Day 6 Breast Flashcards
Fibroadenosis
(fibrocystic disease, benign mammary dysplasia)
(2)
Most common in middle-aged women
‘Lumpy’ breasts which may be painful. Symptoms may worsen prior to menstruation
A 45-year-old office-clerk had come in to see her GP regarding a rash around the right nipple area. She complains that the areola region is itchy and sore. Further questioning also reveals that the rash has been there for 6 weeks and has not improved with E45 cream. She has a history of eczema that is well controlled with E45 only. She also reported that the rash started on the nipple and spreads outwards to the areola On examination the rash looks erythematous and crusty, it does not extend beyond the nipple-areola complex.
What further steps should be taken?
What is the diagnosis?
The key to this question is in the history, the rash started on the nipple and spreads outwards involving the areola.
Even if she has a history of eczema, this needs urgent attention by a breast consultant to rule out Paget’s disease.
Fibroadenoma (2)
- Common in women under the age of 30 years
- Often described as ‘breast mice’ due as they are discrete, non-tender, highly mobile lumps
A 38-year-old lady who smokes heavily presents with recurrent episodes of infection in the right breast. On examination, she has an indurated area at the lateral aspect of the nipple areolar complex. Imaging shows no mass lesions. What is the most likely diagnosis?
Periductal mastitis is common in smokers and may present with recurrent infections. Treatment is with co-amoxiclav.
A 52-year-old lady presents to her general practitioner.
She is concerned about a lump which she has noticed on her left breast associated with a green nipple discharge.
On examination, she has a tender lump on her left breast next to her areola. It is not discoloured or hot to touch.
What is the diagnosis?
Duct ectasia: non-malignant breast disease with thick green nipple discharge, occurring with breast involution
Typically occurring around menopause as the breasts undergo involution. Duct ectasia reflects a shortening and widening of the terminal breast ducts around the nipple.
Breast cancer (2)
- Characteristically a hard, irregular lump. There may be associated nipple inversion or skin tethering
- Paget’s disease of the breast - intraductal carcinoma associated with a reddening and thickening (may resemble eczematous changes) of the nipple/areola
A 52-year-old lady presents with an episode of nipple discharge. It is usually clear in nature.
On examination the discharge is seen to originate from a single duct and although it appears clear, when the discharge is tested with a labstix it is shown to contain blood.
Imaging and examination shows no obvious mass lesion.
The correct answer is: Intraductal papilloma
Intraductal papilloma usually cause single duct discharge. The fluid is often clear, although it may be blood stained.
If the fluid is tested with a labstix (little point in routine practice) then it will usually contain small amounts of blood. A microdocechtomy may be performed.
Breast abscess (2)
- More common in lactating women
- Red, hot tender swelling
A 55-year-old women presents with nipple discharge. On examination she has a slit like retraction of the nipple in the centre of this area is a small amount of cheese like material. No discrete mass lesion is palpable in the underlying breast.
The correct answer is: Duct ectasia
Duct ectasia is a common alteration in the breast that occurs with ageing. As the ducts shorten and dilate a degree of symmetrical slit like retraction occurs. A small amount of cheese like discharge may occur.
Mammary duct ectasia (4)
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
A 49-year-old woman presents with a tender lump around the areola associated with a green nipple discharge.
Mammary duct ectasia
- Dilatation breast ducts.
- Most common in menopausal women
- Discharge typically thick and green in colour
- Most common in smokers
A 44-year-old woman is diagnosed with breast cancer. She has no past medical history of note, is pre-menopausal and has no family history of breast or ovarian cancer.
Staging suggests early disease and she has a wide-local excision followed by whole-breast radiotherapy.
Pathology results show that the tumour is oestrogen receptor positive, HER2 negative.
Which adjuvant treatments is she most likely to be offered?
Tamoxifen is used as the women is pre-menopausal.
There is ongoing debate about whether therapy should be for 5 years or longer.
A 64-year-old obese female presents with a breast lump. She was hit on the breast by a cricket ball when playing with her grandson.
