Surgery EOR: Breast Surgery (Smarty PANCE)

What is a breast abscess?

A breast abscess is a pus-filled lump that grows under the skin as a result of an infection. Most common in non-lactating women, symptoms same as mastitis but less severe.

Causes of breast abscess?

Breast abscesses develop most commonly as a progression of non lactational mastitis or cellulitis that does not respond to antibiotic treatment, but an abscess can also be the first presentation of breast infection.

The most common bacteria of breast abscess?

The most common bacteria are Staphylococcus aureus and Streptococcus. Sometimes anaerobic bacteria can cause breast abscesses.

Symptoms of breast abscess?

Patients with primary breast abscess present with localized, painful inflammation of the breast associated with fever and malaise, along with a fluctuant, tender, palpable mass

What is the treatment of breast abscess?

Management of primary breast abscess consists of drainage and antibiotic therapy. In the setting of lactational infection, milk drainage (either by breastfeeding or pumping) is important for resolution of infection and relief of discomfort

What must be ruled out with a breast abscess in a nonlactating woman?

Inflammatory breast cancer should be considered if a breast infection does not resolve with appropriate treatment

What is lactational mastitis?

Infection of the breast during breastfeeding (no abscess) —most commonly caused by S. aureus; treat with antibiotics and follow for abscess formation

Benign Breast Disease

What is a fibroadenoma?

Fibroadenoma is a benign, slow-growing breast tumor w/ epithelial and stromal components. Most common benign breast lesion in women <30yo.

What is the clinical presentation of a fibroadenoma?

Solid, mobile, well-circumscribed round breast mass, usually < 40 years of age

What is the recommended work-up for suspected fibroadenoma?

Diagnostic mammogram with ultrasound. If indeterminant, fine-needle aspiration of the mass with pathology. In women younger than 25 years, fibroadenomatous mass should be biopsied.

What is the treatment for fibroadenoma?

Surgical resection for large or growing lesions; small fibroadenomas can be observed closely

How is a well-defined solid mass with imaging features consistent with fibroadenoma managed?

A well-defined solid mass with imaging features consistent with fibroadenoma can be managed with core biopsy or short-term (three to six months) follow-up with a repeat ultrasound and breast examination. Definitive diagnosis can only be confirmed with a core biopsy or excision.

Are women with simple fibroadenomas at increased risk of developing breast cancer?

For the majority of women with simple fibroadenomas, there is no increased risk of developing breast cancer. The risk of subsequent breast cancer is slightly elevated only if there is associated proliferative disease or if there is a significant family history of breast cancer.

What is fibrocystic breast disease?

Fibrocystic breast disease, commonly called fibrocystic breasts or fibrocystic change, is a benign (noncancerous) condition in which the breasts feel lumpy. Fibrocystic breasts aren't harmful or dangerous, but may be bothersome or uncomfortable for some women.

Symptoms is fibrocystic breast disease?

Symptoms include a change in breast texture, pain or tenderness, and lumpiness. These may be more bothersome before menses and usually resolves with the start of the menstrual cycle

Peak incidence of fibrocystic breast disease?

Peak incidence of fibrocystic breast disease is 30 to 40 year old's

What distinguishes fibrocystic breast changes from carcinoma?

Pain, size fluctuation, and multiple lesions distinguish fibrocystic changes from carcinoma. A huge clue that this is fibrocystic disease is that the pain is commonly worse and mass size increases during the premenstrual part of the cycle

After the establishment of fibrocystic breast disease, what is the recommended treatment?

Avoiding trauma and by wearing a bra with adequate support. Combined oral contraceptive agents limit the severity of the cyclical changes in the breast tissue. Many patients report relief of symptoms after abstinence from coffee, tea, and chocolate.

Women should be encouraged to perform monthly self-breast exams when?

Women should be encouraged to perform monthly self-breast exams one week after a period when cysts are at their smallest

Are fibrocystic changes harmful?

Fibrocystic breast changes aren't harmful. And the chances of getting cancer don't increase if patient's have them. But it can make it tricky to feel for new lumps or changes in the breasts during self-exams

What is galactorrhea?

Galactorrhea is a milky nipple discharge unrelated to the normal milk production of breast-feeding. Galactorrhea itself isn't a disease, but it could be a sign of an underlying problem

What is the most common cause of galactorrhea?

Galactorrhea is generally due to a prolactin-secreting pituitary adenoma (prolactinoma).

● May be caused by ingestion of certain drugs

● Primary hypothyroidism can cause hyperprolactinemia and galactorrhea

● Prolactin levels may rise in circulation as a consequence of renal insufficiency

● Nipple stimulation and pregnancy are physiologic causes of increased prolactin secretion

Signs and symptoms associated with galactorrhea?

