Disorders of the breast Flashcards
breast abscess
local, exudate-filled pocket that forms within the breast tissue. It should be suspected in patients with presumed mastitis or cellulitis that does not resolve with antibiotic treatment
Risk factors for the development of a breast abscess secondary to lactational mastitis
maternal age > 30 years, first pregnancy, gestational age ≥ 41 weeks, and tobacco use
most common pathogen responsible for a breast abscess
Staphylococcus aureus, which presents in aspirated fluid cultures as gram-positive cocci in clusters
sx and PE breast abscess
localized, painful inflammatory area of the breast with associated fever and malaise. The breast mass is palpable, tender, and fluctuant
dx breast abscess
breast milk sample for culture, ultrasound can aid in both diagnosis and guidance of aspiration of the abscess
tx for all breast abscess despite abx tx
Needle aspiration or surgical treatment with incision and drainage
risk factors for methicillin-resistant S. aureus for breast abscess
recent surgery, hemodialysis, injection drug use, HIV infection
abx tx breast abscess for ppl without RF
dicloxacillin or cephalexin
tx breast abscess for ppl with RF
clindamycin or trimethoprim-sulfamethoxazole
what is a good abx for breast abscess in ppl w hypersensitivity to beta lactams
clindamycin
tx breast abscess in Patients who demonstrate hemodynamic instability or other signs of severe infection
admission with IV vanc
should lactating mothers w breast abscess continue to nurse on affected breast
yes
promotes full drainage of the breast and provide pain relief
what if pt has trouble nursing w breast abscess
If the patient experiences troubles with infant latching or pain secondary to the incision, pumping can be implemented until nursing can resume
Which risk factor is associated with recurrent breast abscesses?
smoking
What type of breast cancer is associated with breast abscess?
inflammatory breast CA
What are possible complications of a breast abscess?
Recurrent infection, poor cosmetic outcome, mammary duct fistula, milk fistula, and antibioma (tough walled abscess due to inadequate pus drainage or inadequate use of abx)
how often may needle aspiration need to be repeated to ensure adequate drainage
every 2-3 days
when is mastitis MC seen
in lactating women within 3 months of delivery
RF mastitis
first-time breastfeeding and difficulty with breastfeeding
prior history of mastitis, an oversupply of milk, infrequent feedings, nipple trauma, maternal stress, or maternal malnutrition
MC bacterial cause of mastitis
staph aureus
is mastitis usually unilateral or bilateral
unilateral
sx mastitis
engorged breast or fissured nipple that progresses to breast tenderness, warmth, swelling, and erythema. Fever and chills may be present
PE mastitis
central or peripheral breast induration and purulent nipple discharge.
The presence of fluctuance indicates a breast abscess!!!
nonpharm tx mastitis
regular emptying of the breast through breastfeeding or a mechanical suction device to avoid the development of a breast abscess. A cool or warm compress and analgesics (e.g., acetaminophen, ibuprofen) may be used for pain management.
pharm tx mastitis if MSSA
Dicloxacillin, cephalexin, or clindamycin may be used as empiric therapy for coverage against Staphylococcus and Streptococcus
7-10 days
pharm tx mastitis MRSA
Trimethoprim-sulfamethoxazole
7-10 days
infective mastitis vs noninfective mastitis
pain, redness, and fever, persist beyond 24 hours = infective
tx noninfective mastitis
NSAIDs and cold compress
What is the medical term for a painless, asymptomatic, cystic collection of milky fluid caused by an obstructed milk duct?
galactocele (milk retention cyst)
in what population do breast fibroadenomas commonly occur
premenopausal women within 20 years of puberty. They can occur at earlier ages in Black women
when do fibroadenomas increase in size and go away
they tend to increase in size during high estrogen states (e.g., pregnancy and with use of estrogen-containing contraceptives) and involute after menopause.
how large are fibroadenomas
1-5 cm
PE fibroadenomas
firm, round, and mobile with discrete borders
well-defined, rubbery, nontender mass
no axillary lymph node involvement or nipple discharge
what can confirm fibroadenoma
US
US fibroadenoma
echogenic well-defined solid mass
dx fibroadenoma
For women under the age of 30 years, a clinical diagnosis can be made without ultrasound or core needle biopsy
what tumor is indistinguishable from fibroadenoma
phyllodes tumor – except that these tumors grow rapidly; rarely malignant
tx fibroadenomas that do not cause pain
surveillance with self-breast exams and repeat ultrasound after 3–6 months
tx fibroadenomas that are painful
For painful masses, masses that are rapidly changing, or if the patient desires removal, surgical excision may be performed. Cryoablation is also a possible treatment for breast fibroadenomas but must only be done if the diagnosis has been confirmed with needle core biopsy
MC benign tumor of the breast
fibroadenoma
what fibroadenomas should be surgically excised
Fibroadenomas that are symptomatic, rapidly growing, or ≥ 3 cm
definitive dx fibroadenoma
biopsy
in what portion of the breast are fibroadenomas MC found
upper outer quadrants
CA risk fibroadenomas
There is no increased risk of breast cancer for individuals with simple fibroadenomas, but a small increased risk of breast cancer is present in those with complex fibroadenomas or when there is a family history of breast cancer
MC lesion of the breast
fibrocystic breast disease
when does fibrocystic breast dz usually occur
usually occurs in women 30–50 years of age and rarely develops post menopause unless the woman is taking hormone replacement therapy
factors that may increase risk of fibrocystic breast dz
estrogen
increased alcohol intake
sx fibrocystic breast dz
pain or tenderness, a palpable asymptomatic mass, cysts that fluctuate in size rapidly, worsening pain and enlarged cysts during the premenstrual cycle, multiple or bilateral breast masses, and serous nipple discharge
what is recommended If a discrete mass is found on a physical exam
mammography or ultrasonography is recommended for evaluation, with ultrasound being the imaging modality of choice for women under 30 years of age
tx fibrocystic breast dz
conservative tx for at least 6 mos
avoiding trauma, wearing a supportive brassiere day and night, and taking acetaminophen or nonsteroidal anti-inflammatory medications for pain
eliminating caffeine from the diet and supplementing vitamin E 400 IU daily
decrease fat intake
decrease chocolate intake
use evening primrose oil
tx severe fibrocystic breast dz
Danazol is a synthetic androgen approved for patients with severe pain. Its mechanism of action is to suppress the pituitary gonadotropins
Tamoxifen also reduces symptoms but should only be used to reduce cancer risk in those with high-risk changes and not as a treatment for pain (this is preferred over Danazol due to fewer ADE)
Gamolenic acid has been shown to reduce pain in about one-half of patients, and the dose is typically 3,000 mg (six 500 mg capsules) taken twice a day
what findings for fibrocystic breast dz may increase CA risk
increased breast density on mammogram, epithelial proliferation (especially with atypia), and papillomatosis are at an increased risk of breast cancer
PE fibrocystic breast dz
may feel dense on palpation, with rope-like or cobblestoning texture
smooth, firm, and discrete mobile mass that is often tender, with a texture similar to a grape, water balloon, or hard mass
which types of cysts for fibrocystic dz have a higher risk of malignancy
complex cysts
imaging fibrocystic breast dz
Complicated cysts can be observed with ultrasound imaging or diagnostic mammography every 6 months for 2 years. Lesions that undergo rapid change in size or develop a solid component require biopsy. A complex cyst must undergo definitive diagnosis using invasive techniques (e.g., fine-needle aspiration, core biopsy, excisional biopsy). Follow-up in proven benign complex cysts is warranted every 6 to 12 months for 1 to 2 years with imaging and clinical breast examination
