Breast Surgery: Non-Malignant

Question 1

What are types of Benign Breast Tumours?

Answer 1

• Fibroadenoma
• Adenoma
• Papilloma
• Lipoma
• Phyllodes Tumours

Question 2

Describe the lesions in fibroadenomas and management?

Answer 2

Most common benign growth and occurs in women of reproductive age

• Highly mobile, well-defined and rubbery on palpation
• <5cm in diameter
• Can be multiple and bilateral

Managed by reassurance and observation unless symptomatic or >3cm.

Question 3

What are Adenomas?

Answer 3

Benign glandular tumour typically occurring in older female population

Question 4

What are Papillomas?

Answer 4

• Breast lesions occurring in female in their 40-50s
• Occur mostly in subareolar region
• Presents with bloody or clear nipple discharge.
• Large papillomas initially have a mass

Question 5

How are Papillomas managed?

Answer 5

• Appear similar to ductal carcinoma on imaging and usually require biopsy
• Risk increased with multi-ductal papilloma and most treated with mircrodeochectomy

Question 6

What are Lipoma and how are they managed?

Answer 6

• Soft and mobile benign adipose tumour normally asymptomatic
• Low malignant potential
• Only removed if significant enlarging and causing symptomatic compressive or aesthetic issues

Question 7

What are Phyllodes Tumours and how are they managed?

Answer 7

• Rare fibroepithelial tumours commonly occuring in older age group
• 1/3 have malignant potential and 10% recur after excision

Question 8

What are investigations for Benign Breast Tumours?

Answer 8

Triple Assessment

• Examination
• Imaging
• Histology

Question 9

What is Gynaecomastia?

Answer 9

• Common condition which males develop breast tissue due to imbalanced ratio of oestrogen an androgen activity. Usually reversible
• Usually benign disease but breast cancer develops in 1% of cases

Question 10

What is the pathophysiology of Gynaecomastia?

Answer 10

Physiological

• Occurs in adolescence from delayed testosterone surge relative to oestrogen at puberty.
• Occurs secondary to decreasing testosterone level with increasing age

Pathological

• Results form change in oestrogen: androgen activity ratio and wide variety of underlying mechanism

Question 11

What are the forms of pathological Gynaecomastia?

Answer 11

1. Lack of testosterone

• Causes are Klinefelter’s syndrome, Androgen Insensitivity, Testicular Atrophy or Renal Disease

2. Increased oestrogen levels

• Causes include liver disease, hyperthyroidism, obesity, adrenal tumours or certain testicular subtypes

3. Medication

• Common causative agents include digoxin, metronidazole, spironolactone, chemotherapy, goserelin, antipsychotics or anabolic steroids

4. Idiopathic

Question 12

What are clinical features of Gynaecomastia?

Answer 12

• Has insidious onet
• Rubbery or firm mass starting from underneath the nipple and spreading outward

Question 13

What are investigations for Gynaecomastia?

Answer 13

• Triple assessment
• Liver and Renal function test
• Testicular examination essential
• Hormone Profile

Question 14

What are the conclusions drawn form hormone profile test in relation to Gynaecomastia?

Answer 14

• LH high and testosterone low = testicular failure

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• LH low and testosterone low = increased oestrogen
• LH high and testosterone high = androgen resistance or gonadotrophin-secreting malignancy

Question 15

What is the management of Gynaecomastia?

Answer 15

• Most cases should have reassurance.
• If reversible underlying cause, then treatment or reversal of this should also allow for resolution of gynaecomastia
• Tamoxifen can be used in cases to help alleviate symptoms especially if tender.
• In patient with later stage of fibrosis, surgery may be only option if medical treatments fail

Question 16

What is Mastitis?

Answer 16

• Inflammation of breast tissue both acute or chronic.
• Most common cause is infection typically Staph Aureus but can be granulomatous.
• Can be classed by lactation status.

Question 17

What are the classification for Mastitis?