Signs and symptoms associated with galactorrhea include persistent or intermittent milky nipple discharge may be spontaneous or expressed, one or both breasts, absent or irregular menstrual periods, headaches, or vision problems

What pattern of nipple discharge would one expect with benign galactorrhea?

Bilateral, induced, clear/white/yellow color

Diagnosis of galactorrhea?

Diagnosis of galactorrhea due to a prolactin-secreting pituitary adenoma is based on elevated prolactin levels (typically > 5 times normal, sometimes much higher)

● MRI is the method of choice in identifying microadenomas. High-resolution CT may be used when MRI is contraindicated or unavailable.

● Serum gonadotropin and estradiol levels are either low or in the normal range in women with hyperprolactinemia, and testosterone levels may be low in men. Primary hypothyroidism is easily ruled out by absence of elevated TSH.

Treatment of galactorrhea?

The initial treatment for both sexes is usually a dopamine agonist such as bromocriptine or cabergoline which lower prolactin levels. Surgery is second-line therapy in patients whose tumor is resistant to dopamine agonists or patients who are intolerant of medical therapy

Radiation therapy should be used only in patients with progressive disease who do not respond to other forms of therapy.

What is gynecomastia?

Gynecomastia is a common condition which results in enlarged male breast tissue. It can be seen in males of all ages, but usually occurs during the newborn period, puberty and older adulthood

What is pseudogynecomastia?

Pseudogynecomastia is increased breast fat, but no enlargement of breast glandular tissue

Symptoms of physiologic gynecomastia?

Enlargement is usually transient, bilateral, smooth, firm, and symmetrically distributed under the areola; breasts may be tender.

What is the cause of physiologic gynecomastia that develops during puberty?

Physiologic gynecomastia that develops during puberty is due to fluctuating hormones, including drops in testosterone and surges in estrogen that cause breast tissue to grow and usually resolves within about 6 months to 2 years

In adult men, what are the most common causes of gynecomastia?

In adult men, the most common causes are persistent pubertal gynecomastia, idiopathic gynecomastia, and drugs (particularly spironolactone, anabolic steroids, and antiandrogens)

Diagnosisis of gynecomastia?

Extensive testing is often unnecessary, especially for patients in whom the gynecomastia is chronic and detected only during a physical examination. Patients with physiologic or idiopathic gynecomastia are evaluated again in 6 months. If breast cancer is suspected, mammography should be done. If another disorder is suspected, appropriate testing should be done

Treatment of gynecomastia?

In most cases, no specific treatment is needed because gynecomastia usually remits spontaneously or disappears after any causative drug (except anabolic steroids) is stopped or an underlying disorder is treated

What is a galactocele?

A benign milk-filled cyst that typically occurs in lactating women

How does a galactocele typically present?

A painless, soft, and mobile lump in the breast, usually after breastfeeding or weaning

What imaging is used to diagnose a galactocele?

Ultrasound reveals a well-defined cystic mass; aspiration confirms the diagnosis with milk contents

What is the treatment for a galactocele?

Aspiration if symptomatic, but many resolve spontaneously without intervention

How can a galactocele be differentiated from other breast masses?

A galactocele is usually painless, occurs during or after lactation, and aspiration yields milk, unlike other cysts or tumors

What is an intraductal papilloma?

A benign tumor that forms within the milk ducts, often causing nipple discharge

What is the most common symptom of intraductal papilloma?

Spontaneous, unilateral, bloody or serous nipple discharge

What imaging modality is used to evaluate an intraductal papilloma?

Ultrasound or mammography, and sometimes ductography to visualize the affected duct

What is the treatment for an intraductal papilloma?

Surgical excision of the affected duct to rule out malignancy and relieve symptoms

How is an intraductal papilloma differentiated from breast cancer?

Papillomas are benign but can present similarly to cancer, making histological evaluation necessary for diagnosis

What is mammary duct ectasia?

A benign condition where the milk ducts beneath the nipple become dilated and inflamed

How does mammary duct ectasia typically present?

Nipple discharge (green, yellow, or bloody), periductal mastitis, and sometimes nipple retraction or pain

What population is most commonly affected by mammary duct ectasia?

Postmenopausal women, though it can occur at any age

What imaging is used to diagnose mammary duct ectasia?

Mammography and ultrasound to evaluate duct dilation and exclude malignancy

What is the treatment for mammary duct ectasia?

Supportive care, including warm compresses and analgesics, with antibiotics if secondary infection occurs. Surgery is considered for persistent symptoms

What is mastitis?

Superficial infection of the breast (cellulitis)

In what circumstance does it most often occur?

Breast-feeding - Mastitis usually occurs within the first few weeks of breastfeeding but may occur later on

Mastitis symptoms?

