Breast - Lumps, Cysts, Abscesses, Mammary Duct Ectasia

Question 1

Criteria to refer someone onto 2 week wait suspected breast cancer pathway?

Answer 1

1. 30 and over with UNEXPLAINED breast lump (with or without pain)
2. 30 and over with UNEXPLAINED lump in AXILLA
3. 50 and over with UNILATERAL changes in the nipple - discharge, retraction, other changes of concern
4. SKIN CHANGES on breast suggestive of breast cancer

Question 2

Fibroadenoma - what is it?

Answer 2

Most common benign tumour of the stromal/epithelial breast duct tissue

Question 3

Fibroadenoma - what is the feel of the fibroadenoma within the breast?

Answer 3

Small, <3cm, painless, firm, mobile lumps

Referred to as breast mice, as they move around within the breast tissue

Question 4

Fibroadenoma - what age do they commonly present in?

Answer 4

Young women (15-40)

Due to them responding to the female hormones (oestrogen and progesterone) - why they are more common in younger women and often regress after menopause

Question 5

Fibroadenoma - what happens to them over time?

Answer 5

50% - regress spontaneously

25% - remain unchanged

25% - get bigger

Question 6

Fibrocystic Breast Changes - what is it?

Answer 6

Benign

Connective tissue (stroma), ducts and lobules of breast, respond to oestrogen and progesterone, become fibrous (irregular and hard) and cystic, and it fluctuates with the menstrual cycle

Question 7

Fibrocystic Breast Changes - when does it commonly occur and in which women?

Answer 7

Common in women of menstruating age

Symptoms often start prior to menstruation, and resolve once menstruation has finished

Question 8

Fibrocystic Breast Changes - what are the symptoms?

Answer 8

1. Lumpiness
2. Breast pain or tenderness (mastalgia)
3. Fluctuation of breast size

Question 9

Fibrocystic Breast Changes - management?

Answer 9

Management involves exlcuding cancer,

Managing cyclical breast pain (mastalgia) symptoms:

1. Wearing a supportive bra
2. NSAIDs
3. Avoid caffeine
4. Applying heat to the area

Question 10

Breast cysts - what are they?

Answer 10

Benign, individual, fluid-filled lumps

Question 11

Breast cysts - what age and when do they most commonly occur in?

Answer 11

Women aged 30-50

Perimenopausal period

Question 12

Breast cysts - what is the presentation?

Answer 12

Smooth, well-circumcised, mobile

Painful

Fluctuate in size over menstrual cycle

Question 13

Breast cysts - how can you manage the pain?

Answer 13

Aspiration can help pain, whilst also helping to exclude breast cancer

Question 14

Fat necrosis - what is it?

Answer 14

Fat necrosis causes a benign lump formed by localised degeneration and scarring of fat tissue in the breast

Question 15

Fat necrosis - what are the causes?

Answer 15

Trauma

Radiotherapy

Surgery

Question 16

Fat necrosis - presentation within breast?

Answer 16

Painless, frim and irregular

FIXED in local structures

There may be skin dimpling or nipple inversion

Question 17

Fat necrosis - investigations you may need to do?

Answer 17

USS and mammogram may show similar appearance to breast cancer (BC)

Therefore need to do histology (by fine needle aspiration or core biopsy) to exclude BC

Question 18

Fat necrosis - management?

Answer 18

Conservative management

Resolve spontaneously with time

Symptomatic - excision

Question 19

Galactocele - what is it?

Answer 19

After stopping breastfeeding, lactiferous duct gets blocked, so can’t drain

Forms breast milk filled cysts

BENIGN

Question 20

Galactocele - how do they present?

Answer 20

Firm, painless, mobile

Question 21

Galactocele - management?

Answer 21

Usually resolve without any treatment

Can drain them with a needle

Rare - become infected and require abx

Question 22

Phyllodes tumour - what is it?

Answer 22

Tumours of the connective tissue (stroma) that are large and fast growing

‘Leaf-like pattern’

Question 23

Phyllodes tumour - what proportion are benign, borderline, and malignant?

Answer 23

50% benign

25% borderline

25% malignant (can also metastasise)

Question 24

Phyllodes tumour - management?

Answer 24

Wide excision - removal of tumour and surrounding tissue

Chemo - malignant/metastasised tumours

Question 25

Intraductal Papilloma - what is it?

Answer 25

Warty lesion that grows in a breast duct Result of proliferation of epithelial cells

Question 26

Intraductal Papilloma - what is the typical presentation?

