Breast Presentations

Question 1

What is mastalgia? How can it be classified?

Answer 1

Breast pain
Malignancy risk low
Assessment

Cyclical - most common, bilateral, few days before mensuration/ HRT
Non-cyclical - 1/3m medications (contraceptives, anti-depressants/ psychotics)
Extramammary - chest wall/ shoulder

Not indicated for imaging
Pregnancy test

Question 2

If someone presents with mastalgia what should you ask about?

Answer 2

Lumps
Skin changes 
Fevers
Discharge 
Association menstrual cycle 
Trauma
PMH
PDH 
Pregnancy
🚩

Question 3

Management of mastalgia

Answer 3

Pain control - ibuprofen, paracetamol, topical NSAIDs

Cyclical - better fitting bra, soft supporting bra night

If unsuccessful -> refer specialist
Second line: danazol (anti-gonadotropin agent) ❌weight gain, nausea, dizzy

Question 4

What does the breast triple assessment involve?

Answer 4

Hospital based clinic - 2WW referral or suspicious mammography

• history and examination
• full breast examination
• imaging (mammography/ USS <35yrs + men)
• histology (mostly core)
• > grade
• > MDT

Question 5

When would you use a mammogram over an USS?

Answer 5

Men + women <35 = USS

Mammogram (X-rays) works better for less ho,IgE UOS & less dense tissue

MRI - lobular breast cancer + assessing response neoadjuvant therapy

Question 6

When is a core biopsy, FNA & vAC-aspiration used?

Answer 6

Core - mostly, can assess architecture invasive or not

FNA - just cytology, LNS, second lumps, clinically cyst like structure

VAC - not sure where lesion begins and ends

Question 7

Triple assessment grading system

Answer 7

Examination = P
P1 normal
P2 benign 
P3 uncertain 
P4 suspicious 
P5 malignant 

Imaging = Mammography / Ultrasound 
M1/U1 normal
2 benign
3 uncertain 
4 suspicious
5 malignant 

Histology = B

Question 8

What is galactorrhoea?

Answer 8

Copious, bilateral, multi-ductal, milky discharge not associated pregnancy or lactation (6-12months after pregnancy & cessation breastfeeding)

Question 9

How is lactation regulated?

Answer 9

Predominantly by the hormone prolactin - produced & secreted anterior pituitary gland

Controlled dopamine from hypothalamus - inhibits prolactin

TRH & oestrogen - stimulate prolactin from pituitary

Question 10

Hyperprolactinemia is the most common cause of galactorrhoea. What are some causes of hyperprolactinemia galactorrhoea?

Answer 10

• idiopathic 40%
• pituitary adenoma (prolactinomas)
• drug induced (SSRIs, anti-psychotics, H2 antagonists)
• neurological (PWs activated to inhibit D2 levels e.g. varicella zoster infection or spinal cord injury)
• hypothyroidism (elevated TRH can stimulate prolactin, association: cushing’s/ acromegaly/ Addison’s)
• renal F
• liver F
• damage pituitary stalk (surgical resection, Ms, sarcoidosis, Tb)

Question 11

What is normoprolactinaemic galactorrhoea?

Answer 11

Less common & typically idiopathic

Diagnosis of exclusion e.g. normal blood markers & regular menstruation
Reassured & observed

Question 12

Investigations for galactorrhoea

Answer 12

• Sudan IV stain for fat droplets in discharge confirm (rarely used)
• exclude pregnancy
• serum prolactin levels (>1000mU/L absence drug cause suggests prolactinoma)
• thyroid function
• liver function
• renal function
• potentially further endocrine tests (IgF-1, ACTH)
• MRI + contrast (suspect pituitary tumour)
• breast imaging (palpable lumps)

Question 13

Treatment for galactorrhoea

Answer 13

Identify cause

Pituitary tumour - dopamine agonists therapy e.g. cabergoline/ bromocriptine
-> referral neurosurgery

Idiopathic normoprolactinaemic galactorrhoea often resolves, persists trail low dose dopamine agonists

Troublesome, intolerant meds - bilateral total duct excision