Mastitis symptoms may include high fever and breast symptoms: erythema, induration, tenderness, pain, swelling, and warmth to the touch. Mastitis is different from the pain and cracking of nipples that frequently accompanies the start of breastfeeding.

Infectious vs. congestive mastitis

Infectious (unilateral) - Unilateral, fever, chills and color change

Congestive (bilateral) - Bilateral breast engorgement that usually occurs in primigravidas (first pregnancy)

What is the most common causative organism in mastitis, breast infection, or breast abscess?

Staphylococcus aureus

How is mastitis diagnosed?

Diagnosis is clinical - if an abscess is suspected and ultrasound may be warranted

What is the treatment for acute mastitis?

Warm compresses to breast, analgesics, dicloxacillin, or a cephalosporin

Can a nursing mother with mastitis continue to nurse?

Yes! Nursing facilitates the drainage of the infection and the infant will not be harmed because he/she is already colonized

Why must the patient with mastitis have close follow-up?

To make sure that she does not have inflammatory breast cancer! Inflammatory breast cancer presents with breast tenderness and color change, but fever and chills are not usually present

Carcinoma of the Female Breast

What is the most common type of breast cancer in women?

Invasive ductal carcinoma

What is the most important risk factor for developing breast cancer?

Age, particularly women over 50

What genetic mutations increase the risk of breast cancer?

BRCA1 and BRCA2 mutations

What is the first imaging study for a palpable breast mass?

Mammogram followed by ultrasound

What is the gold standard for diagnosing breast cancer?

Core needle biopsy

What is the treatment for localized breast cancer?

Lumpectomy or mastectomy with radiation and/or chemotherapy

What tumor marker is often elevated in breast cancer?

HER2/neu, estrogen receptor (ER), and progesterone receptor (PR) statuses

What role does tamoxifen play in breast cancer treatment?

Tamoxifen is a selective estrogen receptor modulator used in ER-positive tumors

What is the most common site of metastasis for breast cancer?

Bone, lungs, liver, and brain

What is the role of sentinel lymph node biopsy in breast cancer?

To assess the spread of cancer to axillary lymph nodes

Carcinoma of the Male Breast

What is the most common type of breast cancer in men?

Invasive ductal carcinoma

What is a major risk factor for male breast cancer?

BRCA2 mutation and Klinefelter syndrome

How does male breast cancer typically present?

Painless lump near the nipple with possible nipple retraction or discharge

What imaging is used for suspected male breast cancer?

Mammography and ultrasound

What is the role of genetic testing in male breast cancer?

Testing for BRCA mutations is often recommended

What is the primary treatment for male breast cancer?

Mastectomy followed by radiation or chemotherapy

How does the prognosis of male breast cancer compare to female breast cancer?

Prognosis is similar if diagnosed at the same stage, but often diagnosed later in men

What is the role of hormone therapy in male breast cancer?

Hormone receptor-positive cancers may be treated with tamoxifen

What is the most common location for metastasis in male breast cancer?

Lungs, bones, and liver

What are the common symptoms of metastatic male breast cancer?

Bone pain, shortness of breath, or jaundice

Disorders of the Augmented Breast

What is capsular contracture?

A common complication of breast augmentation where scar tissue forms around the implant, causing firmness and discomfort

What are the signs of implant rupture?

Change in breast shape, pain, or fluid accumulation

What imaging is used to assess implant integrity?

MRI or ultrasound

What is breast implant-associated anaplastic large cell lymphoma (BIA-ALCL)?

A rare lymphoma associated with textured breast implants

What are the risk factors for capsular contracture?

Implant placement above the muscle, implant rupture, and infection

What is the treatment for symptomatic capsular contracture?

Implant removal or replacement and capsulectomy

How do silicone and saline implant ruptures differ in presentation?

Silicone rupture may be silent, while saline rupture leads to noticeable deflation

What is the most common reason for breast implant removal?

Capsular contracture or patient dissatisfaction with size/appearance

What is the primary concern with breast implants and mammography?

Implants can obscure breast tissue, requiring specialized views

What is the recommended follow-up imaging for asymptomatic silicone implants?

MRI every 2-3 years to assess for rupture

Fat Necrosis

What is fat necrosis in the breast?

A benign condition where fatty tissue dies and forms a lump

How does fat necrosis typically present?

A firm, irregular, painless mass that may mimic malignancy

What is the most common cause of fat necrosis?

Trauma or surgery to the breast

What imaging findings are associated with fat necrosis?

Calcifications on mammography that may resemble cancer

How is fat necrosis diagnosed definitively?

Core needle biopsy

What is the treatment for fat necrosis?

Observation or excision if symptomatic

How can fat necrosis be differentiated from breast cancer?

Fat necrosis often has a history of trauma, and biopsy confirms benignity

What is the prognosis of fat necrosis?

Excellent, as it is a benign condition with no malignant potential