Benign breast disease

Treatment of puerperal mastitis

- Infectious mastitis = 10 days flucloxacillin (2nd line if allergic to penicillin - erythromycin), warm compresses, paracetamol, encourage patient to continue breast-feeding with the unaffected breast and once let-down occurs in the affected breast, feed with the affected breast until it is completely empty (no risk of passing infection to child as inflammation not in ducts but in the surrounding soft tissue) - Abscess = identified by US and treated with open incision (+ irrigations with saline or local anaesthetic) or percutaneous drainage (+ send swabs for culture) + antibiotics (most effective when abscess drained dry) --- repeated aspiration may be required therefore review twice a week initially --- overlying skin necrosis is an indication for surgical debridement, which may be complicated by the development of a subsequent mammary duct fistula

Phyllodes tumour

Hypercellular strome with atypia Rare tumour that tends to occur in women 40-50yo Usually >4cm and history of recent growth May be benign, borderline or malignant Treatment = wide-local excision + mammograms every 2 years thereafter as benign tumours may re-appear after excision and may become malignant

Epithelial hyperplasia

Increased cellularity of terminal lobular unit, atypical features may be present Variable clinical presentation ranging from generalised lumpiness through to discrete lump Atypical features and family history of breast cancer confers greatly increased risk of malignancy No atypical features = conservative management Atypical features = close monitoring or surgical resection

What is mastitis?

Inflammation of the breast - non-infectious or infectious

Puerperal mastitis

Inflammation of the breast in connection with pregnancy, breastfeeding or weaning Infection of mammary duct often associated with lactation (usually S.aureus) in breastfeeding women in the first 6-weeks post-partum or when weaning (breast ducts become blocked with engorged milk, and bacteria enter from cracks in the nipple) but can be non-infectious (accumulation of milk causing an inflammatory response in the breast) 10-30% of breast-feeding women Painful, hot, swelling, red - usually peripheral in 1 breast Systemic features of infection May be engorgement of the breast and axillary lymphadenopathy Infectious mastitis may lead to breast abscess - tender, fluctuant lump with overlying erythema (tend to be systemically well as infection contained) Not possible to distinguish clinically between infectious and non-infectious mastitis Pregnant women who have not yet given birth do not get breast infections - if you think someone in this group has a breast infection they may have inflammatory carcinoma so arrange triple assessment

Sclerosing adenosis

Lobule sclerosis - benign May cause a lump, pain or be found on routine assessment Can be very difficult to distinguish from malignancy - biopsy is often advised

Most common presenting breast symptoms

Lump, pain

Gynaecomastia investigations

Triple assessment - examination: general, breast tissue, axillary lymph nodes, liver, testes (check for testicular atrophy or cancer) 18-60yo without an obvious cause from the history and examination and significant enlargement of breast tissue (not just fat): U+Es, LFTs, LH, FSH, testosterone, prolactin, alpha fetoprotein and beta HCG If abnormalities are identified from the history or examination further investigation such as testicular US or CXR may be warranted Mammograms recommended if >40yo Breast US recommended if discrete lesion present - may help distinguish fatty swelling from glandular breast tissue in younger men Discrete lesions should undergo core biopsy or FNA although be aware that cytology can be overcalled in gynaecomastia

Management of cyclical breast pain

1st line = well-fitted bra + analgesia Consider 2nd line treatments after 6 months (http://patient.info/doctor/breast-pain-pro) For patients with moderate or severe true cyclical breast pain which merits treatment, Tamoxifen 10-20mgs daily and other agents are occasionally used Antibiotics, diuretics, vitamin B6, vitamin E and progestogens (given orally or in a cream) have not been shown to be of value in cyclical mastalgia

Fibroadenoma epidemiology

2nd most common cause of breast mass in women <35yo (usually presents <35 but can occur up to menopause) Probably represents increased sensitivity to oestrogens Occur in about 1/2 of women who receive ciclosporin after renal transplant Complex and multiple fibroadenomas are associated with a two-fold increase in the risk of breast cancer

Physiological swelling and tenderness (AKA mammary dysplasia or cystic mastopathy)

50-60% of menstruating women experience some degree of tenderness and nodularity in the premenstrual phase which rapidly resolves with menstruation Less frequent with COCP Rare after menopause but may recur with HRT Management: reduction/avoidance of caffeine, vitamin E, pyridoxine, evening primrose oil

What % of people that present with chest pain will need specific treatment?

