Flashcards in Session 7 Deck (45)
CLINICAL PRESENTING FEATURES
Of breast disease
Physiological swelling and tenderness.
Breast pain (not usually associated with malignancy)
Palpable breast lumps.
Nipple discharge including galactorrhoea.
Breast infection and inflammation - usually associated with lactation.
Physiological swelling and tenderness
• Puberty • Breast enlargement, sometimes initially unilateral, is the first
obvious sign of puberty in girls. Breast buds may initially be
unilateral. Pubertal breast development is known as thelarche.
What is the most common benign breast disorder?
Fibrocystic change is the most common benign
This usually affects women aged 20-50 and appears to be hormonal in aetiology. Not often presents with pain and modularity.
• The symptoms are greatest about one
week before menstruation and decrease
when it starts.
• Examination may reveal an area of
nodularity or thickening, poorly
differentiated from the surrounding tissue
and often in the upper outer quadrant of
• If the changes are bilaterally symmetrical,
they are rarely pathological. If there is
asymmetry it is acceptable to review the
patient after one of two menstrual cycles,
seeing her mid-cycle.
The breasts are active organs that change throughout the menstrual cycle and some degree of tenderness and nodularity in the premenstrual phase is so common that it may be considered as normal, affecting up to two thirds of all menstruating women. It rapidly resolves as menstruation starts.
Palpable benign breast lumps
Most benign lumps will be either cysts or fibroadenomas. A benign mass is usually three-dimensional, mobile and smooth, has regular borders and is solid or cystic in consistency.
Breast cysts and Treatment for breast cysts?
• Cysts are most common between the ages of 35 and 50. They are
palpable as discrete lumps and may be recurrent. They cannot be
reliably distinguished from solid tumours on clinical examination
Identify cyst with palpating and drain with needle and syringe.
• These are benign tumours that are common in young women, with
incidence peaking at 20-24 years of age. • They are the most common type of breast lesion. • Fibroadenomas arise in breast lobules and are composed of fibrous
and epithelial tissue. They present as firm, non-tender, highly
mobile palpable lumps. Hormones seem to be involved in
aetiology, and hormone replacement therapy (HRT) increases the
Each breast has multiple milk ducts that converge into an outlet in the nipple. Pathology can only be confined to one nipple. If blocked can become engorged, painful and susceptible to infection.
Mammary duct ectasia
- dilation of major ducts, filled with creamy secretion with periodical inflammation - May be asymptomatic or nipple discharge, (bloody, serous, creamy white or yellow - retracted nipple - Acute inflammation - recurrent common infection.
Treatment : surgical excision of the major duct, correction of nipple retraction.
Generalised cellulitis of the breast
Treated with antibiotics.
Present with point tenderness, erythema, and fever.
Generally related to lactation
Non-lactational abscesses more frequent in smokers.
Caused by staph (usually require I &D) or strep (often more diffuse, superficial infection treated with local wound care and abx)
• Refer people via the suspected cancer pathway referral (to be seen
within two weeks) to a specialist breast clinic if they are: • Aged ≥30 and have an unexplained breast lump with or without pain; or •
Enlarged axillary lymph nodes. Aged ≥50 with any of the following symptoms in one nipple only: • Discharge • Retraction • Other changes of concern
• Consider a suspected cancer pathway
referral (for an appointment within 2
weeks) people: • With skin changes that suggest breast
cancer or • Aged 30 and over with an unexplained
lump in the axilla (new NICE
recommendation for 2015).
Consider non-urgent referral in people aged under 30 with an
unexplained breast lump with or without pain (new NICE
recommendation for 2015).
Describe stages of grief
What does normal breast tissue look like histologically?
What physiological changes are seen in breast tissue?
• Prepubertal breast – few lobules (before
puberty male and female breasts are identical) • Menarche – increase in number of lobules,
increased volume of interlobular stroma • Menstrual cycle – follicular phase lobules
quiescent, after ovulation cell proliferation and
stromal oedema, with menstruation see
decrease in size of lobules • Pregnancy – increase in size and number of
lobules, decrease in stroma, secretory changes
seen in breast tissue?
