Breast lump differentials Flashcards
What is the most common cause of breast masses
Fibroadenoma
Normal changes to the breasts during pregnancy and breast-feeding
Tenderness, discomfort or pain
Increase in size
Areolar and nipple changes(darkening of colour, enlargement of nipples, enlargement of the montgomery glands on the areola)
Leaking of colostrum or milk
Normal changes to the breasts during pregnancy and breast-feeding
Tenderness, discomfort or pain
Increase in size
Areolar and nipple changes(darkening of colour, enlargement of nipples, enlargement of the montgomery glands on the areola)
Leaking of colostrum or milk
What are fibroadenomas
Arise in breast lobules and are composed of fibrous and epithelial tissue
Hormones seem to be involved in aetiology, and HRT increases incidence
Fibroadenomas features
Firm, non-tender, highly mobile palpable lumps
What are complex and multiple fibroadenomas associated with
Increase in risk of breast cancer
First line imaging investigation for breast lump
Ultrasound before age 40
Mammogram above 40
What are phyllodes tumours
Rare growths of breast that can have benign or malignant characteristics which present as a rapidly growing, painless breast mass
Which factors are associated with an increased risk of local recurrence for phyllodes tumours
Increased cellularity
Atypia
Mitoses
Positive margins
What is a fibrocystic breast
Spectrum of patholoigcal changes to include epithelial hyperplasia, apocrine metaplasia, and cystic dilation and fibrosis
Which population are commonly affected by benign breast cysts
Premenopausal and perimenopausal women
Features of breast cysts
Characteristically mobile and have distinct borders on exam
Sometimes tender and can fluctuate with the menstrual cycle
What does breast fat necrosis occur secondary to
Injury of the breast
Source may be iatrogenic(e.g. breast biopsy, breast reduction or augmentation) or traumatic(seat belt injury)
How do breast fat necrosis lesions present
Hard, fixed masses and demonstrate acoustic shadowing on ultrasound - characteristics suspicious for malignancy that mandate biopsy
What are breast papillomas
Typically benign, but they can be associated with histological findings of atypia, papillary ductal carcinoma in situ(DCIS) or invasive papillary cancer
Presentation of breast papilloma
Blood nipple discharge
Detected as a mass within the breast
Who does breast abscesses typically occur in
Women who are breastfeeding
Thought to result from ruptured sub-areolar ducts that leak into the periductal space
Genes implicated in breast cancer
BRCA-1 and BRCA-2 mutations are more common in women with a family history of: breast cancer before age 50 years, bilateral breast cancer, breast and ovarian cancer in the same relative, male breast cancer
Ashkenazi jewish ancestry
What should a family history include with regards to eliciting risk of breast cancer
any family members with cancer primary cancer site whether affected relative had multiple primary cancers age of diagnosis age at death and sex
Characteristic features of breast examination indicative of malignancy
Irregular fixed masses Skin thickening(peau d'orange) Nipple changes Enlarged axillae and regional lymph nodes Variation in breast size Dimpling or retraction of skin Nipple inversion
What is nipple inversion or excoriation associated with
Paget’s disease of the breast
When should a person with a breast lump be referred for an urgent assessment by a breast specialist
Women > 30 years with an unexplained breast lump should be referred for an urgent(within 2 weeks) assessment by a breast specialist
Unilateral nipple changes in patients aged above 50
Why should aspirated cyst fluid not be sent for cytology
With the exception of bloody cystic fluid, malignant cells are generally not identified
What may mastitis be associated with
Lactation
Management of mastitis associated with lactation
Warm compresses and analgesia such as ibuprofen/paracetamol
Encourage to continue breast feeding
Penicillianse-resistant antibiotic such as flucloxacillin
Incision and drainage in the event of an abscess
Swabs should be sent for culture
What are spontaneous peripheral abscesses in non-lactating women associated with
Diabetes and immune compromise
Smoking and nipple rings can predispose to non-lactational mastitis
Features of cyclical mastalgia
Tenderness and nodularity of the breasts in the premenstrual phase
Rapidly resolves as menstruation starts
Management of fibrocysts
Analgesia Good well-fitting bra Avoid caffeine Applying heat to the area Hormonal treatments(tamoxifen) under specialist guidance
Management of intraductal papilloma
Triple assessment with examination, imaging and biopsy in a specialist breast clinic
What is duct ectasia
Dilatation and shortening of the terminal breast ducts within 3 cm of the nipple
How does duct ectasia present
Nipple retraction and occasionally creamy nipple discharge
Management of duct ectasia
Patients with troublesome discharge may be treated by microdochectomy(if young) or total duct excision(if older)
In which population are fibroadenomas more common in
Younger women aged between 20 to 40 years
When do fibrocystic breast changes tend to occur
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.
Features of breast cysts
Smooth
Well-circumscribed
Mobile
Possibly fluctuant
Management of breast cysts
Breasts cysts require further assessment to exclude cancer, with imaging and potentially aspiration or excision.
Aspiration can resolve symptoms in patients with pain.
Having a breast cyst may slightly increase the risk of breast cancer.
What is tamoxifen
Selective oEstrogen Receptor Modulator (SERM) which acts as an oestrogen receptor antagonist and partial agonist. It is used in the management of oestrogen receptor positive breast cancer
Adverse effects of tamoxifen
menstrual disturbance: vaginal bleeding, amenorrhoea
hot flushes - 3% of patients stop taking tamoxifen due to climacteric side-effects
venous thromboembolism
endometrial cancer
What causes gynaecomastia
hormonal imbalance between oestrogen and androgens (e.g., testosterone), with higher oestrogen and lower androgen levels
Also raised prolactin
Idiopathic
Physiological(adolescents)
Which conditions can increase oestrogen levels in males to cause gynaecomastia
Obesity (aromatase is an enzyme found in adipose tissue that converts androgens to oestrogen)
Liver cirrhosis and liver failure
Hyperthyroidism
Tumours associated with gynaecomastia
Testicular cancer (oestrogen secretion from a Leydig cell tumour)
Human chorionic gonadotrophin (hCG) secreting tumour, notably small cell lung cancer
Medications which can cause gynaecomastia
Anabolic steroids Antipsychotics Digoxin Spironolactone marijuana opioids
Which conditions reduce testosterone to cause gynaecomastia
Testosterone deficiency in older age
Hypothalamus or pituitary conditions that reduce LH and FSH levels (e.g., tumours, radiotherapy or surgery)
Klinefelter syndrome (XXY )
Orchitis (inflammation of the testicles, e.g., infection with mumps)
Testicular damage
Mx of gynaecomastia
Resolves with time in adolescents
Stop causative drug
Tamoxifen
Surgery
Most common type of breast cancer
DCIS
Mx of DCIS
Complete wide excision
Widespread or multifocal DCIS requires complete mastectomy
Surgical options for breast cancer
Breast conserving - wide local excision
Mastectomy
Axillary surgery - Sentinel node biopsy, axillary node clearance
Complications of axillary node clearance
paraesthesia, seroma formation, and lymphedema in the upper limb
Risk factors for breast cancer
Female Age BRCA1 and 2 Family history Exposure to unopposed oestrogen early menarche
How can paget’s disease be differentiated from eczema
Paget’s always affects the nipple and only involves the areola as a secondary event
Eczema nearly always involves the areola and spares the nipple
Mx of Paget’s disease of breast
Surgical
Radiotherapy if malignancy associated
Criteria for primary breast cancer prognosis
Nottingham prognostic index