90%

Aberrations of normal breast development and involution (ANDI): many "benign diseases" of breast are very common with little or no consistent histological abnormality

<25yo (during breast development) - juvenile hypertrophy (due to stromal hypertrophy) - fibroadenoma (due to lobular hypertrophy) 25-35yo: - cyclical mastalgia/nodularity (diffuse or focal) due to cyclical activity - galactocoele (during lactation) - papilloma-duct discharge (during epithelial turnover) 35-55yo (when involution (shrinkage of an organ in old age or when inactive) sets in) - lobular: macro cysts, periductal mastitis - stromal: sclerosing lesions, hyperplasia, atypia - ductal ectasia

Questions to ask about nipple discharge

Amount Nature Colour Consistency Any blood? Spontaneous/provoked? Unilateral/bilateral? Single or multiple ducts?

Scleroing adenosis (radial scar (RS) and complex sclerosing lesions (CSL))

Arise in the breast without any previous trauma or surgery Not 'scars' in the true sense (likely aetiology either localised inflammatory reaction or ischaemia) Incidence rate risen significantly due to breast screening Appears as asymmetric density or tissue distortion on mammography and US (may mimic carcinoma) Usually presents as breast lump or pain Associated with atypical ductal hyperplasia and sometimes malignancy (50% of cases) - the associated cancer is usually low grade, tubular variety Excision recommended due to risk of malignancy

Fibroadenoma treatment

Assess by triple assessment Tutorial said: assess with US and if <5cm reassess in 6 months Observation and reassurance but if in doubt refer for US (usually conclusive) +/- FNA Check the lump regularly and to return if it starts to enlarge Surgical excision if large (>5cm) or previous investigations inconclusive and for peace of mind of doctor and patient (could by Phyllodes tumour)

Features suggestive of benign and malignant nipple inversion/retraction

Benign = symmetrical, slit-like Malignancy = asymmetrical, distorting, nipple pulled to side

Gynaecomastia

Benign enlargement of the male breast Often occurs in pubertal boys Common but rarely associated with significant pathology - often manifestation of a systemic condition

Atypical hyperplasia

Benign hyperplasia can occur in the ducts or the lobes Lobular carcinoma in situ may develop Risk increased in FMH of breast cancer Annual mammograms recommended

What is a fibroadenoma?

Benign overgrowth of collagenous mesenchyme of 1 breast lobule (terminal duct lobules) (under the age of 25 years the breast is usually classified as undergoing development - lobular units are being formed and a dense stroma is formed within the breast tissue which may result in the development of fibroadenomas)

Mammary duct ectasia

Benign, normal variant of breast involution Dilation of major ducts in subareolar region, containing eosinophilic granular secretions and foamy histiocytes which may undergo calcification Often multiple ducts and bilateral Primarily middle-aged to elderly parous women but can occasionally occur in children Smoking is a risk factor

Galactorrhoea

Copious, milky discharge from multiple ducts in both breasts due to hyperprolactinemia (often causes hyperplasia of Montgomery's tubercles - small rounded projections covering areolar glands) due to pituitary tumour or S/E of some drugs

Breast cyst

Benign, smooth, fluid-filled rounded lump (fluid within distended, involuted lobule) Not fixed to surrounding tissue i.e. mobile Soft and fluctuant when sac pressure is low but hard and painful if pressure is high Simple or complex May occur in multiple clusters Most common in women 35-55yo, esp peri-menopausal Assess using triple assessment: - "halo appearance" on mammography - US will confirm they are fluid-filled - diagnosis confirmed by US-guided FNA (aspiration should cause lump to disappear) Mostly benign but investigate any cysts with blood-stained aspirate or residual mass following aspiration, or which recurs after aspiration (30% recur after aspiration)

Intraduct papilloma

Benign, warty lesion just behind the areola, in the lumen of the mammary ducts Often picked up through screening as can be impalpable Presents as small lump of sticky (possibly blood-stained) discharge, usually from single duct Rarely undergo malignant change Young = multiple more likely 40s = single more likely Treated with microdochectomy

What should always be excluded in patients with an inflammatory lesion which is solid on aspiration and does not settle despite having adequate antibiotic treatment?

