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Y4 CBLs > Surgery: Benign Breast Disease > Flashcards

Surgery: Benign Breast Disease Flashcards

1
Q

Anatomy of the breast

A
  • Modified sweat glands
  • Composed of 15-20 lobules of glandular tissue which is embedded in fat
  • Each lobule drains into a lactiferous duct
  • Then individually open on the nipple
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2
Q

How to explore the symptoms of a breast lump while taking a history?

A

A breast lump

  • How long have you had the lump?
  • Has it changed in size?
  • Does it alter with your periods?
  • Is it tender?
  • Is there any change in the overlying skin?
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3
Q

Considerations while thinking about the symptoms of breast pain

A

Breast pain

  • Common
  • Is it cyclical?
  • Pubertal/peri-menopausal
  • Referred pain
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4
Q

Considerations while thinking about nipple change (what to ask for)

3 problems

A

Nipple change

•Eczema

  • Is the eczema on the nipple or the areola?
  • Ask about other areas of eczema

•Retraction

•Is this longstanding or a new symptom?

•Discharge

  • 5% associated with cancer
  • Is the discharge spontaneous or induced?
  • Is the discharge from one or both breasts?
  • Frequency
  • Colour
  • Recent pregnancy
  • Menopausal status/age
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5
Q

Risk factors for breast cancer

A

•Age → 8 out of 10 cancers are diagnosed in the 50-64 age group

  • Reproductive history
  • Early age of menarche
  • Late age of first child
  • Nulliparous women
  • Bottle rather than breast feeding
  • Delayed menopause
  • Family history
  • 5% of breast cancer is associated with a genetic abnormality
  • Particularly concerned about 1st/2nd degree relatives with cancers at an early age
  • Other risk factors
  • OCP/HRT
  • Radiation exposure
  • Alcohol intake
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6
Q

What to ask about in a ‘previous breast history’ section (5)

A
  • Previous breast cancer
  • Previous benign disease
  • Previous breast surgery
  • Recent mammograms (including screening programme)
  • Previous chest wall radiotherapy
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7
Q

What else (apart from on breast) look for/assess while clinical examination?

A
  • Axillary and supraclavicular lymph nodes
  • Bony tenderness
  • Hepatomegaly
  • Ascites
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8
Q

Radiological investigations for breast problems

A

•Radiological

  • Mammogram (X-ray)
  • Ultrasound scan (specific area)
  • MRI (lobular, mammographically occult, dense breasts, multifocal or bilateral disease)
  • CT and Bone scan (systemic disease)
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9
Q

Pathological investigations for a suspected breast cancer

A
  • Cytology (Fine Needle Aspiration cytology)
  • Core Biopsy
  • Vacuum-assisted biopsy/excision
  • Excision biopsy
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10
Q

Systems/scores used in each component of a triple assessment

A
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11
Q

Name that investigation

A

Mammogram

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12
Q

Name the mode of investigation

A

Core biopsy

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13
Q

Categories of benign breast disease

A
  • Congenital problems
  • Nipple discharge
  • Infection/mastitis, abscess
  • Pain /mastalgia
  • Gynaecomastia
  • Benign neoplasms
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14
Q

Possible congenital problems of the breast

A
  • Extra nipples and breasts
  • Absence or hypoplasia of the breast (Poland’s syndrome)
  • Chest wall abnormalities
  • Accessory tissue
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15
Q

Nipple discharge can be… (2)

A
  • Bilateral/Unilateral
  • Single Duct/ Multiple ducts
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16
Q

Colours of nipple discharge and what they possibly imply

A
  • Clear: physiological
  • Milky: Pregnancy/ pituitary adenoma
  • Brown/green: mammary duct ectasia
  • Bloody: Intraductal papilloma 90%, Cancer 10%
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17
Q

Algorithm for a general management of a nipple discharge

A
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18
Q

What’s that?

A

Breast abscess

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19
Q

Breast abscess

  • types
  • association (1)
  • what’s seen on examination
  • management
A

Infection → pus accumulation → mass formaton

Management: aspiration and antibiotic therapy

*breastfeeding can continue from the other breast

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20
Q

What is mastitis caused by?

A
  • Mastitis describes inflammation of the breast tissue
  • the most common cause is from infection→ S. Aureus, but can occasionally be granulomatous
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21
Q

What’s that?