Answer 26

Clear or blood-stained discharge Tenderness or pain Palpable lump

Question 27

Intraductal Papilloma - investigations?

Answer 27

``` Triple assessment: 1. Clinical assessment 2. Imaging 3. Histology To exclude cancer ``` Ductography - inject contrast into abnormal duct and perform a mammogram to visualise - papilloma seen as area that does not fill with contrast (a “filling defect”).

Question 28

Intraductal papilloma - management?

Answer 28

Complete surgical excision

Question 29

Lactational Mastitis - what is mastitis?

Answer 29

Inflammation of breast tissue

Question 30

Lactational Mastitis - what are the causes of mastitis?

Answer 30

Obstruction - in ducts, accumulation of milk, milk stasis Infection - bacteria enters at nipple, back-tracks to ducts, most common S.AUREUS

Question 31

Lactational Mastitis - what is the presentation?

Answer 31

Pain and tenderness (unilateral) Erythema in a focal area of breast tissue Hot and swollen Nipple discharge Fever - when bacterial infection is the cause

Question 32

Lactational Mastitis - management?

Answer 32

Obstruction - conservative, hot compress, analgesia, express milk regularly, continue breastfeeding Infection - 1ST LINE: FLUCLOXACILLIN as Staph Aureus, (500mg QDS 10-14 days), penicillin allergy: erythromycin

Question 33

Lactational Mastitis - should women continue breastfeeding their babies?

Answer 33

Women should be encouraged to continue breastfeeding, even when an infection is suspected It will not harm the baby and will help to clear the mastitis by encouraging flow

Question 34

Lactational Mastitis - what is a rare complication?

Answer 34

If not adequately treated - breast abscess

Question 35

Breast Abscess - what is it?

Answer 35

Collection of pus within an area of the breast, usually caused by a bacterial infection

Question 36

Breast Abscess - what are the two types of abscesses?

Answer 36

Lactational abscess (associated with breastfeeding) Non-lactational abscess (unrelated to breastfeeding)

Question 37

Breast Abscess - presentation?

Answer 37

Acute - few days ``` Nipple changes Purulent nipple discharge Localised pain Tenderness Warmth Erythema Swelling ``` Key feature - FLUCTUANT, being able to move fluid around within the lump using pressure during palpation Where there is infection without an abscess, there can still be hardness of the tissue, forming a lump, but it will not be fluctuant as it is not filled with fluid

Question 38

Breast Abscess - management?

Answer 38

Management of a breast abscess requires: Referral to the on-call surgical team in the hospital for management Antibiotics Ultrasound (confirm the diagnosis and exclude other pathology) Drainage (needle aspiration or surgical incision and drainage) Microscopy, culture and sensitivities of the drained fluid

Question 39

Breast Abscess - what antibiotics would you give?

Answer 39

Antibiotics for non-lactational mastitis need to be broad-spectrum 1. Co-amoxiclav 2. Erythromycin/clarithromycin plus metronidazole

Question 40

Mammary Duct Ectasia - what is it?

Answer 40

Benign condition, dilation of the large ducts in the breasts Ectasia means dilation Inflammation in the ducts, leading to intermittent discharge from the nipple The discharge may be white, grey or green

Question 41

Mammary Duct Ectasia - presentation?

Answer 41

Nipple discharge Tenderness or pain Nipple retraction or inversion A breast lump (pressure on the lump may produce nipple discharge)

Question 42

Mammary Duct Ectasia - investigations?

Answer 42

Need to exclude breast cancer, so triple assessment: 1. Clinical assessment 2. Imaging 3. Histology Microcalcifications are a key finding on a mammogram Other Ix: 1. Ductography – contrast is injected into an abnormal duct, and mammograms are performed to visualise the duct 2. Nipple discharge cytology 3. Ductoscopy – inserting a tiny endoscope (camera) into the duct

Question 43

Mammary Duct Ectasia - management?

Answer 43

Mammary duct ectasia may resolve without any treatment 1. Reassurance after excluding cancer may be all that is required 2. Symptomatic Rx of mastalgia (supportive bra and warm compresses) 3. Abx if infection suspected or present 4. Surgical excision of the affected duct (microdochectomy)

Question 44

What antibiotics do you give in non-lactational mastitis and lactational mastitis?

Answer 44

Non-lactational mastitis gets co-amoxiclav, lactational mastitis gets flucloxacillin