Breast Conditions

Question 1

What is galactorrhoea

Answer 1

Milky nipple discharge unrelated to normal milk production of breast feeding

Question 2

What are the causes of nipple discharge

Answer 2

Hyperprolactinaemia
Mammary duct ectasia
Infection
Tumour
Fibrocystic disease
Pregnancy

Question 3

Causes of hyperprolactinaemia

Answer 3

Prolactinoma (non cancerous tumour of pituitary gland causes increased prolactin and decreased sex hormones (testosterone and oestrogen)

Hypothyroidism
CKD
Liver disease

Drugs (anti psychotics, SSRI (selective seratonin reuptake inhibitors- antidepressants e.g. sertraline), marijuana)

Ask about mumps, fevers, colour of discharge and listed causes of prolactinoma in history

Question 4

What is prolactin and what is hyperprolactinaemia

Answer 4

Hormone that stimulates breast milk production (lactation)

Hyperprolactinaemia- abnormally high levels of prolactin

Question 5

Causes of diff coloured nipple discharge
- clear
- milky
- bloody
- brown
- yellow
- green

Answer 5

Clear - mammary duct ectasia (benign non proliferative breast disease)
Milky - breast feeding, hormone related, galactorrhoea
Yellow - infection
Green - fibrocystic disease
Brown - fibrocystic disease, mammary duct ectasia
Blood - RED FLAG - intraductal papilloma (benign tumour in breast ducts) - type of breast cancer

Question 6

How does the cause of nipple discharge differ if discharge is unilateral vs bilateral

Answer 6

Bilateral - systemic cause

Question 7

When do you know nipple discharge is associated to infection

Answer 7

Fever and chills part of associated symptoms

Question 8

Investigations for nipple discharge

Answer 8

Age over 50 and unilateral discharge or other nipple changes = 2ww to breast clinic
Urine pregnancy test when appropriate
Serum prolactin (if elevated refer to endocrinology for pituitary MRI
TFTs
U&Es
LFTs
Breast imaging

Question 9

What is mastitis

Answer 9

Inflammation of breast tissue

May have infective cause

Question 10

What causes mastitis with infection

Answer 10

S aureus - present on skin and break in skin causes to get in and cause infection

Question 11

Types and causes of mastitis

Answer 11

Lactation all - milk stains or overproduction and bacteria entering via traumatised nipple

Non lactational/non infectious - smoking, immunosuppression, underlying breast pathology, trauma

Question 12

When is mastitis an emergency

Answer 12

If breast abscess forms

Question 13

Signs and symptoms of mastitis

Answer 13

Malaise
myalgias
Breast redness/erythema (wedge shaped area - lactational cause)
Pain /tenderness
Warm
Swelling and firm
Purulent nipple discharge
Fever

Question 14

Diagnosis and management of mastitis (lactational vs non lactational)

Answer 14

Clinical diagnosis

Culture and sensitivity is sever/recurrent
2ww if mass on palpating of inflamed area (inflammatory breast cancer can mimic mastitis)

Lactational mastitis management
frequent feedings/breast pumping, ibuprofen/paractetamol
Flucloxacillin (effective against s aureus) if Sx not improving after 12-24 hrs

Non lactational mastitis management
Ibuprofen/paracetamol
Warm compress
Co-amoxiclav

Question 15

What is a breast abscess and how does it occur

Answer 15

Localised collection of pus within breast tissue secondary to infection

Usually S aureus
May follow antibiotic failure to treat mastitis or cellulitis

Question 16

Symptoms and clinical signs of breast abscess

Answer 16

History of recent mastitis
FEVER
painful swollen breast
Erythema
Purulent Discharge
Warm to touch
Fluctance and tenderness on palpation

Question 17

Diagnosis and management of breast abscess

Answer 17

Refer urgently
Diagnosis - breast ultrasound and MCS of discharge for correct antibiotic

Management - surgical drainage / US guided needle aspiration
Antibiotics
Continue breastfeeding (if breastfeeding)

