Breast Disorders

Question 1

A localized collection of inflammatory exudate in the breast tissue?

Answer 1

Breast Abscess.

Question 2

What is a common cause of a breast abscess?

Answer 2

Develops most commonly when mastitis or cellulitis does not respond to Abx treatment; an abscess can also be the first presentation of breast infection.

Question 3

Epidemiology of a Breast Abscess?

Answer 3

1. Uncommon; 0.1% incidence and 3% in women with Abx-treated mastitis.
2. Incidence ranges from 0.4-11% of lactating mothers.
3. Occurs more frequently in AAs, obesity,, smokers.

Question 4

Risk factors for Breast Abscess?

Answer 4

1. Maternal age >30 yrs.
2. 1st pregnancy.
3. Gestational age > 41 wks.
4. Smoking – only factor assoc. w/abscess recurrence.

Question 5

What are the classifications of Non-lactational abscesses?

Answer 5

1. Central due to periductal mastitis.
2. Peripheral (< central); sometimes assoc. w/underlying conditions – DM, RA, Steroid Tx, Trauma.
3. Skin.

Question 6

What is the clinical presentation of a breast abscess?

Answer 6

1. Localized, painful inflammation of the breast with fever and malaise.
2. Fluctuant, tender, palpable mass.
3. Time of onset is variable; mastitis and abscess can present together or abscess develops 5-28 days following Tx for mastitis.

Question 7

Diagnosis of a breast abscess?

Answer 7

1. Clinical Dx based on clinical manifestations.
2. U/S can demonstrate a fluid collection and guide aspiration.
3. Women lactating, culture of breast milk is useful to guide Abx selection if no pus obtained.
   - -Severe, Hospital acquired or unresponsive to Abx.
4. Blood cultures warranted in the setting of severe infection, but otherwise not routinely used.

Question 8

DDx of a breast abscess?

Answer 8

1. Skin abscess overlying breast.
2. Inflammatory breast cancer or other breast malignancy.
3. Paget disease of the breast.
4. Superficial thrombophlebitis of breast (Mondor Dz).
5. Morphea – localized scleroderma.
6. Postoperative derma lymphadema.
7. Radiation-induced dermatitis or fibrosis.
8. Spontaneous gangrene of breast.
9. Bite wound.

Question 9

Management of a breast abscess?

Answer 9

**Depends in part on the state of the overlying skin.

1. Nonischemic skin – US guided aspiration under local anesthesia.
   - -May have to repeat aspiration Q2-3 days till no collection remains, usually 2-3 aspirations.
2. Ischemic skin – surgical I and D.

Question 10

Antibiotic management of a breast abscess?

Answer 10

1. Empiric Abx therapy should cover activity of Staph. Aureus.
   - -MRSA not suspected: Dicloxacillin or Cephalexin; clindamycin as alt.
   - -MRSA suspected: Bactrim or Clindamycin.
2. Severe Infections – Inpatient; Vancomycin.
3. 10-14 days following drainage.

Question 11

What are some Abx used in a subareolar breast abscess with a retracted nipple or breast abscess assoc. w/hidradenitis suppurativa?

Answer 11

Augmentin, Clindamycin or Dicloxacillin + Metronidazole.

Question 12

What is the possible anaerobic involved in a subareolar breast abscess with a retracted nipple or breast abscess assoc. w/hidradenitis suppurativa?

Answer 12

An anaerobic infection.

Question 13

What is the most common non-cancerous, benign tumor or mass of the breast?

Answer 13

Fibroadenoma.

Question 14

What breast disorder accounts for 1/2 of all breast biopsies?

Answer 14

Fibroadenoma.

Question 15

What is contained in a fibroadenoma?

Answer 15

Benign solid tumors containing glandular, as well as fibrous tissue.

Question 16

What is the epidemiology and cause of fibroadenomas?

Answer 16

1. MC found in women b/t ages 15-35 yrs.
2. Cause may have a hormonal relationship esp. if they persist during reproductive years, increase in size during pregnancy or w/estrogen therapy, and regress after menopause.

Question 17

Risk factors for a Fibroadenoma?

Answer 17

1. Histologic features of fibroadenoma influence risk of breast cancer.
2. The risk of subsequent breast cancer is slightly elevate if: complex, adjacent proliferative Dz, FH of breast cancer.
3. Majority of women with simple fibroadenomas, no risk of developing breast cancer.

Question 18

Clinical presentation of fibroadenomas?

Answer 18

1. Lump in the breast, smooth to touch and mobile.
2. Painless, but can be tender to the touch.
3. Well-defined, mobile mass on PE.

Question 19

Evaluation and diagnosis of a fibroadenoma?

