Breast - Lumps, Cysts, Abscesses, Mammary Duct Ectasia Flashcards
Criteria to refer someone onto 2 week wait suspected breast cancer pathway?
- 30 and over with UNEXPLAINED breast lump (with or without pain)
- 30 and over with UNEXPLAINED lump in AXILLA
- 50 and over with UNILATERAL changes in the nipple - discharge, retraction, other changes of concern
- SKIN CHANGES on breast suggestive of breast cancer
Fibroadenoma - what is it?
Most common benign tumour of the stromal/epithelial breast duct tissue
Fibroadenoma - what is the feel of the fibroadenoma within the breast?
Small, <3cm, painless, firm, mobile lumps
Referred to as breast mice, as they move around within the breast tissue
Fibroadenoma - what age do they commonly present in?
Young women (15-40)
Due to them responding to the female hormones (oestrogen and progesterone) - why they are more common in younger women and often regress after menopause
Fibroadenoma - what happens to them over time?
50% - regress spontaneously
25% - remain unchanged
25% - get bigger
Fibrocystic Breast Changes - what is it?
Benign
Connective tissue (stroma), ducts and lobules of breast, respond to oestrogen and progesterone, become fibrous (irregular and hard) and cystic, and it fluctuates with the menstrual cycle
Fibrocystic Breast Changes - when does it commonly occur and in which women?
Common in women of menstruating age
Symptoms often start prior to menstruation, and resolve once menstruation has finished
Fibrocystic Breast Changes - what are the symptoms?
- Lumpiness
- Breast pain or tenderness (mastalgia)
- Fluctuation of breast size
Fibrocystic Breast Changes - management?
Management involves exlcuding cancer,
Managing cyclical breast pain (mastalgia) symptoms:
- Wearing a supportive bra
- NSAIDs
- Avoid caffeine
- Applying heat to the area
Breast cysts - what are they?
Benign, individual, fluid-filled lumps
Breast cysts - what age and when do they most commonly occur in?
Women aged 30-50
Perimenopausal period
Breast cysts - what is the presentation?
Smooth, well-circumcised, mobile
Painful
Fluctuate in size over menstrual cycle
Breast cysts - how can you manage the pain?
Aspiration can help pain, whilst also helping to exclude breast cancer
Fat necrosis - what is it?
Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast
Fat necrosis - what are the causes?
Trauma
Radiotherapy
Surgery
Fat necrosis - presentation within breast?
Painless, frim and irregular
FIXED in local structures
There may be skin dimpling or nipple inversion
Fat necrosis - investigations you may need to do?
USS and mammogram may show similar appearance to breast cancer (BC)
Therefore need to do histology (by fine needle aspiration or core biopsy) to exclude BC
Fat necrosis - management?
Conservative management
Resolve spontaneously with time
Symptomatic - excision
Galactocele - what is it?
After stopping breastfeeding, lactiferous duct gets blocked, so can’t drain
Forms breast milk filled cysts
BENIGN
Galactocele - how do they present?
Firm, painless, mobile
Galactocele - management?
Usually resolve without any treatment
Can drain them with a needle
Rare - become infected and require abx
Phyllodes tumour - what is it?
Tumours of the connective tissue (stroma) that are large and fast growing
‘Leaf-like pattern’
Phyllodes tumour - what proportion are benign, borderline, and malignant?
50% benign
25% borderline
25% malignant (can also metastasise)
Phyllodes tumour - management?
Wide excision - removal of tumour and surrounding tissue
Chemo - malignant/metastasised tumours
Intraductal Papilloma - what is it?
Warty lesion that grows in a breast duct
Result of proliferation of epithelial cells
Intraductal Papilloma - what is the typical presentation?
Clear or blood-stained discharge
Tenderness or pain
Palpable lump
Intraductal Papilloma - investigations?
Triple assessment: 1. Clinical assessment 2. Imaging 3. Histology To exclude cancer
Ductography - inject contrast into abnormal duct and perform a mammogram to visualise - papilloma seen as area that does not fill with contrast (a “filling defect”).
Intraductal papilloma - management?
Complete surgical excision
Lactational Mastitis - what is mastitis?
Inflammation of breast tissue
Lactational Mastitis - what are the causes of mastitis?
Obstruction - in ducts, accumulation of milk, milk stasis
Infection - bacteria enters at nipple, back-tracks to ducts, most common S.AUREUS
Lactational Mastitis - what is the presentation?
Pain and tenderness (unilateral)
Erythema in a focal area of breast tissue
Hot and swollen
Nipple discharge
Fever - when bacterial infection is the cause
Lactational Mastitis - management?
Obstruction - conservative, hot compress, analgesia, express milk regularly, continue breastfeeding
Infection - 1ST LINE: FLUCLOXACILLIN as Staph Aureus, (500mg QDS 10-14 days), penicillin allergy: erythromycin
Lactational Mastitis - should women continue breastfeeding their babies?
Women should be encouraged to continue breastfeeding, even when an infection is suspected
It will not harm the baby and will help to clear the mastitis by encouraging flow
Lactational Mastitis - what is a rare complication?
If not adequately treated - breast abscess
Breast Abscess - what is it?
Collection of pus within an area of the breast, usually caused by a bacterial infection
Breast Abscess - what are the two types of abscesses?
Lactational abscess (associated with breastfeeding)
Non-lactational abscess (unrelated to breastfeeding)
Breast Abscess - presentation?
Acute - few days
Nipple changes Purulent nipple discharge Localised pain Tenderness Warmth Erythema Swelling
Key feature - FLUCTUANT, being able to move fluid around within the lump using pressure during palpation
Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid
Breast Abscess - management?
Management of a breast abscess requires:
Referral to the on-call surgical team in the hospital for management
Antibiotics
Ultrasound (confirm the diagnosis and exclude other pathology)
Drainage (needle aspiration or surgical incision and drainage)
Microscopy, culture and sensitivities of the drained fluid
Breast Abscess - what antibiotics would you give?
Antibiotics for non-lactational mastitis need to be broad-spectrum
- Co-amoxiclav
- Erythromycin/clarithromycin plus metronidazole
Mammary Duct Ectasia - what is it?
Benign condition, dilation of the large ducts in the breasts
Ectasia means dilation
Inflammation in the ducts, leading to intermittent discharge from the nipple
The discharge may be white, grey or green
Mammary Duct Ectasia - presentation?
Nipple discharge
Tenderness or pain
Nipple retraction or inversion
A breast lump (pressure on the lump may produce nipple discharge)
Mammary Duct Ectasia - investigations?
Need to exclude breast cancer, so triple assessment:
- Clinical assessment
- Imaging
- Histology
Microcalcifications are a key finding on a mammogram
Other Ix:
- Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct
- Nipple discharge cytology
- Ductoscopy – inserting a tiny endoscope (camera) into the duct
Mammary Duct Ectasia - management?
Mammary duct ectasia may resolve without any treatment
- Reassurance after excluding cancer may be all that is required
- Symptomatic Rx of mastalgia (supportive bra and warm compresses)
- Abx if infection suspected or present
- Surgical excision of the affected duct (microdochectomy)
What antibiotics do you give in non-lactational mastitis and lactational mastitis?
Non-lactational mastitis gets co-amoxiclav, lactational mastitis gets flucloxacillin