A
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22
Q

How can mastitis be classified (2)

A

Classified by lactational status

  • Lactational mastitis (more common) → usually presents during the first 3 months of breastfeeding or during weaning
    • It is associated with cracked nipples and milk stasis (often caused by poor feeding technique), and is more common with the first child
  • Non-lactational mastitis (less common) often in women with other conditions such as duct ectasia, as a peri-ductal mastitis
    • Tobacco smoking is an important risk factor, causing damage to the sub-areolar duct walls and predisposing to bacterial infection
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23
Q

Management of mastitis

A
  • best managed with systemic antibiotic therapy and simple analgesics
  • In lactational mastitis, continued milk drainage or feeding is recommended
  • Cessation of breastfeeding using dopamine agonists (such as Cabergoline) can be considered in women with persistent or multiple areas of infection
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24
Q

What to ask about if a patient presents with breast pain (mastalgia)

A
  • Age
  • Unilateral or bilateral
  • Site
  • Cyclical or non cyclical
  • Contraceptive pills and HRT
  • Associated lumps
  • Examine for lumps and tenderness
  • Reassure/review/refer
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25
Q

Is mastalgia caused by breast cancer?

A
  • usually associated with benign disease (may be uni or bilateral)
  • most commonly related to cycylical changes (menstrual cycle)

*however need to exclude pathology → examination and imaging

26
Q

Classification of pain in the mastalgia (2)

A
  • cyclical pain → associated with the menstrual cycle. Typically, cyclical pain affects both breasts, beginning a few days before the beginning of menstruation and subsiding at the end. It is caused by hormonal changes, therefore most cases come in those actively menstruating or using HRT.
  • non-cyclical pain →unrelated to the menstrual cycle. It can be caused by medication, including hormonal contraceptives, anti-depressants (such as sertraline), or antipsychotic drugs (such as haloperidol). Other causes of breast pain can be extramammary pain, such as chest wall pain or shoulder pain.
27
Q

What to ask about to exclude pathological causes of mastalgia?

A

lumps, skin changes, fevers, or discharge, as well as association with menstrual cycle )if associated - less likely to be pathological)

28
Q

Should we investigate mastalgia?

A
  • Breast pain in isolation with no other relevant features on history or examination (pathological features) is not an indication for imaging
  • All patients within reproductive age should have a pregnancy test
29
Q

Management of mastalgia (1st line)

A
  • any underlying suspicious cause should be investigated and managed as appropriate
  • in most cases, the mastalgia pain will be idiopathic in nature → reassurance and pain control
  • management for cyclical breast pain should include wearing a better fitting bra or soft-support bra during the night

* oral ibuprofen or paracetamol or topical NSAIDs can help alleviate pain

*; non-cyclical pain does not usually respond well to treatment but in idiopathic cases will often resolve spontaneously

30
Q

Management of mastalgia (2nd line)

A

If first line management options are unsuccessful, a referral to a specialist may be needed

Second line treatment for breast pain include:

  • Danazol → anti-gonadotrophin agent (but unpleasant side-effects: nausea, dizziness, and weight gain)

*Many previous suggested treatments, such as the use of OCPs, low-fat diet, or use of vitamin E, are no longer recommended

31
Q

Drugs commonly associated with gynecomastia (5)

A
  • Warfarin
  • Digoxin
  • PPI
  • H2 Antagonists
  • Spironolactone
32
Q

Pathophysiology of gynecomastia

A
  • Gynaecomastia is a condition by which males develop breast tissue due to an imbalanced ratio of oestrogen and androgen activity → hyperplasia of stromal and ductal tissue
  • It is usually a benign disease but breast cancer can develop in about 1% of cases
33
Q

What’s physiological gynecomastia?

A
  • most commonly occurs in adolescence → result of the delayed testosterone surge relative to oestrogen at puberty
  • less commonly it occurs in the older population → decreasing testosterone levels with increasing age
34
Q

Causes of pathological gynecomastia

A

Pathological gynaecomastia → due to changes in the oestrogen:androgen activity ratio

Possible underlying mechanisms:

  • Lack of testosterone
    • Due to: Klinefelter’s syndrome, androgen insensitivity, testicular atrophy, or renal disease
  • Increased oestrogen levels
    • Causes include liver disease, hyperthyroidism, obesity, adrenal tumours, or certain testicular subtypes (e.g. Leydig’s cell tumours)
  • Medication*
    • Common causative agents include digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics, or anabolic steroids

*25% of all cases, either through an increased oestrogen activity or reduced testosterone activity

35
Q

What examination is needed in a young man presenting with gynecomastia?

A
  • Ensure to assess for any evidence of breast malignancy.

*A testicular examination is essential, especially in young patient presenting with the condition

36
Q

What’s pseudogynaecomastia?