Question 18

What is fibroadenoma

Answer 18

Benign solid tumour containing glandular and fibrous tissue

Question 19

Typical presentation and clinical signs of fibroadenoma

Answer 19

20-30s
Maybe hormonal and may have family history of breast cancer

Breast mass not painful - may become painful before menstruation

Mass is well delineated, firm, non tender and mobile

Question 20

Diagnosis and management of fibroadenoma

Answer 20

Refer to breast clinic - 2ww for over 30 and non urgent is under 30

Mammography and breast ultrasound

Fine needle aspiration or core needle biopsy for definitive diagnosis

Management - no treatment - surgical excision if large or symptomatic (becomes tender)

Question 21

What is fibrocystic disease

Answer 21

Lumpy breasts associated with pain and tenderness that FLUCTUATES WITH MENSTRUAL CYCLE

Leads to fluid filled sacs and scar like tissue

Question 22

Typical presentation of fibrocystic breast disease

Answer 22

Bilateral (not likely to be cancer)
Several lumps (lumpy breasts)
Pain and tenderness changes with menstrual cycle (cyclical)
Generalised dull breast pain

Lumps blend into surrounding tissue (not clear and discrete)
May have nipple discharge

Question 23

Diagnosis of fibrocystic breast disease

Answer 23

Refer 2ww is over 30, non urgent referral if under 30

Mammogram and breast ultrasound
Fine needle aspiration and biopsy

Question 24

Management of fibrocystic breast disease

Answer 24

Supportive bra, limit caffeine and sodium (worsens breast pain), paracetamol / ibuprofen

Cystic aspiration for symptomatic cyst
Refer to breast surgeon if nipple discharge also present

Question 25

Difference between in situ and invasive breast cancer

Answer 25

In situ - malignancy cells confined to breast duct - may develop into invasive Invasive - malignancy cells penetrated basement membrane

Question 26

Risk factor of breast cancer

Answer 26

Increasing age Females Family history Genetics (BRCA1 BRCA2 mutations) Hormone replacement therapy - used in post menopausal- risk increases with longer use - CONTRAINDICATION IN PATIENT EITH BREAST CANCER - tell pt about risk before starting it Alcohol Radiation exposure history (other cancer treatment in area e.g. for thyroid cancer) Obesity Smoking cigarettes

Question 27

Breast cancer symptoms and clinical signs

Answer 27

Breast lump (may or may not have pain) - firm, immobile, clear borders, irregular shape but may be regular New breast asymmetry Nipple changes (retraction, discharge, rash) Breast skin changes (peak d’orange, erythema, ulceration, dimpling, nipple scaling) Axillary lymphadenopathy

Question 28

When to refer for breast cancer symptoms

Answer 28

2ww for >30 with lump, >50 with UNILATERAL nipple changes , >30 with Axillary lump, skin changes symptoms of breast cancer Non urgent referral <30 with breast lump

Question 29

Breast cancer diagnosis

Answer 29

Mammogram (ultrasound or MRI if mammogram doesn’t show anything) Definitive diagnosis - biopsy Staging - affected lymph node biopsy

Question 30

Breast cancer management

Answer 30

Lumpectomy or mastectomy Chemotherapy Radiotherapy Tamoxifen (to stop oestrogen if cancer is hormone positive - grows with hormone exposure) Aromatise inhibitor (aromatase normally converts androgens to oestrogen)

Question 31

When is breast cancer screening offered

Answer 31

Mammography every 3 years from 50-70s women Refer if strong family history of breast or ovarian cancer - may start screening and genetic testing earlier)

Question 32

When is genetic screening for BRCA1 and BRCA2 given what is done if screening is positive

Answer 32

Known family member with gene mutation or strong family history of breast/ovarian cancer If positive, annual MRI breast csncer screening form 30 onwards May have double mastectomy and bilateral salingo-oophorectomy (ovaries and fallopian tubes removed)