Answer 19

1. Imaging – mammogram or U/S to further characterize the lesion.
2. DEFINITIVE – core biopsy or excision.
3. Excision mandated if increased in size or symptomatic to r/o malignant change and confirm Dx.
4. Rapid growth of a lesion raises the suspicion for phyllodes tumor.

Question 20

Treatment and management of a fibroadenoma?

Answer 20

1. If < 3 cm, observation; can monitor w/routine breast exams and U/S if changes.

Question 21

What is a phyllodes tumor?

Answer 21

Rare breast tumors that start in the connective tissue and are most common in women in their 30s and 40s.

Question 22

DDx of a fibroadenoma?

Answer 22

BENIGN:

1. Fibroadenoma.
2. Cyst.
3. Fibrocystic changes.
4. Galactocele.
5. Fat necrosis, from trauma to breast.
6. Abscess.

MALIGNANT:

1. Infiltrating ductal breast carcinoma.
2. Infiltrating lobular carcinoma.
3. Mixed ductal/lobular carcinoma.
4. Ductal carcinoma in situ.

Question 23

Management and treatment of a fibroadenoma?

Answer 23

1. Watchful waiting; 3-6 mo f/u w/repeat U/S and breast exam.
2. Core needle biopsy.
3. If Bx proven Fibroadenoma and asymptomatic, can be left in place (some women prefer to have it excised).
4. Excision:
   - -Fibroadenoma > 3 cm.
   - -Increasing in size > 1 cm/yr.
   - -Bothersome (interfere w/ADLs or emotional stress).
5. Cryoablation, alt Tx to surgical excision, only after core Bx diagnosis of fibroadenoma.

Question 24

What is the most common breast condition in women of reproductive years?

Answer 24

Fibrocystic Changes.

*NOT associated with an increased risk of breast cancer.

Question 25

Fibrous tissue similar to scar tissue that is FIRM and RUBBERY, along w/fluid-filled sacs, mostly microscopic but can become macrocysts?

Answer 25

Fibrocystic changes.

Question 26

Epidemiology of fibrocystic changes?

Answer 26

1. Peak incidence b/t 35-50 y/o. 2. Influenced by hormonal function and fluctuation. - -Occurs during lobular development, menstrual cycle changes, and lobular involution in premenopausal and perimenopausal women.

Question 27

What can fluctuating hormone levels during your menstrual cycle cause?

Answer 27

Breast discomfort and areas of lumpy breast tissue that feel tender, sore and swollen.

Question 28

What is the clinical presentation of fibrocystic changes?

Answer 28

1. Particularly common in premenopausal women. 2. Breast tissue more diffuse and tender; does not form a discrete or well-defined mass. 3. May be cyclic or constant and may be bilateral, unilateral or focal. The breast tissue, particularity in the upper quadrant, may increase in size prior to menses then return to baseline after the onset of menstrual flow. 5. On PE, breast tissue frequently is nodular.

Question 29

Evaluation and diagnostics of fibrocystic changes?

Answer 29

1. H and P is the most important aspect of evaluation. 2. Breast U/S can provide information about whether the breast cyst is simple, complicated and complex. 3. Mammography. 4. MRI.

Question 30

Differential diagnosis of fibrocystic changes?

Answer 30

Fibroadenoma, Cysts (simple and complex), Galactocele, Fat necrosis, breast abscess, malignancy.

Question 31

Management of fibrocystic changes?

Answer 31

1. MOST cases require NO treatment and reassurance. 2. If imaging obtained, most are BI-RADS2 (Benign) and do not warrant tissue diagnosis. 3. Symptom relief: - -Warm compresses, well-fitting supportive bra, NSAIDs, reduce caffeine/stimulant intake. 4. Routine f/u. 5. Consider OCP to modulate Sx or to prevent development of new changes.

Question 32

What is the condition of benign proliferation of the glandular tissue of the male breast, which can be unilateral and bilateral?

Answer 32

Gynecomastia.

Question 33

What is the cause of Gynecomastia?

Answer 33

Due to an increase in the ratio of estrogen to androgen activity.

Question 34

Epidemiology of Gyncecomastia?

Answer 34

1. Common in infancy, puberty and in middle-age to older men. 2. Primary peak in infancy. 3. Secondary peak during puberty. - -Onset b/t 10-12 yrs and peaks b/t 13-14, usually Tanner Stage 3. 4. Tertiary peak occurs in middle-aged and older men.

Question 35

What percentage of Gynecomastia can persist into adulthood?

Answer 35

20%.

Question 36

When age group does the incidence of tertiary gynecomastia occur?

Answer 36

Highest prevalence at 50-80 yrs, with as many as many as 24-64% of men being affected.

Question 37

Risk factors for Gynecomastia?

