OBG: Breast Flashcards
Non-milky nipple discharge causes (4)
Intra-ductal papilloma (bloody)
Mammary duct ectasia
Breast abscess
Malignancy (Ductal Carcinoma In Situ)
Patient presents for Galactorrhea
What’s the next step in management?
(4)
HCG (r/o pregnancy)
Prolactin level (r/o prolactinoma or Hypothyroidism)
TSH level (r/o Hypothyroidism)
Creatinine BMP (r/o CKD)
Patient has c/o
one-sided and/or non-milky discharge
what’s the next step in management?
Mammogram (in woman > 30 years)
Subareolar ultrasound (in woman < 30 years)
4 signs that suggest nipple discharge may be 2/2 malignancy
Age > 40 years
bloody discharge
palpable breast mass felt
unilateral discharge
Treatment of Intra-ductal papilloma
Terminal ductal excision
Treatment of Galactorrhea (3 outcomes)
Hyperprolactinemia → Dopamine agonist
Hypothyroidism → Levothyroxine
Normo-prolactin/thyroid → reassurance & avoidance of nipple stimulation (tight clothes, piercing, kinky stuff)
Elevated prolactin, but TSH, HCG, Cr are wnl
what is next best step in management
MRI of pituitary
C/O nipple discharge.
Next step in algorithm? (2)
Is it milky → Get labs
Is it not milky OR unilateral → over or under 30 yo
30+ → Mammo
29/under → U/S nipple
Ductography is indicated in patients who present with unilateral or non-milky nipple discharge if imaging is: ____ (2)
inconclusive
or
looks malignant (ductal irregularity)
If lesion is palpable then do a core needle bx instead of ductography
Ductal Ectasia is a disorder of the breast in which the mammary duct becomes ____.
Presents with __, __ or __ nipple discharge & Nipple ____.
Most commonly seen in ___ women
clogged
unilateral, green or bloody
inversion
peri-menopausal
A FIRM, IMMOBILE, PAINFUL mass UNDER the nipples
and/or
RETRACTED Nipple
in a middle age woman?
Diagnosis & next step?
Treatment?
Ductal Ectasia
Mammogram or U/S
None, usually self resolves
+/- ABx if infected
+/- Surgery if intractable
Most common cause of greenish nipple discharge?
Mammary duct ectasia
Benign Breast Conditions include:
Fibrocystic changes
Breast cyst
Gynecomastia
Fat necrosis
(8)
Mastitis
Ductal ectasia
Galactocele
Mondor’s (superficial thrombophlebitis of breast)
Lobular carcinoma in situ (LCIS)
Benign breast neoplasms:
-Fibroadenoma
-Phyllodes tumor (40+ yo)
-Intra-ductal papilloma
Unilateral or bloody nipple discharge in woman older than 30 yo?
What do next (2):
INTRADUCTAL PAPILLOMA
(1st) Mammogram
(2nd) Core needle biopsy →
Fibro-vascular core
Myo-epithelial cells
Fibro-epithelial mass
(3rd) Surgical Excision
Female less than 30 yo with mobile, tender/non-tender breast mass? What do next?
Reassurance → self-resolves (f/u if not) OR if pt is concerned/anxious just get an u/s now.
Not resolved/symptomatic → U/S
If Fibrocystic changes on u/s → OCPs
If Breast Cyst on u/s → FNA → if reoccur then what?
Causes of Pathological gynecomastia
Estrogen excess
-Leydig cell tumor
-Sertoli cell tumor
Cirrhosis
Hyper-thyroidism: ↑ sex hormon binding globulin
Due to Medications
-Spironolactone
-Cimetidine (H2 blocker for GERD)
-Finasteride (inhibit T)
-Ketoconazole (inhibit T synth)
Mnemonic: Some Hormones Cause Fulminant Kleavage
Milk retention cyst located in the mammary gland
Galactocele
(Firm, nontender mass under nipple → Pain = infection)
*self-resolves, if not, dicloxacillin
Acute, Painful, thickened, cord-like lump or mass
with erythema of the breast or anterior chest wall.
Diagnosis:
Superficial thrombophlebitis of the breast veins (Mondor’s)
Tx: Conservative
Seen on
Ultrasound: well-defined mass
or
Mammogram: Defined mass +/- spotted calcifications
Core needle bx or FNA to confirms →
FIBROUS & GLANDULAR tissue
Fibroadenoma
Treatment: regular f/u
No increased risk of BC
PainLESS, smooth, MULTI-NODULAR lump in the breast, with a variable growth rate (slow or fast)
Seen on
Ultrasound: well-defined mass, appearing compressed or distorted w/ SLIT-like dark lines
or
Mammogram: Defined mass +/- spotted calcifications
Core needle bx → papillary projection
Phyllodes tumor
Treatment: Surgical excision
Lesion near nipple with nipple retraction and bloody discharge
(1st) Mammogram
If lesion is palpable:
If not:
INTRADUCTAL PAPILLOMA
(2nd)
If palpable: Core needle bx (fibro-vascular core)
If not → ductogram
(3rd) Surgical excision
*Papillary Carcinoma → same px, but in POST-meno
women ~70+.
Usually incidental biopsy finding → no mass
+/- Microcalcifications seen on mammogram
Lobular carcinoma in situ (LCIS)
*LCIS lower risk of invasive carcinoma compared to DCIS
Non-milky nipple discharge in an elderly pt w/ FMH + for BC.
Ultrasound shows a poorly circumscribed mass with microcalcifications
Invasive ductal carcinoma
Bloody nipple discharge with red and ulcerated/cracked/itchy or rash around the nipple
U/S findings non-specific
Paget disease of breast
(rare BC affecting lactiferous ducts and nipple +/- underlying DCIS/IDC → Partial Mastectomy)