Answer 17

• Lactational Mastitis
  
  • 1/3 of breastfeeding women. Present in first 3 month of breastfeeding or during weaning. Common with 1st child.
  • Associated with cracked nipples and milk stasis
  • Caused by poor feeding technique
• Non-lactational mastitis
  
  • Occur especially in women with other conditions such as Duct ectasia as peri-ductal mastitis.
  • Tobacco smoking important risk factor causing damage to sub-areolar duct wall and predisposing bacterial infection

Question 18

What are clinical features of Mastitis?

Answer 18

• Tenderness
• Swelling or Induration
• Erythema over area of infection

Question 19

What is the management for Mastitis?

Answer 19

• Systemic antibiotic therapy and simple analgesics
• Continued milk drainage or feeding is recommended
• Cessation of breastfeeding using dopamine agonist (Cabergoline) considered in women with persistent/multiple areas of infection

Question 20

What is a breast abscess?

Answer 20

Collection of pus within breast lined with granulation tissue developing from acute mastitis

Question 21

How do breast abscesses present?

Answer 21

• Tender fluctuant and erythematous masses with punctum potentially present
• Systemic symptoms include fever and lethargy
• Confirmed via ultrasound scan if any doubt regarding diagnosis

Question 22

What is the management of breast abscesses?

Answer 22

• Initial phase
  
  • Empirical antibiotics and US guided needle aspiration
• More advanced abscesses
  
  • Incision and drainage under local anaesthetic

Question 23

What is a breast cyst?

Answer 23

• Epithelial line fluid-fluid cavities formed when lobules become distended due to blockage usually in perimenopausal age group

Question 24

What are complication of breast abscesses?

Answer 24

• Drainage of non-lactational abscess can lead to formation of mammary duct fistula which is communication between skin and sub-areolar breast duct
• Managed surgically
  
  • Fistulectomy and Antibiotics
  • Can often recur

Question 25

What are clinical features of breast cysts?

Answer 25

* Singularly or multiple lumps affecting one or both breast * Distinct smooth masses on palpation. Masses may be tender

Question 26

What are investigations for Breast Cysts?

Answer 26

* Identified by **typical halo shape** on mammography and usually definitively diagnosed with ultrasound * Persisting, symptomatic or undeterminable cystic masses may be aspirated either freehand or using ultrasound. * Cancer excluded if fluid free from blood or lump disappear otherwise cytology * Most require no further management and self-resolve. Larger cysts aspirated for aesthetic reasons or reassurance

Question 27

What are complications of Breast Cysts?

Answer 27

* Carcinoma * Fibroadenosis * Caused by multiple small cysts and fibrotic area. Although benign, often associated with tenderness and asymmetry. Fibrosis can mask malignancy. * Managed with appropriate **A****nalgesia**

Question 28

What is Mammary duct ectasia?

Answer 28

* Dilatation and shortening of major lactiferous ducts * Common in perimenopausal women

Question 29

What are clinical features of Mammary Duct Ectasia?

Answer 29

* Present with coloured green/yellow nipple discharge * Palpable mass * Nipple retraction

Question 30

What are investigations for Mammary Duct Ectasia?

Answer 30

* Mammography * Contain multiple plasma cells on histology if biopsied

Question 31

What is Fat Necrosis?

Answer 31

* Common condition caused by acute inflammatory response in breast leading to ischaemic necrosis of fat lobules * Associated with trauma and previous surgical or radiological interventions

Question 32

What are clinical features of Fat Necrosis?

Answer 32

* Lumps * Fluid discharge * Skin dimple * Pain * Nipple inversion * Chronic fibrotic change

Question 33

What are investigations and management for Fat Necrosis?

Answer 33

* **Investigations** * Positive traumatic history * Ultrasound shows hyperechoic mass * Biopsy is often taken to categorically rule out malignancy. * **Management** * Analgesic management and reassurances