Surgery: Benign Breast Disease Flashcards
Anatomy of the breast
- 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
How to explore the symptoms of a breast lump while taking a history?
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?
Considerations while thinking about the symptoms of breast pain
Breast pain
- Common
- Is it cyclical?
- Pubertal/peri-menopausal
- Referred pain
Considerations while thinking about nipple change (what to ask for)
3 problems
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
Risk factors for breast cancer
•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
What to ask about in a ‘previous breast history’ section (5)
- Previous breast cancer
- Previous benign disease
- Previous breast surgery
- Recent mammograms (including screening programme)
- Previous chest wall radiotherapy
What else (apart from on breast) look for/assess while clinical examination?
- Axillary and supraclavicular lymph nodes
- Bony tenderness
- Hepatomegaly
- Ascites
Radiological investigations for breast problems
•Radiological
- Mammogram (X-ray)
- Ultrasound scan (specific area)
- MRI (lobular, mammographically occult, dense breasts, multifocal or bilateral disease)
- CT and Bone scan (systemic disease)
Pathological investigations for a suspected breast cancer
- Cytology (Fine Needle Aspiration cytology)
- Core Biopsy
- Vacuum-assisted biopsy/excision
- Excision biopsy
Systems/scores used in each component of a triple assessment
Name that investigation
Mammogram
Name the mode of investigation
Core biopsy
Categories of benign breast disease
- Congenital problems
- Nipple discharge
- Infection/mastitis, abscess
- Pain /mastalgia
- Gynaecomastia
- Benign neoplasms
Possible congenital problems of the breast
- Extra nipples and breasts
- Absence or hypoplasia of the breast (Poland’s syndrome)
- Chest wall abnormalities
- Accessory tissue
Nipple discharge can be… (2)
- Bilateral/Unilateral
- Single Duct/ Multiple ducts
Colours of nipple discharge and what they possibly imply
- Clear: physiological
- Milky: Pregnancy/ pituitary adenoma
- Brown/green: mammary duct ectasia
- Bloody: Intraductal papilloma 90%, Cancer 10%
Algorithm for a general management of a nipple discharge
What’s that?
Breast abscess
Breast abscess
- types
- association (1)
- what’s seen on examination
- management
Infection → pus accumulation → mass formaton
Management: aspiration and antibiotic therapy
*breastfeeding can continue from the other breast
What is mastitis caused by?
- Mastitis describes inflammation of the breast tissue
- the most common cause is from infection→ S. Aureus, but can occasionally be granulomatous
What’s that?
How can mastitis be classified (2)
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
Management of mastitis
- 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
What to ask about if a patient presents with breast pain (mastalgia)
- Age
- Unilateral or bilateral
- Site
- Cyclical or non cyclical
- Contraceptive pills and HRT
- Associated lumps
- Examine for lumps and tenderness
- Reassure/review/refer
Is mastalgia caused by breast cancer?
- 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
Classification of pain in the mastalgia (2)
- 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.
What to ask about to exclude pathological causes of mastalgia?
lumps, skin changes, fevers, or discharge, as well as association with menstrual cycle )if associated - less likely to be pathological)
Should we investigate mastalgia?
- 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
Management of mastalgia (1st line)
- 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
Management of mastalgia (2nd line)
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
Drugs commonly associated with gynecomastia (5)
- Warfarin
- Digoxin
- PPI
- H2 Antagonists
- Spironolactone
Pathophysiology of gynecomastia
- 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
What’s physiological gynecomastia?
- 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
Causes of pathological gynecomastia
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
What examination is needed in a young man presenting with gynecomastia?
- Ensure to assess for any evidence of breast malignancy.
*A testicular examination is essential, especially in young patient presenting with the condition
What’s pseudogynaecomastia?
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
Investigations of gynaecomastia
- when to do them
- what if malignancy is suspected
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
Man presenting with gynecomastia. Possible cause if:
- LH high and testosterone low
- LH low and testosterone low
- LH high and testosterone high
- 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
Management of gynecomastia
- 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
(3) features of a lump in a breast cancer
firm, fixed, irregular
(2) features of the breast cyst
fluctuant, mobile
Clinical examination features of fibroadenoma
- highly mobile → “breast mouse”
- well-defined
- rubbery on palpation
- most less than 5cm in diameter
*can be multiple and bilateral
Management of fibroadenoma
- 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
Common age and patients group for breast cyst
- >35 y old
- perimenopausal
Features of breast cyst
- flactuates with menstrual cycle
- firm mobile
- can be tender or non tender
- well demarkated
Breast cysts
- diagnosis
- management
Diagnosis: ultrasound
Management:
- aspiration during triple assessment
- biopsy if the bloody fluid aspirated
- possible excision if not resolved
Is a fibrocystic change malignant?
No → it is considered a variant of normal (not even premalignant)
Cause and symptoms of fibrocystic change
Cause: Imbalance of progesterone and oestrogen
Symptoms change with the menstrual cycle:
- cyclical breast pain (bilateral)
- breast swelling
- palpable mass
- heaviness
Management of fibrocystic change
- Conservative: pain relief, oral contraceptives, evening primrose oil
- Triple assessment if a solitary /pl odosobniony/ lump present
Characteristics (characteristic appearance, common age group, content) of Phyllodes Tumour
- ‘leaf-like’ (due to greek name and histology)
- grow rapidly
- comprise of epithelial and stromal tissue
- occur in older age groups
Complications and management of Phyllodels tumour
- 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)
Pathophysiology of fat necrosis
Fat necrosis
- a common condition
Trauma damages fat cells → immune reaction → fibrosis and painless lump formation
Causes of fat necrosis
- association with trauma
- blunt trauma to the breast is only implicated in 40% cases
- previous surgical or radiological intervention 60%
Presentation of fat necrosis
- 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
How does fat necrosis present on USS?
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.
Management of fat necrosis
- self-limiting
- usually only requires analgesic management and reassurance
- should be aspirated to exclude malignancy and then can be excised
Duct ectasia
- pathophysiology
Duct ectasia
- common cause of nipple discharge
- Pathophysiology: breast duct dilation + periductal inflammation
Symptoms of duct ectasia
- Symptoms: nipple retraction, periareolar inflammation (red and tender nipples), green discharge, possibly lump
Management of duct ectasia
Management:
- Tripple assessment if lump found
- Antibiotics
- Surgery → definitive treatment (excision of all major ducts)
