Breast Conditions

Many breast conditions can present with a lump, which can be malignant or benign.
– When this happens, standard procedure is to conduct a triple assessment, which involves three types of tests:
i) Clinical examination – must involve a chaperone (not a family member)
ii) Radiology – Ultrasound for <35years; mammography and ultrasound for >35 years old
iii) Histology – Fine needle aspiration (FNA) or core biopsy for new lumps

  • Mastitis

This is a condition which refers to inflammation of the breast
– Associated with breastfeeding: milk stasis can cause an inflammatory response -> may then get secondary infection, most commonly with staphylococcus aureus

Symptoms: Erythematous, tender, swollen area of breast
– Systemic upset with fevers, chills and fatigue

Treatment: 1st line is to advise continue breastfeeding, ensuring the breast is fully emptied
– If symptoms do not improve after 24hours of milk removal –> Flucloxacillin 10-14 days

N.B. If this is left untreated in may develop into a breast abscess.

Symptoms
– Gives a tender, red fluctuant mass + associated with history of lactational mastitis

Management
– Urgent referral to surgeon for aspiration/drainage + flucloxacillin

 

  • Mammary duct ectasia

This is dilation and shortening of the subareolar ducts. It causes ducts to become blocked and the secretions to stagnate – Classically arises around menopause in women (>50 years) who have multiple children.

Symptoms:
Presents with thick green-brown nipple discharge + lump behind the nipple

Management:
Refer to gynaecology and advise to stop smoking à the condition is usually self-limiting

 

  • Periductal mastitis

This refers to an inflammatory condition of the subareolar ducts.
– Unlike mammary duct ectasia, it tends to occur in younger women
– The cause of this inflammatory condition is unknown, but smoking is a major risk factor
– It can lead to mastitis, abscess formation and development of fistulae between subareolar ducts and the skin

 

  • Fat necrosis

This is the necrosis of breast fat – usually occur following injury to the fatty breast tissue (e.g. by minor trauma or breast biopsy, radiotherapy or surgery)

Symptoms:
Firm, round breast lump
– May be accompanied by changes of the overlying skin (e.g. red, bruised)

Tests:
Triple Assessment to rule out breast cancer

Management
– No treatment is needed once the diagnosis is confirmed

  • Fibrocystic change/Fibroadenosis

This is the development of fibrosis and cystic changes in the breast
– Most commonly occurs in women in their 40s.

Symptoms
– Lumpy, nodular breasts –> fibrosis is firm/rubbery, cysts are soft + fluctuant
– May be accompanied by breast pain
– Symptoms may fluctuate throughout the menstrual cycle, getting worse just before the time of menstruation

Tests
– Triple assessment to rule out breast cancer if suspected

Management
– Analgesia

  • Fibroadenoma

This is a benign tumour that forms from a breast lobule and is composed of both fibrous and glandular tissue
– It is commonly seen in premenopausal women (<30 years), but there is no increase in the risk of malignancy

Symptoms
– Well circumscribed, non-tender highly mobile marble-like mass
– 1/3 get larger, 1/3 reduce, 1/3 stay the same

Tests
– Triple assessment to rule out breast cancer

Treatment
– Usually none needed, surgical excision if large or complex

 

  • Intraductal Papilloma

This is the growth of a benign wart-like lump that develops in large mammary ducts
– It is completely benign but the most common cause of bloody nipple discharge in women ages 20-40

Symptoms
– Clear or blood-stained nipple discharge, but they are too small to be palpated

Tests
– Can be detected on ultrasound. Galactogram is definitive test

Management
– Surgical excision if symptomatic

 

  • Breast cancer

This is the most common carcinoma in women, and 2nd most common cancer death in women