Answer 37

1. Persistent pubertal gynecomastia - 25% 2. Drugs 10-25%. 3. Idiopathic - 25%. 4. Cirrhosis or malnutrition - 8%. 5. Hypogonadism - Primary 8%, secondary 2%. 6. Testicular tumors - 3%. 7. Hyperthyroidism - 1.5%. 8. CKD - 1%.

Question 38

Condition where breast enlargement is caused by fat accumulation?

Answer 38

Pseudogynecomastia.

Question 39

What is the clinical presentation of Gynecomastia?

Answer 39

1. Usually found incidentally. 2. Adolescents may present w/PAINFUL, TENDER Gynecomastia. 3. PE in true Gynecomastia, a ridge of glandular tissue will be felt that is symmetrical to the nipple-areolar complex. 4. Can usually be detected when the size of the glandular tissue exceeds 0.5 cm in diameter. - -Centrally located, symmetrical in shape, usually bilateral and tender to palpation (during the early growth phase).

Question 40

Evaluation of Gynecomastia?

Answer 40

1. History! 2. Review meds, OTC meds, dietary supps and herbal products. 3. Review Hx for Sx of liver and kidney disease, overt hyperthyroidism and hypogonadism. 4. Imaging is not routinely recommended unless concern for breast cancer. 5. Usual imaging -- mammography and U/S. - -U/S most specific. - -Mammo difficult to perform unless significant gynecomastia; is the most sensitive modality.

Question 41

What is the main PE finding of gynecomastia?

Answer 41

A concentric, rubbery to firm disk of tissue, often mobile; and located directly beneath the areolar area.

Question 42

When is there a concern for breast cancer in Gynecomastia evaluation?

Answer 42

With a new onset or rapid growth of a unilateral, nontender, and/or fixed mass that is ECCENTRIC to an areola.

Question 43

When is Biochemical Testing or hormone testing necessary in the evaluation of Gynecomastia?

Answer 43

1. If the gynecomastia is of RECENT ONSET, is PAINFUL or TENDER, or is GREATER than 5 cm -- serum hCG, FSH, LH, Testosterone and estradiol should be evaluated for tumors. 2. In Middle-age to older men -- morning serum total testosterone -- repeat if low -- if low, then order FSH, LH.

Question 44

DDx of Gynecomastia?

Answer 44

1. Pseudogynecomastia. | 2. Breast cancer.

Question 45

Management of Gynecomastia?

Answer 45

1. Watchful waiting -- recent onset often regresses spontaneously. 2. D/C of medications. 3. Early medical therapy - -Significant breast enlargement >4 cm in young men. - -Pain, tenderness, cosmetic concerns. 4. Surgical intervention with persistent gynecomastia. - -Surgery effectively removes excess breast tissue at any time.

Question 46

What condition is defined as nonpathologic nipple discharge unrelated to pregnancy or breast feeding?

Answer 46

Galactorrhea or Physiologic nipple discharge.

Question 47

What is the 3rd most common breast-related complaint, after breast pain and breast mass?

Answer 47

Galactorrhea; up to 80% of women will have an episode of nipple discharge.

Question 48

What must galactorrhea be differentiated from?

Answer 48

Galactorrhea (benign nipple discharge) must be differentiated from an underlying papilloma, high-risk lesion or cancer.

Question 49

What are the risk factors for Galactorrhea?

Answer 49

1. Age is predictive of the risk of cancer w/nipple discharge. 2. Malignancy in women: - -3% under < 40, 10% of those age 40-60 yrs, and 32% of those age over 60 yrs. 3. In men, nipple discharge is associated with an even higher incidence of breast cancer (23-57%), which may be their only clinical manifestation.

Question 50

What is the clinical presentation of Galactorrhea?

Answer 50

Nipple discharge.

Question 51

What is the most helpful in distinguishing physiologic from pathologic nipple discharge?

Answer 51

HISTORY! - Bloody vs Nonbloody, frequency, spontaneous or provoked, unilateral vs bilateral, uniductal vs multiductal. - Hx of recent trauma. - Recent onset of amenorrhea or other Sx of hypogonadism = hyperprolactinemia. - Med history.

Question 52

What indicates breast imaging and possible pathologic discharge of Galactorrhea?

Answer 52

1. Unilateral nipple discharge. 2. Blood nipple discharge. 3. Nipple discharge associated with a mass or skin lesion.

Question 53

Diagnostic evaluation of physiologic discharge?

Answer 53

1. Bilateral and NONbloody. 2. Possible eval for Hyperprolactinemia. 3. No specific imaging. 4. Lab eval -- preg test, prolactin levels, renal and TFTs. 5. Consider endo referral.

Question 54

What is the first line imaging if indicated in the evaluation of Galactorrhea?