Fat necrosis
An obese, post menopausal woman, with a history of trauma points towards fat necrosis. Trauma causes inflammation of fat cells, leading to formation of a lump. Mammography will be needed to differentiate it from breast disease
An 88-year-old lady presents with a large mass in the upper inner quadrant of her right breast. Investigations confirm an oestrogen receptor positive, invasive ductal carcinoma. She has declined operative treatment.
The correct answer is: Endocrine therapy using letrozole
Elderly patients may be managed using endocrine therapy alone. Eventually most will escape hormonal control. In post menopausal women oestrogens are produced by the peripheral aromatization of androgens and aromatase inhibitors are therefore the most popular agent in this age group.
A 74-year-old woman presents with a breast lump. On examination, it has a soft consistency.
The lump is removed and sliced apart. Macroscopically there is a grey, gelatinous surface.
Mucinous carcinoma
Mucinous carcinomas comprise 2-3% of all breast cancers.
They are one of the special type of carcinomas. These have a better prognosis that tumours of Non Special Type (NST) and axillary nodal disease is rare in this group.
Duct papilloma (3)
- Local areas of epithelial proliferation in large mammary ducts
- Hyperplastic lesions rather than malignant or premalignant
- May present with blood stained discharge
You are working in general practice. An 87-year-old lady complains that her right nipple is exquisitely itchy. On examination, you note that the nipple is erythematous and there is some blood-stained discharge on the inside of her bra.
What is the most appropriate management?
What is the diagnosis
Imaging and biopsy
Paget’s disease of nipple
A 65-year-old lady presents with a lesion affecting her right breast.
On examination she has a weeping, crusting lesion overlying the right nipple, the areolar region is not involved.
There is no palpable mass lesion in the breast, there is a palpable axillary lymph node.
What is the most likely diagnosis?
A weeping, crusty lesion such as this is most likely to represent Pagets disease of the nipple (especially since the areolar region is spared). Although no mass lesion is palpable, a proportion of patients will still have an underlying invasive malignancy (hence the lymphadenopathy).
Discuss (5)Improve
What is a triple assessment?
triple assessment, as the name indicates, includes three modalities, physical examination, imaging (mammography and/or ultrasound), and biopsy (FNAC and core biopsy).
A 41-year-old woman presents with a two-month history of an irregular fixed lump in her left breast.
What is the diagnosis?
Breast cancer
The combination of a persistent lump spanning at least one menstrual cycle and the irregularity point to a diagnosis of cancer.
A 53-year-old woman presents with a bloody nipple discharge. On mammography there is calcification behind the nipple areolar complex. A core biopsy shows background benign change, but cells that show comedo necrosis which have not breached the basement membrane.
Ductal carcinoma in situ
Comedo necrosis is a feature of high nuclear grade ductal carcinoma in situ. It is has a high risk of being associated with foci of invasion.
A 64-year-old woman attends oncology clinic following a diagnosis of oestrogen receptor (ER) positive breast cancer. Her consultant decides to commence treatment with anastrozole, an aromatase inhibitor.
Of the following, which is a potential complication associated with this treatment?
Osteoporosis
Aromatase inhibitors (AIs) such as anastrozole and letrozole reduce peripheral oestrogen synthesis. This accounts for the majority of oestrogen synthesis in post-menopausal women, and therefore aromatase inhibitors are used in this group.
A 48-year-old female attends for an appointment with her GP as she has been experiencing some green-brown coloured nipple discharge.
She is otherwise well and denies any other changes to her breasts.
She has had 3 children which she has breastfed and isn’t on any hormonal contraception.
What is the most common cause of brown-green nipple discharge?
Brown-green nipple discharge is most commonly associated with duct ectasia.
Fat necrosis (4)
- More common in obese women with large breasts
- May follow trivial or unnoticed trauma
- Initial inflammatory response, the lesion is typical firm and round but may develop into a hard, irregular breast lump
- Rare and may mimic breast cancer so further investigation is always warranted
