Breast Surgery: Non-Malignant Flashcards
What are types of Benign Breast Tumours?
- Fibroadenoma
- Adenoma
- Papilloma
- Lipoma
- Phyllodes Tumours
Describe the lesions in fibroadenomas and management?
Most common benign growth and occurs in women of reproductive age
- Highly mobile, well-defined and rubbery on palpation
- <5cm in diameter
- Can be multiple and bilateral
Managed by reassurance and observation unless symptomatic or >3cm.
What are Adenomas?
Benign glandular tumour typically occurring in older female population
What are Papillomas?
- Breast lesions occurring in female in their 40-50s
- Occur mostly in subareolar region
- Presents with bloody or clear nipple discharge.
- Large papillomas initially have a mass
How are Papillomas managed?
- Appear similar to ductal carcinoma on imaging and usually require biopsy
- Risk increased with multi-ductal papilloma and most treated with mircrodeochectomy
What are Lipoma and how are they managed?
- Soft and mobile benign adipose tumour normally asymptomatic
- Low malignant potential
- Only removed if significant enlarging and causing symptomatic compressive or aesthetic issues
What are Phyllodes Tumours and how are they managed?
- Rare fibroepithelial tumours commonly occuring in older age group
- 1/3 have malignant potential and 10% recur after excision
What are investigations for Benign Breast Tumours?
Triple Assessment
- Examination
- Imaging
- Histology
What is Gynaecomastia?
- Common condition which males develop breast tissue due to imbalanced ratio of oestrogen an androgen activity. Usually reversible
- Usually benign disease but breast cancer develops in 1% of cases
What is the pathophysiology of Gynaecomastia?
Physiological
- Occurs in adolescence from delayed testosterone surge relative to oestrogen at puberty.
- Occurs secondary to decreasing testosterone level with increasing age
Pathological
- Results form change in oestrogen: androgen activity ratio and wide variety of underlying mechanism
What are the forms of pathological Gynaecomastia?
1. Lack of testosterone
- Causes are Klinefelter’s syndrome, Androgen Insensitivity, Testicular Atrophy or Renal Disease
2. Increased oestrogen levels
- Causes include liver disease, hyperthyroidism, obesity, adrenal tumours or certain testicular subtypes
3. Medication
- Common causative agents include digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics or anabolic steroids
4. Idiopathic
What are clinical features of Gynaecomastia?
- Has insidious onet
- Rubbery or firm mass starting from underneath the nipple and spreading outward
What are investigations for Gynaecomastia?
- Triple assessment
- Liver and Renal function test
- Testicular examination essential
- Hormone Profile
What are the conclusions drawn form hormone profile test in relation to Gynaecomastia?
- LH high and testosterone low = testicular failure
- LH low and testosterone low = increased oestrogen
- LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy
What is the management of Gynaecomastia?
- Most cases should have reassurance.
- If reversible underlying cause, then treatment or reversal of this should also allow for resolution of gynaecomastia
- Tamoxifen can be used in cases to help alleviate symptoms especially if tender.
- In patient with later stage of fibrosis, surgery may be only option if medical treatments fail
What is Mastitis?
- Inflammation of breast tissue both acute or chronic.
- Most common cause is infection typically Staph Aureus but can be granulomatous.
- Can be classed by lactation status.
What are the classification for Mastitis?
-
Lactational Mastitis
- 1/3 of breastfeeding women. Present in first 3 month of breastfeeding or during weaning. Common with 1st child.
- Associated with cracked nipples and milk stasis
- Caused by poor feeding technique
-
Non-lactational mastitis
- Occur especially in women with other conditions such as Duct ectasia as peri-ductal mastitis.
- Tobacco smoking important risk factor causing damage to sub-areolar duct wall and predisposing bacterial infection
What are clinical features of Mastitis?
- Tenderness
- Swelling or Induration
- Erythema over area of infection
What is the management for Mastitis?
- Systemic antibiotic therapy and simple analgesics
- Continued milk drainage or feeding is recommended
- Cessation of breastfeeding using dopamine agonist (Cabergoline) considered in women with persistent/multiple areas of infection
What is a breast abscess?
Collection of pus within breast lined with granulation tissue developing from acute mastitis
How do breast abscesses present?
- Tender fluctuant and erythematous masses with punctum potentially present
- Systemic symptoms include fever and lethargy
- Confirmed via ultrasound scan if any doubt regarding diagnosis
What is the management of breast abscesses?
- Initial phase
- Empirical antibiotics and US guided needle aspiration
- More advanced abscesses
- Incision and drainage under local anaesthetic
What is a breast cyst?
- Epithelial line fluid-fluid cavities formed when lobules become distended due to blockage usually in perimenopausal age group
What are complication of breast abscesses?
- Drainage of non-lactational abscess can lead to formation of mammary duct fistula which is communication between skin and sub-areolar breast duct
- Managed surgically
- Fistulectomy and Antibiotics
- Can often recur
What are clinical features of breast cysts?
- Singularly or multiple lumps affecting one or both breast
- Distinct smooth masses on palpation. Masses may be tender
What are investigations for Breast Cysts?
- Identified by typical halo shape on mammography and usually definitively diagnosed with ultrasound
- Persisting, symptomatic or undeterminable cystic masses may be aspirated either freehand or using ultrasound.
- Cancer excluded if fluid free from blood or lump disappear otherwise cytology
- Most require no further management and self-resolve. Larger cysts aspirated for aesthetic reasons or reassurance
What are complications of Breast Cysts?
- Carcinoma
- Fibroadenosis
- Caused by multiple small cysts and fibrotic area. Although benign, often associated with tenderness and asymmetry. Fibrosis can mask malignancy.
- Managed with appropriate Analgesia
What is Mammary duct ectasia?
- Dilatation and shortening of major lactiferous ducts
- Common in perimenopausal women
What are clinical features of Mammary Duct Ectasia?
- Present with coloured green/yellow nipple discharge
- Palpable mass
- Nipple retraction
What are investigations for Mammary Duct Ectasia?
- Mammography
- Contain multiple plasma cells on histology if biopsied
What is Fat Necrosis?
- Common condition caused by acute inflammatory response in breast leading to ischaemic necrosis of fat lobules
- Associated with trauma and previous surgical or radiological interventions
What are clinical features of Fat Necrosis?
- Lumps
- Fluid discharge
- Skin dimple
- Pain
- Nipple inversion
- Chronic fibrotic change
What are investigations and management for Fat Necrosis?
-
Investigations
- Positive traumatic history
- Ultrasound shows hyperechoic mass
- Biopsy is often taken to categorically rule out malignancy.
-
Management
- Analgesic management and reassurances
