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Yr3 Surgery: Breast > Common Breast Conditions > Flashcards

Common Breast Conditions Flashcards

1
Q

State some common causes for breast lumps (9)

A
  • Fibroadenoma
  • Fibrocystic breast disease (fibroadenosis)
  • Breast cysts
  • Breast abscess
  • Fat necrosis
  • Lipoma
  • Phyllodes tumour
  • Breast cancer
  • Mammary duct ectasia
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2
Q

Of the breast lumps we have previously stated, state which are inflammatory

A
  • Breast abscess
  • Breast cyst
  • Fat necrosis
  • Mammary duct ectasia
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3
Q

Of the breast lumps we have previously stated, state which are benign tumours

A
  • Fibroadenoma
  • Fibrocystic breast disease
  • Lipoma
  • Phyllodes tumour
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4
Q

Discuss for fibroadenoma:

  • Alternative name
  • What they are
  • Who they are common in
  • How they feel on examination
  • Prognosis/development
  • Indications for surgical removal
A
  • Breast mouse (because they are small & mobile)
  • Benign tumours of stromal and epithelial breast duct lobules
  • Younger pts (<40yrs)
  • Smooth, well-circumcised, firm, mobile lump, usually up to 3cm
  • 10% dissappear ever yr, hormone dependent so regress after menopause. Very low malignant potential
  • Size >3cm or pt preference
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5
Q

Discuss for fibrocystic breast disease (fibroadenosis):

  • Symptoms & signs
  • Who they are common in
  • Whether they change throughout menstrual cycle
  • Prognosis/progression
  • Management
A
  • Symptoms & signs:
    • Bilateral breast lumpiness
    • Bilateral breast pain/tenderness (mastalgia)
    • Fluctation of breast size
  • Fibrous & cystic changes in breast epithelium; refers to wide variety of benign histological changes in breast epithelium
  • Menstruating women (pre-menopausal)
  • Related to hormonal changes in menstrual cycle; symptoms occur prior to menstruating (~10 days) and resolve afterwards
  • Benign but can vary in severity and therefore have impact on quality of life. Usually resolve after menopause
  • Treatment:
    • Supportive clothing/bras
    • NSAIDs
    • Weight loss
    • Hormone contraception may worsen so consider stopping this
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6
Q

Discuss for breast cysts:

  • What they are
  • Who they are common in
  • How they feel upon examination
  • Any variation with menstrual cycle
  • Management
  • Complications
A
  • Epithelial lined fluid-filled cavities, which form when lobules become distended due to blockage
  • 30-60yrs
  • Smooth, well-circumscribed, mobile, possibly fluctuant lump that may be tender on palpation. Can be singular, multiple. Can be unilateral or bilateral.
  • Can fluctate in size during menstrual cycle
  • Management:
    • Usually resolve therefore no further management
    • If large, symptomatic or persisting may be aspirated (so long as aspirate contains no blood don’t need to send for cytology)
  • Complications:
    • Re-occurence (common)
    • Fibrocystic breast disease
    • Increased risk of breast ca (2-3 times greater risk)
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7
Q

Discuss for breast abscess:

  • What it is
  • Symptoms & signs
  • How the lump feels on examination
  • Management
A
  • A breast abscess is a collection of pus within the breast lined with granulation tissue due to an infection in breast tissue (usually bacterial)
  • Breat lump & associated features e.g. fever, pus discharge from nipple, local erythema, tenderness & heat
  • Fluctuant lump
  • Mangement:
    • Antibiotics and therapeutic needle aspiration
    • Larger abscesses may require surgical drainage
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8
Q

Discuss for fat necrosis of breast:

  • What it is
  • Common causes
  • Symptoms
  • How the lump feels on examination
  • Associated signs upon examination
  • Management
A
  • Acute inflammatory response in breat tissue leading to ischaemic necrosis of fat lobules/tissue in breast; can lead to fibrotic changes in breast (the lump)
  • Trauma, breast surgery, radiological intervention
  • Usually asymptomatic or presents with lump; lump may sometimes has associated signs
  • Firm, irregular, fixed
  • Skin dimpling, nipple inversion, nipple discharge
  • Management: usually conservative (reassurance, analgesia if required).
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9
Q

Discuss for lipoma:

  • What it is
  • Symptoms
  • How lump feels on examination
  • Management
A
  • Benign collection of fat
  • Asymptomatic other than lump
  • Soft, mobile lump, non-tender
  • Mangement: reassurance. Only excise if becoming large, have compressive symptoms or aesthetic issues
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10
Q

Discuss for phyllodes tumour:

  • What it is
  • Who it is common in
  • Whether they are benign or malignant
  • Common?
  • Management
A
  • Fibroepithelial tumours compromised of both epithelial and stromal tissue
  • Older (40-50’s)
  • About 50% benign, 25% bordeline and 25% malignant
  • Rare
  • Rare (1% of breast neoplasms)
  • Management: excision (because of malignant potential)
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11
Q

Discuss for mammary duct ectasia:

  • What it is
  • Symptoms
  • Mammography findings
  • Biopsy findings
  • Management
A
  • Inflammation of blocked mammary ducts resulting in dilation and shortening of mammary ducts; fluid can then collect in the widened ducts
  • Palpable mass, yellow/green nipple discharge, nipple retraction
  • Dilated calcified ducts on mammography
  • Multiple plasma cells
  • Managed conservatively (as usually resolves). May do surgical excision if persistent nipple dischare
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12
Q

Discuss for intra-ductal papilloma:

  • What it is
  • Is it common
  • Age it affects
  • Typical presentation
  • Increased risk of breast cancer?
  • Management
A
  • Benign tumour in ducts of breast tissue
  • Rare
  • 40-50yrs
  • Often present with clear or bloody discharge. Some will present with a subareolar lump
  • Risk of breast cancer only increased with multi-ductal papilloma
  • Microdochectomy (removal of duct/affected ducts)
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13
Q

Discuss for breast cancer:

  • Presentation
  • How lump feels on examination
A
  • Presentation varies as pt may be aysmptomatic and cancer picked up on screening or pt may have: breast lumps, swelling, asymmetry, nipple retraction, nipple discharge, peau d’orange, Paget’s-like changes, mastalgia, lump in axilla
  • Hard, irregular, fixed, painless to palpate
  • Mangaement: surgical excision, hormone therarpy, radiotherapy, chemotherapy (more on this in Yr4 Cancer care)
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14
Q

Nipple retraction can be slit like or circumferential; which is more likely to be associated with underlying carcinoma?

A
  • Circumferential= more likely underlying carcinoma
  • Slit like= often associated with duct ectasia
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15
Q

Discuss which pts you would refer by the two week wait referral for breast cancer (NICE 2021)

A

Refer people using a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer if:

  • They are aged 30 years and over and have an unexplained breast lump with or without pain, or
  • They are aged 50 years and over with any of the following symptoms in one nipple only:
    • Discharge.
    • Retraction.
    • Other changes of concern.

Consider a suspected cancer pathway referral (for an appointment within 2 weeks) for breast cancer in people:

  • With skin changes that suggest breast cancer, or
  • Aged 30 years and over with an unexplained lump in the axilla.

Consider non-urgent referral in people aged under 30 years with an unexplained breast lump with or without pain.

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16
Q

What is the triple assessment clinic?

A
  • Hosptial based assessment clinic that allows for the early and rapid detection of brest cancer.
  • One stop clinic that pts are referred to if breast cancer is suspected
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17
Q

Discuss what is involved in the triple assessment

A
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18
Q

State some key questions to ask in breast cancer history; include breast specific questions, lump specific questions (if appropriate) and general questions

A

Breast specific

  • Lump
  • Pain
  • Nipple retraction
  • Nipple discharge
  • Skin changes
  • Breast distortion
  • Swelling/inflammation

Lump specific

  • Site
  • Size
  • Shape
  • Margins
  • Increase in size
  • Fixed/moile
  • Hard/firm/smooth
19
Q

How do we convert results of triple assessment into a universally understood format/grading system?

A

At each stage, the suspicion for malignancy is graded based on examination score (P), imaging score (M or U) and histology score (B). Graded 1-5.

20
Q

State some features on mammogram that may suggest breast cancer

A
  • Irregular, spiculated, radioopaque mass with microcalcification
21
Q

Who are mammograms more suitable for and why?

Who are USS more suitable for and why?

A
  • Mammograms: >40yrs
  • USS: <40yrs

Younger pts have denser breasts

22
Q

State some common places for breast cancer to metastasise to

A
  • Lung
  • Liver
  • Bone
  • Brain
  • Adrenal
  • Ovary
23
Q

Discuss a potential treatment regime for someoen with breast cancer

A

DXT= radiotherapy

24
Q

What are the two options for breast surgery for cancer?

A
  • Wide local excision
  • Mastectomy
  • +/- axillary dissection/clearance
25
Q

Hormonal treatments for breast cancer can be oestrogen antagonists or aromatase inhibitors; for each discuss:

  • Examples
  • Mechanism of action
  • Whether works in pre & post-menopausal women
  • DVT risk
  • Osteoporosis risk
  • Risks of developing any other cancers
A
26
Q

Oncoplastic surgery to reconstruct breast may be required after surgery for breast cancer; state some of the options for oncoplastic surgery

A
27
Q

For Paget’d disease of the nipple discuss:

  • How it appears
  • What it is associated with
  • How to differentiate from eczema
A
  • Red, scaley rash of skin over nipple & areola. May be ithcy, painful or have burning sensation. May have discharge or bleeding from nipple. Nipple may become inverted.
  • Associated with breast cancer
  • Paget’s always starts at nipple and moves outwards
28
Q

What is mastitis?

What is the most common cause?

