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Benign Breast Disease - Coggle Diagram
Benign Breast Disease
Mastalgia
Breast Pain
Need to Contrast from Chest Wall Pain
Features
Unilateral -> Broguht on by activity
Lateral or medial in breast
Reproduced by pressure on specific area
Post menopausal women not taking HRT are more likely to have chest wall
Treatment
Reassurance, NSAIDS, If localize, prednisolone + Bupivicaine
Causes
Non Cyclinical
Non Breast
Cervical/thoracic spondylosis, lung disease, gallstones, HRT, Thoracic outlet syndrome
True Breast
Diffuse breast pain, triggers spots in breast
Chest wall
Tietze's Syndrome
Characteristics
Typically cyclinical (worst the week priro to menses and relieved with onset
Treatment
Reassurance, NSAIDs, Lifestyle modifiction, Medications (Danazol, Tamoxifen)
Nipple Discharge
Causes
Physiological, duct ectasia, Mild Inflammation, Post-Partum, papilloma, DCIS, Invasive Ca, Abscess, Rare (Endocrine, Joggers nipple)
Risk Factors for pathologic Discharge
Spontaenous, Bloody, Unilateral, Uniductal, Associated mass, abnormal imaging, Age >60
Galactorrhea
Milk Secretion can continue up to 6 months post-partum and post cessation of breast feeding
Bloody nipple discharge can be seen in 2nd and 3rd trimester and is usually benign
Workup
Prolactin Level
Not Elevated: No Treatment Needed or dopamine agonist if galactorrhea is bothersome
Elevated: TSH (Hypothyroidism), hCG (Pregnancy), Creatine (Renal Insufficiency), Medication (Discontinue/replaces), No other causes (Lesion -> Dopamine agonist)
Physiologic Nipple Discharge
Usually bilateral, can be milky and multi-ductal, can be unilateral and variety of colours
Pathologic Nipple Discharge
Spontaneous, single duct, unilateral, clear, blood, serous
Diagnostic Work-up
History and Physical, FOcused ultrasound, Mammogram if >35, consider MRI, Cytology, Ductoscopy
Surgical Approaches: Terminal/total duct excision, selective excision or microductectomy (lacrimal probe guided, blue dye guided, ductoscopy guided)
Palpable Lump
History
HPI
Onset, variation with time, associated symptoms, any prior breast disease/lumps
Breast Cancer Risk Factors
Age at menarche, menopause, OCP use, hormone replacement, hx of breast cancer in the family, partiy, age of first live birth, previous biopsies and investigation, history of radiation
Systemic Symtpoms
Weight changes, Energy, Appetite
Physical Examination
Benign (smooth, round, mobile, rubbery)
Malignant (Hard, irregular, non-mobile at times, fixed to skin or pectoralis muscle, less well defined borders)
Non-Proliferative
Fibroadenomas
Most common, occurs in 10% of women
Presentation
Discrete, firm, mobile, well defined (may be multilobulated),
Characteristics
displace rather than invade breast tissue, hormonally sensitive, carriers no risk of carcinoma
Solid mass, proliferation of glandular tissue and stromal elements
Defintiions
Giant
5 cm
Juvenile
5 cm, rapidly growing in teenagers
Treatment
Observe, Surgical Excision
Complex
Fibroadenoma with sclerosing adenosis, papillary apocrine hyperplasia, cysts, or epithelial calcifications
Vs Phyllodes
Characterized by "leaf-like" stroma increased stromal cellularity
Management
Excise without margin
Cyst
Simple
Characteristics
Commonly in 30s, 40s but diminishes after menopasue
Ultrasound
Round oval shape, anechoic, sharp demarchation
Treatment
Symptomatic: Ultrasound guided aspiration
Complicated
Characteristics
Thickened wall, thickened internal septations, mix of cystic and solid components, assoicated mass lesion
CNB
Should undergo CNB, cysts that do not collapse after aspiration should undergo CNB
Apocrine Metaplasia
Dilated ducts and adjacents cysts can contain inspissated secretions which can calcify
Not thoguht to elevate teh risk
No Treatment required
Mild Hyperplasia
Hyperplasia = Increased cell proliferation
Ducts normally have 2 layers of epihtelail cells
Mild ductal hyperplasia = 3 layers
Fat necorsis of the Breast
Presentation
