Inflammatory breast disease

Question 1

Types of mastitis

Answer 1

• Lactational - more common, in breast feeding women, usually within first 3 months or during weaning, associated with cracked nipples and milk stasis
• Non-lactational - less common, usually with other conditions eg duct ectasia as a peri-ductal mastitis, tobacco smoking important RF causing damage to sub-areolar duct walls and pre-disposing to infection

Question 2

Management mastitis

Answer 2

• Simple analgesia and warm compress
• If lactational - continue feeding or milk drainage on that side
• If symptoms not improved in 12-24hrs, abx can be started

Question 3

Management if formed abscess

Answer 3

• May need needle aspiration (or less commonly incision and drainage)

Question 4

How can cessation or breastfeeding be achieved if persistent or multiple areas of infection?

Answer 4

Dopamine agonists eg Cabergoline can be considered

Question 5

Presentation of breast abscess

Answer 5

• Secondary to acute mastitis
• Tender, fluctuant erythematous mass with punctum present - may or may not be discharging pus, systemic symptoms

Question 6

How to confirm suspected abscess?

Answer 6

• USS - if doubts
• Then US guided needle therapeutic aspiration can be performed - help resolve and guide abx
• If advanced may need I&D

Question 7

Complication of drainage of a non-lactational abscess

Answer 7

• Formation of mammary duct fistula - communication between skin and subareolar breast
• Can recur even when managed with fistulectomy and abx

Question 8

Breasts cyst - how do these form

Answer 8

• Epithelial lined fluid-filled cavities - form when lobules become distended due to blockage
• Usually perimenopausal age

Question 9

Palpation of breast cysts

Answer 9

• Can be singular or multiple
• One or both breasts
• Distinct smooth massess on palpation

Question 10

Investigations for breast cysts

Answer 10

• Halo shape on mammograph
• Definitive diagnosis via USS
• Aspirate if persistent or symptomatic - free hand or using US - can exclude cancer if free of blood or lump disappears, otherwise send for cytology

Question 11

Management breast cysts

Answer 11

• Once diagnosed, no further management often needed - self resolve
• Women are higher risk of recurrence
• Larger cysts can be aspirated for aesthetic reasons or patient reassurance

Question 12

Complications of breast cysts

Answer 12

• 2% of patients with cysts have carcinoma at presentation - usually not related to cyst itself
• Patients with cysts have 2-3x greater risk of breast cancer
• Fibrocystic change - fibroadenosis caused by multiple small cysts and fibrotic areas, benign but can mask malignancy as tenderness and assymmetry

Question 13

Management fibrocystic change

Answer 13

• Treat tenderness with analgesia
• Cyclical pain can be treated with high dose gamolenic acid or Danazol

Question 14

Mammary duct ectasia presentation

Answer 14

• Dilation and shortening of lactiferous ducts
• Perimenopausal women - coloured green/yellow nipple discharge, palpable mass or nipple retraction

Question 15

Investigations for ?duct ectasia

Answer 15

• Mammograph - dilated calcified ducts with no other features of malignancy
• If biopsied - multiple plasma cells on histology - plasma cell mastitis

Question 16

Management duct ectasia

Answer 16

• Conservative
• Unless mammogram cannot exclude malignancy
• If unremitting discharge –> duct excision

Question 17

Fat necrosis - what is it

Answer 17

• Common
• Caused by acute inflammatory response in breast which leads to ischaemic necrosis of fat lobules
• Blunt trauma to breast implicated in 40% cases, previous surgery or radiological intervention make up rest

Question 18

Presentation of fat necrosis

Answer 18

• Asymptomatic
• Lump
• But can be fluid discharge, skin dimpling, pain and nipple inversion

Question 19

Investigations for fat necrosis

Answer 19

• USS may show hyperechoic mass
• More developed fibrotic lesions may mimic carcinoma on mammogram - calcified irregular speculated masses and can feel suspicious –> core biopsy to rule out malignancy

Question 20

Management fat necrosis

Answer 20

• Self limiting - analgesic management and reassurance