Benign Breast Disease Case Based Discussion Fayyaz Mazari and
Emma MacInnes Supervised by Miss Clare Rogers Regional Registrars
Teaching Day November 2013, Doncaster Royal Infirmary
Slide 2
Case Study 1 Miss X Age 29 years Referred by GP left breast
lump Husband noticed lump 2 weeks ago Doesnt self examine, not sure
how long its been there PMH = migraines Drugs = none regular Ex
smoker 2 children, both breast fed for a few weeks FH = maternal
cousin had breast cancer in 60s Periods regular, no hormonal
contraception
Slide 3
Miss X - Examination Looks generally well BMI 28 Breasts appear
symmetrical No skin tethering with movement Palpable lump in left
UOQ, ~2-3cm, firm, mobile No other abnormalities in either breast
or axilla P2 (probably benign) What is the next appropriate step in
management?
Slide 4
Miss X - Investigations Ultrasound 28mm well circumscribed,
Homogeneous, oval, hypoechoic mass, Typical of fibroadenoma. U2. Is
further imaging required? What are the next steps in management
?
Slide 5
Miss X - MDT 28 year old, no previous breast disease, P2, U2
Histology of core biopsies of left breast lesion (UOQ) showed
Typical fibroadenoma, stroma of low cellularity, regular cytology,
B2 MDT recommended reassure and discharge
Slide 6
Miss X Follow up Clinic Seen and given results of biopsy
Recommendation from MDT explained Miss X not happy wants lump
removing What are her options?
Slide 7
Miss X - Management Offered either vacuum assisted biopsy or
open excision under general anaesthetic as a day case Opts for
surgical excision of fibroadenoma Final histology confirms
fibroadenoma
Slide 8
Fibroadenoma An example of an ANDI benign breast presentation
(aberration in normal breast development and involution) Other
examples include cysts, cyclical mastalgia, duct ectasia Common,
mostly late teens/20s Can be giant if over 5cm Can be confused with
Phyllodes tumours
Slide 9
Fibroadenoma 25 y/o fibroadenomas should be core biopsied
Lesions >4cm should be excised Lesions rapidly growing should be
excised Lesions with any histological doubt should be excised
Slide 10
Case Study 2 Miss Y 42 year old lady Seen in A&E on
Saturday night Left sided breast pain 10 days, worsening Redness in
the LIQ adjacent to the NAC Tenderness in same area, no fluctuation
Systemically well Given Augmentin 625mg TDS Follow up appointment
arranged in breast clinic in 3 days
Slide 11
Miss Y More history PMH hypothyroid, diet controlled diabetes
Previous breast disease - none Drugs Levothyroxine, Mirena coil
NKDA Smokes 12-15/day long term No significant FH of breast disease
3 children, youngest 14, none breast fed
Slide 12
Miss Y - Examination BMI 37 Temp 37.5, HR 90, BP 141/74, sats
96% in air What are the options for management?
Slide 13
Miss Y - Management Went to ultrasound image guided aspiration
of 10mls of blood stained pus Sample sent for MC&S Changed to
IV Flucloxacillin Regular analgesia What are the other necessary
steps in her managements?
Slide 14
Miss Y Further Management Counselled on smoking cessation and
offered smoking cessation support Re-examined daily Remained
generally well, apyrexial, comfortable Cultures = mixed growth,
continued on Flucloxacillin Fullness and tenderness increased on
day 4 Reimaged and repeat aspiration attempted but thick pus in
loculated collection and not fully aspirated, despite using local
anaesthetic to dilute pus What is the next appropriate step?
Slide 15
Miss Y Incision & Drainage Taken to theatre for incision
and drainage Small, ~1cm periareolar stab incision through area of
thinned skin allowing pus to drain freely Left open and packed
General anaesthetic Further samples for MC&S Recovered well on
ward Allowed home on day 3 post op, onto oral abx What follow up is
required?
Slide 16
Miss Y Follow up Clinic Seen in breast clinic 2 weeks later
Breast still sore, though less red and tender and oozing pus freely
from wound District nurse coming alternate days to repack GP
changed to clindamycin 2 days ago Remains systemically well Has cut
back a bit on cigarettes What next?
Slide 17
Miss Y Follow up 6 weeks after I&D and then again at 4
months Still smoking Still sore (though a bit less) Still oozing
pus from wound On examination no longer appears red or inflamed,
chronic appearing sinus adjacent to NAC, likely representing a
fistula
Slide 18
Miss Y Final Outcome Several months of conservative treatment
of chronic breast infection Eventually stopped smoking 18 months
later had elective excision of mammary duct fistula, complicated by
post-op wound infection which resolved over 6 weeks
Slide 19
Breast Sepsis Lactational Affects 5% puerperal women Usually
staph aureus Treatment encourage milk flow / continue
breastfeeding, antibiotics +/- aspiration, prevention (breast
feeding support) Non-lactational Periductal (usually in smokers,
mixed growth +/- anaerobes) Peripheral (usually immunosuppressed,
staph aureus) Consider inflammatory breast cancers
Slide 20
Breast Sepsis Aim to avoid incising and draining most abscesses
can be managed by aspiration (repeatedly) Review in breast clinic
over 35yrs should have a mammogram to rule out underlying
abnormalities Smoking cessation is important in PDM management
Slide 21
CASE STUDY 3 MISS Z 46 years old bus driver Found a small lump
in upper outer quadrant of right breast on self examination No
other associated symptoms. How will you proceed?
Slide 22
Previous History and Risk Factors No systemic history Menarche
13 years 2 children both breast fed Smoker 10 cig./day No hormonal
use Auntie (paternal) had breast cancer at the age of 72 years
Slide 23
Examination and Investigation Palpable lump upper outer
quadrant of right breast 25mm (P2) Mammogram benign looking
calcifications, otherwise NAD (M2) USS well circumscribed lump with
some calcifications (U2) Axilla - NAD USS guided biopsy on
histology B3 lesion What else would you like to know?
Slide 24
Histological Features Papillary lesion / PapillomaRadial
Scar
Slide 25
Histological Features Columnar Cell Change with Atypia Atypical
Ductal Hyperplasia / Atypical Intraductal Epithelial
Proliferation
Slide 26
Histological Features Atypical Lobular HyperplasiaLobulare
Carcinoma in situ
Slide 27
Management DISCUSS IN MDT Consider excision preferably target
excision Patient choice WHAT IF - Patient is asymptomatic / screen
detected lesion? VAB Vacuum assisted biopsy Wait and watch
depending on histological type Surgery
Slide 28
Summary History and risk factor assessment is crucial Quadruple
assessment is the key MDT discussion should be undertaken in all
cases most important step B3 lesions management is controversial
Patient choice should be always taken into consideration
*Guidelines for B3 vacuum assisted biopsy 2011 Humber and Yorkshire
Coast Cancer Network