Answer 54

1. Mammography. 2. U/S provides a useful tool for Dx of ductal disease. 3. MRI for pt's with pathologic nipple discharge but negative mammo and U/S.

Question 55

DDx of Galactorrhea?

Answer 55

1. Physiologic nipple discharge often caused by hyperprolactinemia. 2. Breast cancer -- invasive ductal cancer, papillary cancer, or ductal carcinoma in situ. 3. No identifiable lesion.

Question 56

Management of Galactorrhea?

Answer 56

1. D/C offending medication. 2. Tx of other causes of hyperprolactinemia. 3. Transient idiopathic galactorrhea (w/normal prolactin levels) can also occur, usually premenopausal women and can be reassessed in 2-3 months. 4. For non-lactating women or men with pathologic nipple discharge -- surgical mgmt depending on the result of the imaging studies and biopsy.

Question 57

What condition involves inflammation of the breast tissue that may or may not be accompanied by infection?

Answer 57

Mastitis. *Mastitis does not necessarily occur during lactation, is not always accompanied by microbial infection and may not resolve with Abx.

Question 58

What is the epidemiology of Mastitis?

Answer 58

1. Est. to occur in 2-10% of breastfeeding women. 2. The risk of recurrence of mastitis in women w/prior Hx of lactational mastitis is higher than in women with no prior history. 3. MC in the 1st 3 months of breastfeeding.

Question 59

What are the risk factors associated with Mastitis?

Answer 59

*Lactational mastitis often occurs in the setting of the below breastfeeding problems, which typically present in prolonged engorgement or poor drainage. - Partial blockage of milk duct (reduced drainage results in stagnant milk distal to the obstruction). - Oversupply of milk, infrequent feedings, nipple excoriation or cracking, rapid weaning, illness in mother or baby, maternal stress or excessive fatigue, maternal malnutrition. *Prior Hx of mastitis, poor milk drainage, cracked nipples, use of cream on nipples (antifungal cream) and using a breast pump.

Question 60

Clinical presentation of Mastitis?

Answer 60

1. Breast becomes painful and swollen. 2. Engorgement occurs because of poor milk drainage. 3. If Sx persist beyond 12-24 hrs, infective lactational mastitis develops. 5. Reactive Lymphadenopathy -- check the axilla and epitrochlear LNs.

Question 61

What happens if symptoms of mastitis persist beyond 12-24 hrs?

Answer 61

The condition of infective lactational mastitis develops since breast milk contains bacteria. **Firm, red, painful, swollen area of one breast associated with fever >38.3C and a nursing mother, milk secretion may be diminished, myalgia, chills, malaise, and flu-like symptoms.

Question 62

Diagnostic evaluation of mastitis?

Answer 62

1. Diagnosis is based on clinical manifestations; lab tests not needed. 2. Culture of the breast milk can be useful to guide selection of Abx. 3. Blood cultures. 4. Imaging is useful if lactational mastitis does not respond within 48-72 hrs to supportive care and Abx.

Question 63

When are blood cultures indicated in the evaluation of mastitis?

Answer 63

In the setting of severe infection -- hemodynamic instability, progressive erythema.

Question 64

What is the most effective method of differentiating mastitis from a breast abscess?

Answer 64

U/S.

Question 65

DDx of Mastitis?

Answer 65

1. Severe engorgement. 2. Breast abscess. 3. Plugged duct. 4. Galactocele. 5. Inflammatory breast cancer -- should be considered if mastitis does not resolve with appropriate treatment.

Question 66

How can lactational mastitis be reduced?

Answer 66

By frequent, complete emptying of the breast and by optimizing breastfeeding techniques.

Question 67

What is the most common cause of Infective Lactational mastitis?

Answer 67

1. Most episodes cause by Staphylococcus Aureus. | 2. MRSA has also become an important pathogen.

Question 68

Describe the management of mastitis?

Answer 68

1. Sx treatment to reduce pain and swelling (NSAIDs, cold compress) and complete emptying of the breast; cessation of lactation is not required. 2. Mgmt of infective Lactational mastitis -- Abx therapy. 3. No clinical improvement within 48-72 hrs, eval with U/S to determine if there is an underlying abscess should be pursued.

Question 69

What is the antibiotic management of mastitis?

Answer 69

Abx therapy should cover Staph Aureus. - NONSevere Infection in absence of RFs for MRSA -- Dicloxacillin or Cephalexin (Clindamycin or Erythromycin). - NONSevere infection with risk for MRSA -- Bactrim (if no breastfeeding) or Clindamycin. - Severe infection -- Vancomycin. - Tx for 10-14 days, shorter courses (5-7) if response to therapy is rapid and complete.