• Cessation of lactation – atrophy of lobules
but not to former levels • Increasing age – terminal duct lobular
units (TDLUs) decrease in number and
size, interlobular stroma replaced by
adipose tissue (mammograms easier to
What does breast tissue look like in pregnancy?
How can breast conditions present?
• Pain • Palpable mass • Nipple discharge • Skin changes • Lumpiness
• Mammographic abnormalities
Which breast conditions cause pain?
• May be cyclical and diffuse, in which case
often physiological • Non-cyclical and focal – ruptured cysts,
injury, inflammation • Occasionally presenting complaint in
Which breast conditions cause a palpable mass?
• Causes include:
– Normal nodularity
– Invasive carcinomas
– Cysts • Most worrying if hard, craggy and fixed • No woman should be allowed to have a
lump in the breast without a firm diagnosis
Which breast conditions cause mammographic abnormalities?
• Worrying findings include densities and
– Densities – invasive carcinomas, fibroadenomas,
cysts – Calcifications – ductal carcinoma in situ (DCIS),
• Found during mammographic screening • Women between 47-73 years invited every 3
years • Easier to detect lesions in breasts of older
Are breast conditions common?
• Breast symptoms and signs are common • Most breast symptoms and signs will be
benign • Fibroadenoma most common benign
tumour • Breast cancer most common non-skin
malignancy in women • Mammographic screening increases
detection of small invasive tumours and in
What are the common breast condition?
– Can occur at any age during reproductive
period – Often <30 years
• Phyllodes tumours
– Most present in 6th decade
• Breast cancer
– Rare before 25 years (except for some
familial cases) – Incidence rises with age – 77% occurs in women >50 years – Average age at diagnosis is 64 years – In UK:
• 45,500 new female cases and 300 new male cases
a year • 12,500 deaths per year
How do we classify pathological conditions of the breast?
• Disorders of development • Inflammatory conditions • Benign epithelial lesions • Stromal tumours • Gynaecomastia • Breast carcinoma
What inflammatory conditions can be Seen in the breasts?
• Acute mastitis
– Almost always occurs during lactation
– Usually Staphylococcus aureus infection from
nipple cracks and fissures – Erythematous painful breast, often pyrexia – May produce breast abscesses – Usually treated by expressing milk and
• Fat necrosis
– Presents as a mass, skin changes or
mammographic abnormality – Often history of trauma or surgery – Can mimic carcinoma clinically and
What benign epithelial lesions can be seen in the breasts?
• Fibrocystic change
– Commonest breast lesion
– May present as a mass or mammographic
abnormality – Mass often disappears after fine needle
aspiration (FNA) – Histology – cyst formation, fibrosis and
apocrine metaplasia – Can mimic carcinoma clinically and
What stromal tumours can be seen in the breasts?
• Stromal tumours – e.g., fibroadenoma, phyllodes tumours,
lipoma, leiomyoma, hamartoma • Fibroadenomas
– Present with a mass, usually mobile, or mammographic
abnormality – ‘Breast mouse’ – mobile and elusive – Can be multiple and bilateral – Can grow very large and replace most of the breast – Macroscopically - well circumscribed, rubbery,
greyish/white – Histology - composed of a mixture of stromal and epithelial
elements – Can mimic carcinoma clinically and mammographically – Localised hyperplasia rather than true neoplasm
What is gynaecomastia?
• Enlargement of male breast • Unilateral or bilateral • Often seen at puberty and in the elderly • Caused by relative decrease in androgen effect or
increase in oestrogen effect • Can mimic male breast cancer especially if
unilateral • No increased risk of cancer
What causes gynaecomastia?
– Occurs in most neonates secondary to
circulating maternal and placental oestrogens
– Transient gynaecomastia affects more than
half of boys in puberty as oestrogen production
peaks earlier than that of testosterone – Klinefelter’s syndrome
– Oestrogen excess - cirrhosis of the liver (when
oestrogen not metabolised effectively) – Gonadotrophin excess - functioning testicular
tumour, e.g., Leydig and Sertoli cell tumours,
testicular germ cell tumours
– Drug-related – spironolactone, chlorpromazine,
digitalis, cimetidine, alcohol, marijuana,
heroin , anabolic steroids