Disclaimer no conflict of interest

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1 Disclaimer no conflict of interest

2 Benign Breast Disease Alison Hayes FRACS

3 Content Clinical assessment of the breast Triple assessment Focal nodularity Breast pain Cysts Infection Nipple discharge Gynaecomastia

4 Clinical Assessment of the Breast Breast parenchyma tends to be lumpy Adipose tissue makes the breast feel smooth progressive glandular atrophy and fat accumulation begins to occur around menopause

5 What is triple assessment? Clinical examination Imaging Pathology (FNA/core biopsy)

6 Case 1 : 37 year old woman presents with asymmetrical area of thickening in R) breast what would you do? A) Reassure her there is no lump B) Perform a fine needle aspirate C) Refer to a Breast Specialist +/- request imaging D) Treat with a course of antibiotics

7 Answer C Refer to specialist +/- imaging Asymmetrical thickening/ focal nodularity difficult Imaging required Mammography/USS Biopsy may be required Refer for an opinion

8 What can cause focal nodularity? fibrocystic change islands of glandular tissue cluster of microcysts cancer

9 Case 2 47 year old woman complains of breast pain. What would you do? a) Reassure her it is normal to experience discomfort with hormonal fluctuations b) Take a full history and examine breasts & chest wall c) suggest trial of evening primrose oil d) advise reduction in caffeine intake

10 Answer B History/Examination aim is first to determine whether pain due to normal physiologic changes or due to a pathologic process requires thorough history and examination Cyclical pain 2/3 of cases Non cyclical pain multiple etiologies Referred pain

11 Pertinent questions to ask in the history Pattern /relation to cycle/effect of movement Severity & interference with ADL s Patient concerns Recent history of trauma thorough evaluation of physical activity

12 Examination of the chest wall

13 Management of Breast Pain Cyclical pain 20-30% resolve Simple analgesia Severe pain requires a pain diary +refer Non cyclical pain treat reversible causes Referred pain 50% resolve spont NSAID s local anaesthetic/steroid injection for point tenderness

14 Investigations? Mammography (women 35 years) Can help determine aetiology in non cyclical pain In any woman with abnormalities on examination Exclude cancer Reassurance??

15 Case 3 42 year old woman presents with a tense smooth, discrete & balotable lump. What should you do? a) Aspirate as it is likely to be a cyst b) Refer for a mammogram and ultrasound c) Reassure her it is probably a cyst and nothing is required d) Perform an ultrasound in your rooms +/- aspiration

16 Answer B refer for Mamm/USS it may not be a cyst! cysts may be simple or complex. The difference is NOT distinguishable on clinical examination alone. Imaging is ALWAYS required breast USS requires a high frequency probe and is a difficult skill to learn. complex cysts can have subtle findings which can be easily missed, especially if aspirated before imaging

17 Breast Cysts Result from fluid distension of terminal lobule/duct unit Solitary or multiple masses smooth, firm, tender mass cluster of small masses or ill defined mass Management Simple cyst Complex USS aspiration if large/symptomatic USS guided Biopsy of solid component clip placement & Require follow-up

18 Breast Infection Parenchymal Lactating Non- Lactating - central/sub areola Peripheral Skin related Sebaceous cysts Hidradenitis suppurativa intertrigo

19 What is the most appropriate management? a) Prescribe 10/7 course of flucloxacillin (if no penicillin allergy) b) Encourage milk flow c) Review in 48 hours & refer to hospital if worsening or area feels fluctuant d) All of the above

20 Answer D all of the above common first 6/52, initially localised segment Rx fluclox/co amoxiclav 10 days (non penicillin allergic) no evidence for antifungal treatment

21 What is the most appropriate initial management? a) Antifungal cream b) Refer for a mammogram/uss c) Co-amoxyclav for 10/7 if not penicillin allergic d) Steroid cream

22 Answer C co-amoxiclav Central/subareolar 1 periductal mastitis presentation subareolar inflammation, abscess, fistula Rx co-amoxiclav Smoking cessation advice and support When to Refer - suspicion of abscess recurrent infection/abscess suspicion of fistula

23 Peripheral Breast Infection Less common associations - diabetes, steroids, trauma, RA granulomatous lobular mastitis * All require mammography 4-6 weeks later

24 Skin related infection Sebaceous cysts Hidradenitis suppurativa Intertrigo Keep area clean and dry Avoid creams and talcum powder No role for anti-fungals

25 Which are features of pathological nipple discharge? a) Unilateral spontaneous discharge b) Discharge from a single duct c) Blood stained discharge d) Serous discharge from a single duct e) All of the above

26 Answer E all of the above Causes of Pathologic discharge - papilloma ( 55%) - duct ectasia - fibrocystic change - malignancy (10-15%)

27 Intraduct papilloma

28 Duct Ectasia

29 Nipple Discharge 20% of women can express fluid most discharge is benign differentiate physiological from pathological discharge Physiological - bilateral/ multi-duct - opalescent/green/brown - usually expressed - galactorrhea

30 Pertinent points in the History is discharge spontaneous or expressed? what is the colour? medical hx and medications menstrual hx (if milky, multi-duct & bilateral) hx of trauma or recent surgery

31 Features to look for on examination Full Breast examination Nipple position, retraction, ulceration, masses Elicit discharge BOTH nipples Single or multiple ducts Colour Test discharge for Hb on urine dipstick (sensitivity 50%) Imaging focused USS + Mammography ( 35yrs)

32 Nipple Discharge Who to refer Those with unilateral or bloody discharge Troublesome multi-duct discharge Women with a mass New onset nipple retraction

33 What is the diagnosis A) Inflammatory breast cancer B) Pagets disease C) Fungal infection D) Eczema

34 What are these lesions? What else needs to be considered?

35 A) pseudo-gynaecomastia What is the most likely diagnosis B) breast cancer C) gynaecomastia D) ruptured pectoralis implant

36 Answer C - Gynaecomastia Aetiology idiopathic physiological trimodal pattern production production pathological decreased androgen increased oestrogen increased aromatization Drugs medication, illicit and supplements

37 Pertinent features in the history Drug hx inc recreational, anabolic steroids, alcohol Medical hx renal, hepatic, testicular complaints Sx of low testosterone Previous cancers & treatment Family hx breast, ovarian, prostate ca Effect on quality of life

38 Examine the patient Breasts, axillae Abdomen Testes!

39 Gynaecomastia work up Imaging - > 40 yrs mammography, < 40 yrs USS/discrete lesions U&E, LFT, Prolactin, LH, FSH, testosterone, oestradiol, ßHCG, AFP, thyroid function Refer first or with results of above Core biopsy if discrete lesion or indeterminate imaging

40 Management of Gynaecomastia Dependent on cause Reassurance if physiologic Reverse/treat identifiable causes if possible Medical treatment - tamoxifen Surgical options liposuction, subcutaneous mastectomy

41 Summary Benign breast conditions are much more common than cancers but women worry about cancer Work up aims to determine aetiology + exclude cancer History and examination are key Beware of focal or benign feeling abnormalities in young women Most women will require imaging Refer all patients with suspicious examination findings +/or when initial treatment fails to resolve the problem Call for advice if you are not sure

42 Thank you for your time Alison Hayes FRACS