A

psuedogynaecomastia → adipose tissue in the breast region associated with being overweight

*This can usually be tested on examination by pinching to see if there is an obvious disc of breast tissue present however if not palpable then further imaging and / or histology may be required to definitively exclude

37
Q

Investigations of gynaecomastia

  • when to do them
  • what if malignancy is suspected
A

Tests are only necessary if the cause for gynaecomastia is unknown

  • triple assessment → if malignancy is suspected

Unknown cause:

  • U&Es and LFTs should be checked initially
  • LH and testosterone → if renal and liver function are normal
38
Q

Man presenting with gynecomastia. Possible cause if:

  • LH high and testosterone low
  • LH low and testosterone low
  • LH high and testosterone high
A
  • 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
39
Q

Management of gynecomastia

A
  • depends on the causative factors and the phase of gynaecomastia
  • a reversible underlying cause → treatment or reversal of this should also allow for the resolution
  • In most cases, reassurance may be enough for the patient
  • Tamoxifen can also be used to help alleviate symptoms ( e.g.tenderness)
  • surgery → later stages of fibrosis and if anything else failed
40
Q

(3) features of a lump in a breast cancer

A

firm, fixed, irregular

41
Q

(2) features of the breast cyst

A

fluctuant, mobile

42
Q

Clinical examination features of fibroadenoma

A
  • highly mobile → “breast mouse”
  • well-defined
  • rubbery on palpation
  • most less than 5cm in diameter

*can be multiple and bilateral

43
Q

Management of fibroadenoma

A
  • very low malignant potential → can be left in situ with routine follow up appointments

*over a 2 year period, up to 30% will get smaller

  • main indications for potential excision are >3cm in diameter or patient preference
44
Q
A
45
Q

Common age and patients group for breast cyst

A
  • >35 y old
  • perimenopausal
46
Q

Features of breast cyst

A
  • flactuates with menstrual cycle
  • firm mobile
  • can be tender or non tender
  • well demarkated
47
Q

Breast cysts

  • diagnosis
  • management
A

Diagnosis: ultrasound

Management:

  • aspiration during triple assessment
  • biopsy if the bloody fluid aspirated
  • possible excision if not resolved
48
Q

Is a fibrocystic change malignant?

A

No → it is considered a variant of normal (not even premalignant)

49
Q

Cause and symptoms of fibrocystic change

A

Cause: Imbalance of progesterone and oestrogen

Symptoms change with the menstrual cycle:

  • cyclical breast pain (bilateral)
  • breast swelling
  • palpable mass
  • heaviness
50
Q

Management of fibrocystic change

A
  • Conservative: pain relief, oral contraceptives, evening primrose oil
  • Triple assessment if a solitary /pl odosobniony/ lump present
51
Q

Characteristics (characteristic appearance, common age group, content) of Phyllodes Tumour

A
  • ‘leaf-like’ (due to greek name and histology)
  • grow rapidly
  • comprise of epithelial and stromal tissue
  • occur in older age groups
52
Q

Complications and management of Phyllodels tumour

A
  • one-third of Phyllodes tumours have malignant potential
  • 10% of benign tumours will recur after excision
  • most Phyllodes tumours should be widely excised (or mastectomy if the lesion is large)
53
Q

Pathophysiology of fat necrosis

A

Fat necrosis

  • a common condition

Trauma damages fat cells → immune reaction → fibrosis and painless lump formation

54
Q

Causes of fat necrosis

A
  • association with trauma
  • blunt trauma to the breast is only implicated in 40% cases
  • previous surgical or radiological intervention 60%
55
Q

Presentation of fat necrosis

A
  • usually asymptomatic
  • may present as a lump
  • can present with fluid discharge, skin dimpling, pain and nipple inversion
  • the acute inflammatory response can persist, causing a chronic fibrotic change → subsequently develop into a solid irregular lump
56
Q

How does fat necrosis present on USS?

A

hyperechoic mass on ultrasound

More developed fibrotic lesions will mimic carcinoma on mammogram, appearing as calcified irregular speculated masses and the solid irregular lump may feel suspicious on palpation. Therefore a core biopsy is often taken to categorically rule out malignancy.

57
Q

Management of fat necrosis

A
  • self-limiting
  • usually only requires analgesic management and reassurance
  • should be aspirated to exclude malignancy and then can be excised
58
Q
A
59
Q

Duct ectasia

  • pathophysiology
A

Duct ectasia

  • common cause of nipple discharge
  • Pathophysiology: breast duct dilation + periductal inflammation
60
Q

Symptoms of duct ectasia

A
  • Symptoms: nipple retraction, periareolar inflammation (red and tender nipples), green discharge, possibly lump
61
Q

Management of duct ectasia

A

Management:

  • Tripple assessment if lump found
  • Antibiotics
  • Surgery → definitive treatment (excision of all major ducts)

Y4 CBLs (32 decks)

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