a:
=Lactational abscess (associated with breastfeeding)
=Non-lactational abscess (unrelated to breastfeeding)

-RF: smoking, damage to nipple (eczema, candida infection, piercing), underlying breast disease affects drainage of breast

-Presentation of mastitis:
=Nipple changes, purulent discharge, localised pain, tenderness, warmth, erythema, hardening of sin or breast tissue, swelling
-Presentation of abscess:
=Swollen, fluctuant tender lump, muscle aches, fatigue, fever, signs of sepsis

-Diagnosis: clinical

-Management:
=Lactational: conservative so continued breastfeeding, expressing milk, breast massage, heat packs, warm showers, simple analgesia, flucloxacillin or erythromycin/ clarithromycin 10-14 days
=Non-lactational: analgesia, antibiotics (co-amoxiclav/ erythromycin or clarithromycin plus metronidazole), treatment for underling cause
=Abscess: referral to on call surgical team, antibiotic, USS, drainage (needle aspiration or surgical incision and drainage), microscopy culture ad sensitivities

Question 25

Causes of breast infection

Answer 25

-Lactational
=Usually in early weeks postpartum(poor latch, nipple trauma, milk stasis)

-Non-lactational
=Often associated with smoking
=Periductal infection
=Often chronic and difficult to treat

-Skin e.g. sebaceous cyst
=Unrelated to breast
=Treat as you would anywhere else in body

Staphylococcus aureus (the most common)
Streptococcal species
Enterococcal species
Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci)

Question 26

Describe Phyllodes tumour

Answer 26

-Phyllodes tumours are rare tumours of the connective tissue (periductal stomal cells) of the breast, occurring most often between ages 40 and 50.
-They are large and fast-growing.
-They can be benign (~50%), borderline (~25%) or malignant (~25%). Malignant phyllodes tumours can metastasise.
-All regarded as having malignant potential.
-Treatment is excision(chemotherapy and radiotherapy not effective). Treatment involves surgical removal of the tumour and the surrounding tissue (“wide excision”). They can reoccur after removal. Chemotherapy may be used in malignant or metastatic tumours

Question 27

Describe fibrocystic breast changes

Answer 27

-Fibrocystic breast changes were previously called fibrocystic breast disease. However, fibrocystic breast changes, and generalised lumpiness to the breast, is considered a variation of normal and not a disease. The connective tissues (stroma), ducts and lobules of the breast respond to the female sex hormones (oestrogen and progesterone), becoming fibrous (irregular and hard) and cystic (fluid-filled). These changes fluctuate with the menstrual cycle.

-It is a benign (non-cancerous) condition, although it can vary in severity and significantly affect the patient’s quality of life if severe. It is common in women of menstruating age. Symptoms often occur prior to menstruating (within 10 days) and resolve once menstruation begins. Symptoms usually improve or resolve after menopause.

-Symptoms can affect different areas of the breast, or both breasts, with:
=Lumpiness
=Breast pain or tenderness (mastalgia)
=Fluctuation of breast size

Management of fibrocystic breast changes is to exclude cancer and manage symptoms. Options to manage cyclical breast pain (mastalgia) include:
=Wearing a supportive bra
=Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen
=Avoiding caffeine is commonly recommended
=Applying heat to the area
=Hormonal treatments (e.g., danazol and tamoxifen) under specialist guidance

Question 28

Describe fat necrosis

Answer 28

-Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast. It may be associated with an oil cyst, containing liquid fat. Fat necrosis is commonly triggered by localised trauma, radiotherapy or surgery, with an inflammatory reaction resulting in fibrosis and necrosis (death) of the fat tissue. It does not increase the risk of breast cancer. Obese women with large breasts.

-On examination, fat necrosis can be:
=Painless
=Firm
=Irregular
=Fixed in local structures
=There may be skin dimpling or nipple inversion

-Ultrasound or mammogram can show a similar appearance to breast cancer. Histology (by fine needle aspiration or core biopsy) may be required to confirm the diagnosis and exclude breast cancer.

-After excluding breast cancer, fat necrosis is usually treated conservatively. It may resolve spontaneously with time. Surgical excision may be used if required for symptoms

Question 29

Describe lipoma

Answer 29

-Lipomas are benign tumours of fat (adipose) tissue. They can occur almost anywhere on the body where there is adipose tissue, including the breasts.

-On examination, lipomas are typically:
=Soft
=Painless
=Mobile
=Do not cause skin changes

-They are typically treated conservatively with reassurance. Alternatively, they can be surgically removed.

Question 30

Describe Galactocele

Answer 30

Galactoceles occur in women that are lactating (producing breast milk), often after stopping breastfeeding. They are breast milk filled cysts that occur when the lactiferous duct is blocked, preventing the gland from draining milk. They present with a firm, mobile, painless lump, usually beneath the areola. They are benign and usually resolve without any treatment. It is possible to drain them with a needle. Rarely, they can become infected and require antibiotics

Question 31

Breast anatomy

Answer 31

The breasts sit in front of the chest wall, which contains the ribs and pectoral muscles. Most of the breast is adipose (fatty) tissue. The areola surrounds the nipple. Behind the nipple are the ducts, which lead into the lobules, where breast milk is produced. Milk is secreted through the ducts and out of openings on the nipple.

Question 32

Raynaud’s disease of the nipple

Answer 32

In Raynaud’s disease of the nipple, pain is often intermittent and present during and immediately after feeding. Blanching of the nipple may be followed by cyanosis and/or erythema. Nipple pain resolves when nipples return to normal colour.

Options of treatment for Raynaud’s disease of the nipple include advice on minimising exposure to cold, use of heat packs following a breastfeed, avoiding caffeine and stopping smoking. If symptoms persist consider specialist referral for a trial of oral nifedipine (off-license).