Pseudo-mass, may cause breast cancer pain
Etiology
Breast injury -> Gradual change of fatty breast tissue into scar/oil cyst
Physical Exam
Firm irregular nodule
Imagine
Dense spiculated and irregular mass associated with coarse calcifations
Diagnostic
Core biopsy
Pseudoangiomatous Stromal Hyperplasia
Charactersitics
Benign stromal proliferation mimicking vascular lesion
Imaging
Solid, well-defined, non-calcified mass
Treatment
Surgical Excision if: Discordant, suspicious, symtpomatic, enlarging/changing
Proliferative
Papilloma
Characteristics
Polyps of epihtlium lined breast ducts, exists on fibrovacular stalk, locaed close to areola, presents as spontaneous nipple discharge, found with ultrasound
Treatment
Excise is discordant, palpable, atypia present, size >1 cm, symptomatic age >60
Radial Scar
Characteristics
Fibroelastic core entrapped ducts with surrounding radiating ducts
Radial Scar <1 cm
Complex sclerosing lesion >1 cm
Treatment
Surgical excision if atypia, >1 cm, discordant, incompletely remed with biopsy
Sclerosing adenosis
Adenosis: Fibrocystic change resulting from an increase in number of acini
Sclerosing: Proliferative disease wherby number is double, and acini lose normal appearance
Proliferative with Atypia
Atypical Ductal Hyperplasia
Epihtelial proliferative lesion that demonstrates cytologic and architectural changes
ADH <2 ducts and <2 mm
Therefore can be difficult to impossible to different ADH from DCIS on CNB
Treatment
Excise
Atypical Lobular Hyperplasia
Different entity than ADH
Proliferative lesion in whcih the epithelial cells grow in a confluent fashion
Treatment
Excise if discordant, incompletely sampled
Lobular Carcinoma in Situ
Typucally an incidental finding but may be associated with microcalcs
Historic upgrade rates
Treatment
Excise if discordant, inadequately sampled
Breast Infections
Lactational
Mastitis
Signs and Symptoms
Found commonly in breast feeding patients, erythema, fever, tenderness, leukocytosis, warmth to skin
Pathophysiology
Arises from entry of bacteria through the nipple into duct system
With Abscess
Physical Presentation
Red, Swollen, hard, tender, hot
Etiology
Typically a bacterial through infection through damaged nipple during breast feeding
Most often Staph Aureus
Characteristics
Central cavity with pus, inflammatory infiltration with involvement of gland, foamy histiocytes in regional dilated ducts
Treatment
Warm compresses, analgesics and NSAIDS, repeated aspiration, Oral antibiotics, continue breast feeding/using breast pump, percutaneous drainage
Non-Lactational
Abscess
Peridutal Mastitis
Squamous metaplasia -> KEratin plugs -> Build up of cellular debris and ductal distension -> Secondary infection due to stagnantion -> Periareolar fistula can develop to relieve pressure
Treatment
Ultrasound guided drainage
Incision and drainage
Fistula dn duct excision
Granulomatous Mastitis
Pathophysiology
Unknown
Risk Factors
Young age, asian descent, recent pregnancy, breastfeeding, non-smokers
Characteristics
Non-caseating granulomas, micro/macro abscesses, multinucleated giant cells, lymphocytes, plasma cells, esosinophils, cystic changes with neutrophillic infiltrates
Management
General Principles: treat bacterial/fungal infections, avoid surgery, many cases are self-limited
Mondor's Disease
Chracteristics
Superficial thromboplebitis of teh anterolateral thoracoabdominal wall (self-limiting)
Treatment
Heat, anti-inflammatory medications, supportive bra
Gynecomastia
Defintiion
Excessive development of male breast tissue caused by increased ratio of estrogens/androgens
Etiology
Physiologic/Idiiopathy
Non-physiologic: pharmacologic/Pathologic
True Vs False
True
Increase in breast size secondary to glandular hypertrophy
Pseudo
Increase in breast size secondary to dysplasia
Treatment
Non-Surgical
Reasurance, tamoxifen, anastrazol, danazol
Surgery
Symptomatic patients, adolescent males with persistent enlargemnet, long duration leading to fibroids, patients at risk for carcinoma