Breast cancer

Congenital absence or hypoplasia of breast

Breast doesn't respond to hormones during puberty - often unilateral Huge negative psychological effect Offer implant

Congenital extra nipple

Breast tissue can develop anywhere along the mammary line (from the axilla to groin) Spot or small mole in mammary line - suspect extra nipple Asymptomatic = do nothing Excise if uncomfortable

Mammary duct ectasia symptoms

Can mimic invasive carcinoma clinically May present in one of several ways: - Microcalcification on a routine mammogram (most common) - Nipple discharge - green/brown/like cheese, often blood-stained - Palpable tender subareolar mass - Non-cyclical mastalgia - Nipple inversion or retraction (often symmetrical and slit-like) If ruptures may cause local inflammation, sometimes referred to as 'plasma cell mastitis'

Hydradinitis suppuretiva

Chronic inflammation of the axillary apocrine sweat glands Recurrent infections, abscesses, scar formation Treatment: antibiotics, drainage of abscesses, excision of the affected area

Breast pain

Cyclical mastalgia: - Related to the menstrual cycle - usually worse in the latter half of the cycle and relieved by period - Tends to be in the upper outer quadrant(s) and may extend to the axillae - Mild, dull, throbbing ache - usually diffuse and bilateral Non-cyclical: - Constant or intermittent but not associated with the menstrual cycle - More likely to be unilateral or focal Extramammary (non-breast) pain - interpreted as having a cause within the breast but arises from elsewhere (the chest wall or other sources) e.g. musculoskeletal pain - more likely if localised pain in the mid-axillary line or lateral sternum - lingers for a few months - modify provoking activities e.g. lifting heavy objects, supportive bra, paracetamol, NSAIDs

Mammary duct ectasia investigations and treatment

Diagnosis made by combination of: mammography + US +/- ductography +/- ductal lavage and cytology Usually no treatment needed but persistent/recurrent cases managed with surgical total excision of ducts below the nipple (Hadfield's procedure)

Management of gynaecomastia

Directed at underlying cause if identified - refer to endocrine if needed Reassure patient if innocent nature of the condition and the fact that it often resolves spontaneously although this may take some months, especially in pubertal boys (do not attempt treatment in these cases!) If treatment is justified, tamoxifen 20mg daily for up to 6 months is recommended initially (aromatase inhibitors may be considered in older men) Surgery rarely required and results of open surgery are often disappointing Referral to a plastic surgeon for consideration of liposuction may be considered

Causes of gynaecomastia

Drugs - cannabis, alcohol, oestrogens used to treat prostate cancer, spironolactone, cimetidine, digoxin, omeprazole, bendroflumethiazide, allopurinol, anabolic steroids, opioids Decreased androgen production in Klinefelter's syndrome Increased oestrogen levels - chronic liver disease, thyrotoxicosis, some adrenal tumours, testicular cancers Neonatal gynaecomastia due to hormone exposure in utero - will resolve itself

Causes of blood-stained nipple discharge, other than malignancy

Duct ectasia Intraduct papilloma

Congenital accessory axillary breast

During development, some breast tissue left behind in the axilla Can become more prominent during pregnancy Can excise for cosmetic reasons

Breast abscess due to skin lesions

Epidermoid cysts, sebaceous cyst, hidradenitis - treat with flucloxacillin - abscesses due to skin lesions may require review in a few weeks to assess for excision of underlying lesion

Fat necrosis

Fibrosis and calcification often after injury or procedures (often trivial or unnoticed) to breast tissue Lump: usually painless, typically firm and round but may become hard and irregular, may increase in size initially Skin around it may look red, bruised or dimpled Tends to affect obese women with large, fatty breasts May be mistaken for breast cancer so always do tripple assessment Biopsy may be required for diagnosis No management needed as tend to resolve spontaneously but slowly

Drugs that cause mastalgia

HRT, COCP Antidepressants (including sertraline, venlafaxine and mirtazapine) Antipsychotics (including haloperidol) Cardiovascular drugs (including digoxin and spironolactone) Antibiotics (including metronidazole) and antifungals (including ketoconazole)

Breast nodularity/fibrocystic change/fibroadenosis

Normal, hormonally-mediated change with lumpiness of the breast and varying degrees of pain and tenderness Symptoms greatest 1 week before menstruation, decreases with menstruation Area of nodularity or thickening (rubbery, irregular), poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast Usually bilaterally symmetrical but if asymmetrical, review after 1 or 2 menstrual cycles (if symptoms persist - refer for further investigation) Treatment: well-fitted bra + analgesia

Infective mastitis/breast abscess - non-lactational

Occur as an extension of periductal mastitis Usually occur in young female smokers (most commonly), diabetics, immune compromised patients Usually found under areola Often associated with nipple inversion May occasionally discharge spontaneously through a fistula (usually at the areolocutaneous border) - treat with fistula and total duct excision Chronic recurrent course with noncyclical mastalgia, nipple discharge or retraction, peri-areolar abscess, subareolar mass or cellulitis of the overlying skin Treatment: co-amoxiclav (2nd line if allergic to penicillin = erythromycin + metronidazole) Follow-up and image to rule out mammary fistula or other underlying lesion

