OBG: Breast

Question 1

Non-milky nipple discharge causes (4)

Answer 1

Intra-ductal papilloma (bloody)
Mammary duct ectasia
Breast abscess
Malignancy (Ductal Carcinoma In Situ)

Question 2

Patient presents for Galactorrhea
What’s the next step in management?
(4)

Answer 2

HCG (r/o pregnancy)
Prolactin level (r/o prolactinoma or Hypothyroidism)
TSH level (r/o Hypothyroidism)
Creatinine BMP (r/o CKD)

Question 3

Patient has c/o
one-sided and/or non-milky discharge
what’s the next step in management?

Answer 3

Mammogram (in woman > 30 years)
Subareolar ultrasound (in woman < 30 years)

Question 4

4 signs that suggest nipple discharge may be 2/2 malignancy

Answer 4

Age > 40 years
bloody discharge
palpable breast mass felt
unilateral discharge

Question 5

Treatment of Intra-ductal papilloma

Answer 5

Terminal ductal excision

Question 6

Treatment of Galactorrhea (3 outcomes)

Answer 6

Hyperprolactinemia → Dopamine agonist

Hypothyroidism → Levothyroxine

Normo-prolactin/thyroid → reassurance & avoidance of nipple stimulation (tight clothes, piercing, kinky stuff)

Question 7

Elevated prolactin, but TSH, HCG, Cr are wnl
what is next best step in management

Answer 7

MRI of pituitary

Question 8

C/O nipple discharge.
Next step in algorithm? (2)

Answer 8

Is it milky → Get labs
Is it not milky OR unilateral → over or under 30 yo

30+ → Mammo
29/under → U/S nipple

Question 9

Ductography is indicated in patients who present with unilateral or non-milky nipple discharge if imaging is: ____ (2)

Answer 9

inconclusive
or
looks malignant (ductal irregularity)

If lesion is palpable then do a core needle bx instead of ductography

Question 10

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

Answer 10

clogged

unilateral, green or bloody

inversion

peri-menopausal

Question 11

A FIRM, IMMOBILE, PAINFUL mass UNDER the nipples
and/or
RETRACTED Nipple
in a middle age woman?
Diagnosis & next step?
Treatment?

Answer 11

Ductal Ectasia

Mammogram or U/S

None, usually self resolves
+/- ABx if infected
+/- Surgery if intractable

Question 12

Most common cause of greenish nipple discharge?

Answer 12

Mammary duct ectasia

Question 13

Benign Breast Conditions include:
Fibrocystic changes
Breast cyst
Gynecomastia
Fat necrosis
(8)

Answer 13

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

Question 14

Unilateral or bloody nipple discharge in woman older than 30 yo?
What do next (2):

Answer 14

INTRADUCTAL PAPILLOMA

(1st) Mammogram
(2nd) Core needle biopsy →
Fibro-vascular core
Myo-epithelial cells
Fibro-epithelial mass

(3rd) Surgical Excision

Question 15

Female less than 30 yo with mobile, tender/non-tender breast mass? What do next?

Answer 15

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?

Question 16

Causes of Pathological gynecomastia

Answer 16

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

Question 17

Milk retention cyst located in the mammary gland

Answer 17

Galactocele
(Firm, nontender mass under nipple → Pain = infection)

*self-resolves, if not, dicloxacillin

Question 18

Acute, Painful, thickened, cord-like lump or mass
with erythema of the breast or anterior chest wall.
Diagnosis:

Answer 18

Superficial thrombophlebitis of the breast veins (Mondor’s)

Tx: Conservative

Question 19

Seen on
Ultrasound: well-defined mass
or
Mammogram: Defined mass +/- spotted calcifications

Core needle bx or FNA to confirms →
FIBROUS & GLANDULAR tissue

Answer 19

Fibroadenoma

Treatment: regular f/u

No increased risk of BC

Question 20

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

Answer 20

Phyllodes tumor

Treatment: Surgical excision

Question 21

Lesion near nipple with nipple retraction and bloody discharge

(1st) Mammogram

If lesion is palpable:
If not:

Answer 21

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+.

Question 22

Usually incidental biopsy finding → no mass

+/- Microcalcifications seen on mammogram

Answer 22

Lobular carcinoma in situ (LCIS)

*LCIS lower risk of invasive carcinoma compared to DCIS

Question 23

Non-milky nipple discharge in an elderly pt w/ FMH + for BC.

Ultrasound shows a poorly circumscribed mass with microcalcifications

Answer 23

Invasive ductal carcinoma

Question 24

Bloody nipple discharge with red and ulcerated/cracked/itchy or rash around the nipple

U/S findings non-specific

Answer 24

Paget disease of breast

(rare BC affecting lactiferous ducts and nipple +/- underlying DCIS/IDC → Partial Mastectomy)

Question 25

Palpable, hard, nontender, mass

Mammography → irregular mass, microcalcifications, Oil cysts.

Core Needle bx → Multinucleated giant cells, Foam cells

Answer 25

Fat Necrosis

(reassurance; excision only if significant discomfort)

Question 26

Both Intra-ductal Papilloma and Mammillary Ductal Ectasia can present with bloody nipple discharge, subareolar mass, and nipple retraction. How are you able to distinguish them?

Answer 26

MDE
- Green and bloody discharge (many more colors)
- Focal Dilated/Tortuous lactiferous ducts
- Endoluminal loss of elastin
- Periductal Fibrosis (thick tubes around nipple)

IDP
-only bloody discharge
-focal ductal hyperplasia (cyst like pocket in duct)