define mastalgia and the different kinds
breast pain can be cyclical = associated with menstrual cycle
- usually bilateral
- caused by hormonal changes, starts a few days before period and end when it ends
- seen in menstruating and HRT using women
non- cyclical = unrelated to menstrual cycle
- can be medical = hormonal contraceptives, antidepressants (sertraline), antipsychotics (haloperidol)
- extramammary pain = chest or shoulder pain -
- gallstones
- angina
- Tietze’s syndrome
- Bornholm disease
What investigations do you do when you have breast pain
- pregnancy test
- mammography/mammogram
- US
- ductogram
How would you manage breast pain?
Conservative
- topical NSAIDS, paracetamol, ibuprofen
- firm better fitting bra (cyclial pain)
- reassurance
- Danazol (anti-gonadogrophin agent)
- (SE = dizziness, nausea, weight gain)
what are the 2 kinds of invasive carcinoma of the breast
invasive ductal carcinoma (80%)
invasive lobular carcinoma
How does invasive breast carcinoma present?
- Asymmetry = Breast lump or swelling
- abnormal nipple discharge
- nipple retraction
- skin changes eg. dimpling, paget’s (ulceration of nipple), peau d’orange
- mastalgia
- palpable lump in axilla
What increases your risk of developing invasive breast carcinoma?
- female
- old age
- BRCA1/2
- FHx of 1st degree relative
- previous benign disease
- obesity
- alcohol
- increased exposure to oestrogen eg. early menarche + late menopause
How would you manage invasive breast cancer?
- 50-70 y/o women have a mammogram every 3 years
- triple assessment for investigation (exam, imaging, histology)
MEDICAL
- check for receptor status for targeted therapy options (HER2, Oestrogen receptor, Progesterone receptor sensitivity)
- hormonal therapy after surgery or for those unfit for surgery
- tamoxifen
- premenopauseal women, blocks oestrogen receptors BUT i_ncreases risk of thromboembolism and uterine cancer_
- aromatase inhibitors eg. letrozole, anastrozole
- post-menopausal women, binds to oestrogen receptors BUT expensive
- tamoxifen
- Immunotherapy = HER2 positive cancers treated with Herceptin (Trastuzumab)
SURGICAL
- Wide Lobe excision (leave 1cm margin of normal tissue)
- curative Mastectomy (remove whole breast)
- prophylactive mastectomy (BRCA1/2, previous Hx, FHx)
- axillar surgery (sentinal node biopsy or axillary node clearance sent for histology)
What are the different options for breast reconstruction after surgery?
- Wide lobe excision + breast reduction technique (nipple and areola preserved + blood supply)
- Flap formation
- Latissimus dorsi flap (smaller breast)
- Transverse Rectus Abdominus Muscle flap (uses abdo fat, muscle, skin)
- Deep Inferior Epigastric Perforator Flap (uses abdo tissue and skin, no muscle)
define a carcinoma in situ, and the two most common types in breast.
a carcinoma that is contained within the basement membrane tissue (pre-malignant)
1) ductal carcinoma in situ (most common)
2) lobular carcinoma in situ (greater risk of developing into invasive breast malignancy)
How would you manage carcinoma insitu in breasts?
DCIS
- appears as microcalcifications on mammography, confirm with biopsy.
- complete wide excision or complete mastectomy if widespread.
LCIS
- monitored first
- bilateral prophylactic mastectomy for those with BRCA1/2
Define mastitis and how is it classified
inflammation of the breast tissue, commonly from S.Aureus
- Lactational mastitis
- presents in first 3 months of breastfeeding. associated with cracked nipples, milk stasis, poor feeding technique
- Non lactational mastitis
- presents in women with other conditions eg. duct ectasia (per-ductal mastitis)
- smoking is a huge risk as it damages sub-areolar duct walls, predisposing to bacterial infection
How does mastitis present?
tender, swollen, erythematous irritated breast.
What are some complications of mastitis?
- breast abscess = collection of pus in breast lined with granulation tissue
- confirm via US guided aspiration
- incise + drain + local anaesthetic + antibiotics
- complications = mammary duct fistulas can form on drainage
How would you manage mastitis?
- antibiotics
- analgesics
- dopamine agonists like cabergoline
What is a breast cyst and how do they present?
- benign epithelial lined fluid filled cavities that form usually in perimenopausal women
- single or multiple
- smooth, fluid filled, not fixed
- may be tender
- halo shaped on mammography
How would you diagnose and manage a breast cyst?
- US and aspiration
- Send cystic fluid to cytology exclude cancer if there is no blood or lump disappears
- cysts can be fully aspirated for cosmetic reasons, but most self-resolve.
What complications can happen from breast cysts?
fibroadenosis due to multiple small cysts and fibrotic areas
It is benign but associated with asymmetry and can mask malignancy
define mammary duct ectasia
- dilation and shortening of the major lactiferous ducts
- common in perimenopausal women
- Occurs because the ducts become blocked and secretions stagnate
How does mammary duct ectasia present?
- yellow/green nipple discharge (any blood stained discharge sent for triple assessment)
- palpable mass
- nipple retraction
- dilated calcified ducts on mammography
- multiple plasma cells (plasma cell mastitis) on histology
How would you manage mammary duct ectasia?
- stop smoking
- duct excision if nipple discharge does not stop
what is fat necrosis of the breast?
- due to an acute inflammatory response, ischaemic necrosis of fat lobules occurs.
- usually a response to blunt trauma of the breast
- results in fibrosis and calcification after breast tissue injury.
How does fat necrosis present?
- asymptomatic
- a lump
- fluid discharge
- skin dimpling
- pain
- nipple inversion
- sometimes a solid irregular lump due to chronic fibrotic change caused by the inflammatory response
- positive traumatic Hx
- hyperechoic mass on US
- on mammogram mimics the way a carcinoma would look (calcified, irregular masses) so biopsy to rule out
define gynaecomastia
males develop breast tissue due to an imbalanced ratio of oestrogen & androgen activity
enlarged hyperplasia of breast tissue
What are some common causes of gynaecomastia
physiological gynaecomastia:
- delayed testosterone surge relative to oestrogen at puberty
- decreasing testosterone levels in old age
pathological gynaecomastia:
- lack of testosterone eg. androgen insensitivity, renal disease, testicular atrophy
- increased oestrogen levels eg. Leydig cell tumours, liver disease, obesity, adrenal tumours, hyperthyroidism
- medication eg. digoxin, metronidazole, spironolactone, chemo, antipsychotics, anabolic steroids