Gygantomastia

Overgrowth of breast tissue leading to massively oversized breasts Sometimes develop breast tissue inflammation which can lead to septic shock

Further questions to ask in breast history

PMH = any previous lumps/malignancies, previous mammograms/clinical breast examinations/USS?FNA/core biopsies Drugs e.g. HRT, the Pill? Number of pregnancies? Postnatal? Breast feeding? Age at first birth? Age of menarche? Age of menopause? FMH? - breast or ovarian cancer - what relation were/are they to you and when were they diagnosed? Screen for metastatic disease: weight loss, SOB, back pain, abdominal mass?

Ways of classifying benign breast diseases

Pathological classification (indication of potential future cancer risk): •Non-proliferative disorders - no increased risk •Proliferative disorders without atypia - mild to moderate increase in risk •Atypical hyperplasias - substantial increase in risk Clinical classification: •Physiological swelling and tenderness •Nodularity •Breast pain •Palpable breast lumps •Nipple discharge including galactorrhoea •Breast infection and inflammation

When to investigate nipple discharge

Persistent single duct discharge or blood-stained (micro- or macroscopic) discharge - can use urinalysis dipstick to test for microscopic blood

Features suggestive of physiological and malignant nipple discharge

Physiological (small amount of fluid may be expressed from multiple ducts by breast massage) = bilateral, multiple ducts, provoked, clear/serous Malignancy = unilateral, blood-stained, spontaneous, single duct

Questions to ask about breast lump

Previous lump? When was it first noticed? Pain? Nipple discharge (side, site, single duct, multiple duct, colour blood) or inversion? Skin changes? Change in size or any other way? Change in size related to menstrual cycle? First/last/latest period?

Risk factors for puerperal mastitis

Problems with attachment of infant to breast during feeding e.g. technique problems, anatomical anomalies Reduced number of feeds, or duration of feeds, leading to milk accumulation due to: partial bottle feeding, changes in regime, rapid weaning, painful breasts, preferred breast leading to accumulation in the other Pressure on the breast - tight clothing, seat belt, sleeping prone Nipple fissures, cracks and sores Trauma Blocked milk ducts

Poland syndrome

Rare birth defect Underdevelopment or absence of pectoralis muscle unilaterally Webbing of the fingers (cutaneous syndactyly) of the ipsilateral hand May also be rib cage abnormalities e.g. shortened ribs, and the ribs may be noticeable due to less subcutaneous fat Breast and nipple abnormalities may also occur, and axillary hair is sometimes sparse or abnormally placed Mostly affects right side of body and males

Lipoma

Rare, benign slow-growing tumour composed mainly of fat tissue encapsulated by a thin fibrous capsule Mostly found in 40-60yos, most commonly in post-menopausal women Tend to be <1cm and often not clinically palpable (often incidental findings on mammography) - usually painless, soft to touch, mobile if palpable Do not increase risk of breast cancer

Galactocele

Retention cyst containing milk or a milky substance caused by a protein plug that blocks off the outlet Seen in lactating women on cessation of lactation (once lactation has ended the cyst should resolve on its own without intervention Large, soft, fluctuating lump in lower part of breast, not usually painful Does not cause infection as the milk within is sterile and has no outlet to be contaminated via Draining is unsuccessful because the protein plug remains intact and milk production continues

Questions to ask about breast pain

SOCRATES - use pain chart to establish timing of symptoms Bilateral/unilateral? Related to menstrual cycle? Any relationship to activity Rule out cardiac chest pain History of trauma? Any associated problems? E.g. problems with: sleep, sex, work, quality of life

Mondor's disease

Self limiting, benign thrombophlebitis of the superficial vein on the breast and axilla Redness, pain and cord like thickening of the vein Rarely associated with underlying malignancy Treatment :NSAIDs

Symptoms of breast fibroadenoma

Smooth, mobile (therefore referred to as "breast mice" as they easily slip under your finger during examination), discrete, firm, rubbery lumps Most stop growing at 2-3cm Painless May be multiple Juvenile (form in early adolescence), common or giant (>4cm) 1/3 regress (especially after menopause), 1/3 stay the same, 1/3 get bigger

Congenital inverted nipple

Typically manifests in 20s and 30s Can become more prominent during pregnancy and breastfeeding Treatment: 1st line - suction device overnight 2nd line - surgery (risk of cutting milk ducts and preventing breastfeeding from the breast in the future, risk of losing nipple sensation or blood supply and become necrotic)