Discuss the two different types of mastitis

A
  • Inflammation of breast tissue
  • Infection with Staphylococcus auerus
  • Types:
    • Lactational mastitis: associated cracked nipples, milk stasis, more common first child, more common in first few months and when weaning
    • Non-lactational mastitis: more common in women with conditions such as duct ectasia or in women who smoke
29
Q

How does smoking increase risk of non-lactational mastitis?

A

Causes damage to subareolar ducts which prediposes them to bacterial infection

30
Q

State signs & symptoms of mastitis

A

The affected breast may be:

  • Painful (mastalgia)
  • Tender
  • Swollen
  • Erythematous
31
Q

Discuss the mangaement of mastitis, include any additional management for lactational mastalgia

A

Mastitis management:

  • Abx
  • Simple analgesics e.g. paracetamol, NSAIDs

Additional management for lactational mastitis:

  • Continue to feed from affected breast or express milk if cannot feed from it
  • Dopamine agonists e.g. cabergoline may be used in women with persistent or multiple areas of infection
32
Q

What is galactorrhoea?

A

Copious, bilateral, multi-ductal, milky discharge, not associated with pregnancy or lactation.

  • In post-partum women this includes milk production occuring 6-12 months after pregnancy and the cessation of breast feeding.*
  • IMPORTANT to distinguish between true galactorrhoea and other causes of nipple discharge*
33
Q

Galactorrhoea is usually caused by hyperprolactinaemia; normoprolactinaemic galactorrhoea is rarer and typically idiopathic. State some causes of hyperprolactinaemia

A
  • Idiopathic (40%)
  • Pituitary Adenoma/prolactinoma
  • Drugs e.g. SSRIs, anti-psychotics, or H2-antagonists
  • Neurological (neurogenic pathways are activated to inhibit dopamine levels) such as varicella zoster infection or spinal cord injury
  • Hypothyroidism (elevated TRH can also stimulate prolactin release)
  • Cushing’s disease, Acromegaly, and Addison’s disease have also been associated with the condition.
  • Renal failure
  • Liver failure
  • Damage to the pituitary stalk from surgical resection, multiple sclerosis, sarcoidosis, or tuberculosis (results in reduced dopamine reaching pituitary to inhibit prolactin release)
34
Q

What might you find on clinical examination of someone with galactorrhoea?

A
  • Breast examination often normal
  • Check for other findings that may suggest cause of hyperprolactinaemia e.g. bitemporal hemianopia, signs of hypothyroidism
35
Q

What investigations, and why, would you do for galactorrhoea include:

  • Bedside
  • Bloods
  • Imaging
A

Bedside

  • Pregnancy test

Bloods

  • Prolactin: is it hyperprolactinaemic galactorrhoea
  • TFTs: rule out hypothryoidsm as cause
  • LFTs: rule out liver failure
  • U&Es: check kideny func, ?renal failure

Imaging

  • MRI head with contrast: pituitary adenoma
36
Q

Discuss the management of galactorrhoea, inlcude management of:

  • Hyperprolactinaemic galactorrhoea
  • Normoprolactinaemic galactorrhoea
A

Hyperprolactinaemia galactorrhoea

  • Treat underlying cause
  • Dopamine agonists e.g. cabergoline if awaiting definitive treatment

Normoprolactinaemic galactorrhoea

  • Often resolves spontaenously but if doesn’t can trial low dose dopamine antagonist
  • *NOTE: if troublesome galactorrhoea intolerant of treatment can have bilateral total duct excision*
37
Q

Gynaecomastia can be physiological or pathological; explain the difference

A
  • Physiological occurs during adolescence resulting from delayed testosterone surge relative to oestrogen in puberty
  • Pathological results from increase in oestrogen:androgen ratio and usually has an underlying cause
38
Q

State some potential causes of pathological gynaecomastia

A
  • Lack of testosterone
    • Androgen insensitivtiy
    • Testicular atrophy
    • Renal disease
  • Increased oestrogen
    • Liver disease
    • Hyperthyroid
    • Obesity
    • Adrenal tumours
    • Testicular tumours e.g. Leydig tumours
  • Medication:
    • Anabolic steroids
    • Spironolactone
    • Metronidazole
    • Digoxin
  • Idiopathic
39
Q

How does gynaecomastia feel on examination?

A

Rubbery, firm mass that starts underneath nipple and spreads outwards

40
Q

Tests are only necessary if cause of gynaecomastia is uncertain; true or false?

A

True

41
Q

What do following results suggest about gynaecmastia:

  • LH high and testosterone low
  • LH low and testosterone low
  • LH high and testosterone high
A
  • 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
42
Q

Discuss the management of gynaecomastia

A
  • Treat underlying reversible cause
  • Tamoxifen can be used to alleviate symptoms e.g. tenderness
  • Surgery if other treatment fails
43
Q

If someone young presents with gynaecomastia, particularly a young person, what do you want to examine?

A

Testes

44
Q

Compare the age distribution of the 4 main types of breast lumps according to age:

  • Fibroadenoma
  • Fibrocystic chagnes
  • Cysts
  • Cancer
A

Yr3 Surgery: Breast (2 decks)

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