Common Breast Conditions Flashcards
State some common causes for breast lumps (9)
- Fibroadenoma
- Fibrocystic breast disease (fibroadenosis)
- Breast cysts
- Breast abscess
- Fat necrosis
- Lipoma
- Phyllodes tumour
- Breast cancer
- Mammary duct ectasia
Of the breast lumps we have previously stated, state which are inflammatory
- Breast abscess
- Breast cyst
- Fat necrosis
- Mammary duct ectasia
Of the breast lumps we have previously stated, state which are benign tumours
- Fibroadenoma
- Fibrocystic breast disease
- Lipoma
- Phyllodes tumour
Discuss for fibroadenoma:
- Alternative name
- What they are
- Who they are common in
- How they feel on examination
- Prognosis/development
- Indications for surgical removal
- 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
Discuss for fibrocystic breast disease (fibroadenosis):
- Symptoms & signs
- Who they are common in
- Whether they change throughout menstrual cycle
- Prognosis/progression
- Management
- 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
Discuss for breast cysts:
- What they are
- Who they are common in
- How they feel upon examination
- Any variation with menstrual cycle
- Management
- Complications
- 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)
Discuss for breast abscess:
- What it is
- Symptoms & signs
- How the lump feels on examination
- Management
- 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
Discuss for fat necrosis of breast:
- What it is
- Common causes
- Symptoms
- How the lump feels on examination
- Associated signs upon examination
- Management
- 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).
Discuss for lipoma:
- What it is
- Symptoms
- How lump feels on examination
- Management
- 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
Discuss for phyllodes tumour:
- What it is
- Who it is common in
- Whether they are benign or malignant
- Common?
- Management
- 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)
Discuss for mammary duct ectasia:
- What it is
- Symptoms
- Mammography findings
- Biopsy findings
- Management
- 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
Discuss for intra-ductal papilloma:
- What it is
- Is it common
- Age it affects
- Typical presentation
- Increased risk of breast cancer?
- Management
- 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)
Discuss for breast cancer:
- Presentation
- How lump feels on examination
- 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)
Nipple retraction can be slit like or circumferential; which is more likely to be associated with underlying carcinoma?
- Circumferential= more likely underlying carcinoma
- Slit like= often associated with duct ectasia
Discuss which pts you would refer by the two week wait referral for breast cancer (NICE 2021)
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.
What is the triple assessment clinic?
- 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
Discuss what is involved in the triple assessment
State some key questions to ask in breast cancer history; include breast specific questions, lump specific questions (if appropriate) and general questions
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
How do we convert results of triple assessment into a universally understood format/grading system?
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.
State some features on mammogram that may suggest breast cancer
- Irregular, spiculated, radioopaque mass with microcalcification
Who are mammograms more suitable for and why?
Who are USS more suitable for and why?
- Mammograms: >40yrs
- USS: <40yrs
Younger pts have denser breasts
State some common places for breast cancer to metastasise to
- Lung
- Liver
- Bone
- Brain
- Adrenal
- Ovary
Discuss a potential treatment regime for someoen with breast cancer
DXT= radiotherapy
What are the two options for breast surgery for cancer?
- Wide local excision
- Mastectomy
- +/- axillary dissection/clearance
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
Oncoplastic surgery to reconstruct breast may be required after surgery for breast cancer; state some of the options for oncoplastic surgery
For Paget’d disease of the nipple discuss:
- How it appears
- What it is associated with
- How to differentiate from eczema
- 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
What is mastitis?
What is the most common cause?
Discuss the two different types of mastitis
- 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
How does smoking increase risk of non-lactational mastitis?
Causes damage to subareolar ducts which prediposes them to bacterial infection
State signs & symptoms of mastitis
The affected breast may be:
- Painful (mastalgia)
- Tender
- Swollen
- Erythematous
Discuss the mangaement of mastitis, include any additional management for lactational mastalgia
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
What is galactorrhoea?
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*
Galactorrhoea is usually caused by hyperprolactinaemia; normoprolactinaemic galactorrhoea is rarer and typically idiopathic. State some causes of hyperprolactinaemia
- 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)
What might you find on clinical examination of someone with galactorrhoea?
- Breast examination often normal
- Check for other findings that may suggest cause of hyperprolactinaemia e.g. bitemporal hemianopia, signs of hypothyroidism
What investigations, and why, would you do for galactorrhoea include:
- Bedside
- Bloods
- Imaging
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
Discuss the management of galactorrhoea, inlcude management of:
- Hyperprolactinaemic galactorrhoea
- Normoprolactinaemic galactorrhoea
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*
Gynaecomastia can be physiological or pathological; explain the difference
- 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
State some potential causes of pathological gynaecomastia
- 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
How does gynaecomastia feel on examination?
Rubbery, firm mass that starts underneath nipple and spreads outwards
Tests are only necessary if cause of gynaecomastia is uncertain; true or false?
True
What do following results suggest about gynaecmastia:
- LH high and testosterone low
- LH low and testosterone low
- LH high and testosterone high
- 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
Discuss the management of gynaecomastia
- Treat underlying reversible cause
- Tamoxifen can be used to alleviate symptoms e.g. tenderness
- Surgery if other treatment fails
If someone young presents with gynaecomastia, particularly a young person, what do you want to examine?
Testes
Compare the age distribution of the 4 main types of breast lumps according to age:
- Fibroadenoma
- Fibrocystic chagnes
- Cysts
- Cancer