Risk factors
– These are related to oestrogen exposure and specific genes
– Age (most breast cancers occur in women >50yrs)
– Early menarche/lase menopause
– Obesity
– Not breastfeeding
– Combined oral contraceptive pill/combined HRT
– 1st degree relative with breast cancer
– BRCA1 and 2 gene mutations
– Li-Fraumeni syndrome – autosomal dominant mutations in p53 tumour suppressor gene.
–> Leads to high incidence of sarcomas and leukhaemias
–> Diagnosed if patient gets sarcoma < 45 years and first degree relative + family member gets cancer < 45 years

 

There are many different types of breast cancer, which have a specific pathology:
i) Ductal carcinoma in situ (DCIS)
– Proliferation of duct cells with no invasion of the basement membrane

 

ii) Invasive ductal carcinoma
– malignant proliferation of ductal cells
– This is the most common invasive carcinoma in the breast, called non-special type with tumour marker CA 15-3
– Tends to occur in older women (70 years) with a better prognosis

iii) Lobular carcinoma in situ
–proliferation of cells in lobules with no invasion of the basement membrane
– This does not produce a mass or calcification and is discovered incidentally

 

iv) Invasive lobular carcinoma
– a malignant proliferation of lobule cells associated with e-cadherin mutations

v) Hereditary breast cancer
– associated with BRCA1 and BRCA2 mutations which are autosomal dominant
– This gives 40% lifetime risk of breast + ovarian cancer (BRCA2 also gives prostate cancer in men) so women undergo bilateral mastectomy to reduce risk of getting cancer

 

vi) Inflammatory breast cancer
– cancer cells block lymph drainage giving inflamed “orange-peel” breast appearance

 

vii) Paget disease of the breast =
An eczematous change of the nipple associated with breast cancer
– It presents as nipple ulceration and erythema (looking like eczema) that can give bloody discharge

Screening
– Women aged 43-73 are offered a mammogram every 3 years to screen for breast cancer

Investigation
– All lumps undergo triple assessment

Management – Usually involves curative surgery with neoadjuvant and adjuvant chemoradiotherapy: – Surgery ➔ This is the definitive curative treatment which is given to most women with breast cancer. – Types include:

  • Wide local excision (a.k.a. ‘lumpectomy) = removal of the cancer + a margin of normal breast tissue – Mastectomy = removal of the entire breast
  • Decision is based on size, location and number of cancerous lesions as well as patient preference
  • All women who have wide local excision are offered radiotherapy to reduce recurrence risk

– Drug treatments ➔ These include chemotherapy, hormone therapy and biological therapy
– Used before surgery to reduce the size of the cancer –> neoadjuvant therapy
– Can also be used after surgery to reduce the risk of recurrence –> adjuvant therapy

 

To determine which drug treatment will be most effective, breast cancers are tested for the presence of oestrogen receptors (ER), progesterone receptors (PR) and human epidermal growth receptors (HER2).

 

ER positive cancers

HER-2 positive cancers

Triple negative cancers

Hormone therapy used:
– Pre-menopause: Tamoxifen or GnRH analogue
– Post-menopause:
Anastrozole (aromatase inhibitor)

Biological therapy used:
Trastuzumab (Herceptin)
– Not used in heart disorder patients.
– Need an ECG and echo before treatment is started + regular cardiac tests)

Chemotherapy used:
– Usually a combination of drugs
– One specific regimen is FEC-T: fluorouracil, epirubicin, cyclophosphamide, docetaxel

 

NICE Referral Guidelines:

Urgent (2 weeks):
if Age > 30 with unexplained breast lump with or without pain

if Age > 50 with any of following symptoms in one nipple only: discharge, retraction or other changes that are concerning

 

Non-urgent referral:
if Age < 30 unexplained breast lump with or without pain

Atlas of clinical surgery; with special reference to diagnosis and treatment for practitioners and students (1908). Bockenheimer, Ph. (Philipp), b. 1875
Wellcome Images/ CC BY (https://creativecommons.org/licenses/by/4.0)
https://cks.nice.org.uk/breast-cancer-recognition-and-referral#!scenario

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