Duct Papilloma

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    • Mastitis
      • Usual etiologic agent: Staphylococcus aureus or Streptococcus spp.
      • Most commonly occurs during early weeks of breast-feeding.(MCQ)
      • Focal tenderness with erythema and warmth of overlying skin, fluctuant mass occasionally palpable. (MCQ)
      • Diagnosis:
        • Ultrasound can be used to localize an abscess
        • if abscess present, aspirate fluid for Gram stain and culture.
      • Treatment:
        • Continue breast-feeding
        • recommend use of breast pump as an alternative.
        • Cellulitis: Wound care and IV antibiotics. (MCQ)
        • Abscess: Incision and drainage followed by IV antibiotics.
    • Fat Necrosis
      • Firm, irregular mass of varying tenderness
      • History of local trauma elicited in 50% of patients
      • Predisposing factors: Chest wall or breast trauma
      • Irregular mass without discrete borders that may or may not be tender; later, collagenous scars predominate
      • Often indistinguishable from carcinoma by clinical exam or mammography (MCQ)
      • Diagnosis and treatment:
        • Excisional biopsy with pathologic evaluation for carcinoma(MCQ)
    • Fibroadenoma
      • Fibrous stroma surrounds duct-like epithelium and forms a benign tumor that is grossly smooth, white, and well circumscribed. (MCQ)
      • Typically occurs in late teens to early 30s;
      • estrogen-sensitive (increased tenderness during pregnancy).
      • Signs and symptoms: Smooth, discrete, circular, mobile mass. (MCQ)
      • Diagnosis: FNA. (MCQ)
      • Treatment:
        • If FNA is diagnostic for fibroadenoma and patient is under 30, may observe depending on severity of symptoms and size (< 3 cm). (MCQ)
        • If FNA is nondiagnostic, patient is over 30, or is symptomatic, must excise mass. (MCQ)
        • The mass is well encapsulated and can be shelled out easily at surgery.
    • Mondor’s Disease
      • Superficial thrombophlebitis of lateral thoracic or thora- coepigastric vein.
      • Predisposing factors: (MCQ)
        • Local trauma, surgery, infection
        • repetitive movements of upper extremity.
      • Presentation: Acute pain in axilla or superior aspect of lateral breast. (MCQ)
      • Physical exam: Tender cord palpated. (MCQ)
      • Diagnosis: Confirm with ultrasound.
      • Treatment:
        • If Clear diagnosis is done by ultrasound(MCQ)
          • Salicylates, warm compresses, limit motion of affected upper extremity
          • Usually resolves within 2 to 6 weeks.
          • If persistent, surgery to divide the vein above and below the site of thrombosis or resect the affected segment.
        • If Ultrasound nondiagnostic or an associated mass present: (MCQ)
          • Excisional biopsy.
    • Fibrocystic Changes
      • Usually diagnosed in 20s to 40s. (MCQ)
      • Breast swelling (often bilateral), tenderness, and/or pain. (MCQ)
      • Discrete areas of nodularity within fibrous breast tissue.
      • Evaluation:
        • Serial physical examination with documentation of the fluctuating nature of the symptoms is usually sufficient unless a persistent discrete mass is identified
        • definitive diagnosis requires aspiration or biopsy with pathologic evaluation. (MCQ)
      • Symptoms thought to be of hormonal etiology and tend to fluctuate with the menstrual cycle. (MCQ)
      • Associated with a group of characteristic histologic findings, each of which has a variable relative risk for the development of cancer.
      • Not associated with an increased risk for breast cancer unless biopsy reveals lobular or ductal hyperplasia with atypia. (MCQ)
      • Treatment:
        • For cases with a classic history or absence of a persistent mass:
          • Conservative management; options include (MCQ)
            • NSAIDs ,OCPs
            • danazol, or tamoxifen
            • advise patient to avoid products that contain xanthine (e.g, caffeine, tobacco, cola drinks).
        • If single dominant cyst, (MCQ)
          • aspirate fluid;
          • discard if green or cloudy but must send to cytology and excise cyst if bloody.
    • Mammary Duct Ectasia (Plasma Cell Mastitis)
      • Inflammation and dilation of mammary ducts
      • Most commonly occurs in the perimenopausal years
      • Noncyclical breast pain with lumps under nipple/areola with or without a nipple discharge(MCQ)
      • Palpable lumps under areola, possible nipple discharge
      • Diagnosis:  
        • Based on exam 
        • excisional biopsy required to rule out cancer(MCQ)
      • Treatment: Excision of affected ducts
    • Cystosarcoma Phyllodes
      • A variant of fibroadenoma. (MCQ)
      • Majority are benign.
      • Patients tend to present later than those with fibroadenoma (> 30 years).
      • Indistinguishable from fibroadenoma by ultrasound or mammogram.
      • The distinction between the two entities can be made on the basis of their histologic features (phylloides tumors have more mitotic activity). (MCQ)
      • Most are benign and have a good prognosis. (MCQ)
      • Exam: Large, freely movable mass with overlying skin changes. (MCQ)
      • Diagnosis:
        • Definitive diagnosis requires biopsy with pathologic evaluation. (MCQ)
      • Treatment:
        • Smaller tumors:
          • Wide local excision with at least a 1-cm margin(MCQ)
        • Larger tumors:
          • Simple mastectomy(MCQ)
    • Intraductal Papilloma
      • A benign local proliferation of ductal epithelial cells.
      • Unilateral serosanguineous or bloody nipple discharge. (MCQ)
      • Subareolar mass and/or spontaneous nipple discharge. (MCQ)
      • Radially compress breast to determine which lactiferous duct expresses fluid; mammography. (MCQ)
      • Diagnosis:
        • Definitive diagnosis by pathologic evaluation of resected specimen. (MCQ)
        • Treatment:  Excise affected duct.
    • Gynecomastia
      • Definition: Development of female-like breast tissue in males.
      • May be physiologic or pathologic.
      • At least 2 cm of excess subareolar breast tissue is required to make the diagnosis. (MCQ)
      • Treatment:
        • Treat underlying cause if specific cause identified
        • if normal physiology is responsible, only surgical excision (subareolar mastectomy) may be effective. (MCQ)
    • Clinical Pearls :
      • Clinical scenario:
        • A female presents complaining of nipple pain during breast-feeding with focal erythema and warmth of breast on physical exam.
        • Dignosis : Mastitis breast abscess(MCQ)
        • Incise and drain if fluctuance (abscess) present.
      • Clinical scenario:
        • A 29- year-old female presents with a painful breast mass several weeks after sustaining breast trauma by a seat belt inacar accident.
        • Diagnosis : The most common cause of a persistent breast mass after trauma is fat necrosis. (MCQ)
      • Clinical scenario:
        • A 23- year-old female from New Delhi presents with a well-circumscribed mass in her left breast.
        • It is mobile, nontender, and has defined borders on physical exam. (MCQ)
        • Diagnosis : Fibroadenoma until proven otherwise. (MCQ)
      • Mondor’s disease most commonly develops along the course of a single vein.
      • Clinical scenario:
        • A female presents complaining of acute pain in her axilla and lateral chest wall, and a tender cord is identified on physical exam.
        • Diagnosis :  Mondor’s disease vs. chest wall infection.
        • Confirm with ultrasound.
        • Ten percent of all women develop clinically apparent fibrocystic changes. (MCQ)
      • Clinical scenario:
        • A 35- year-old female presents with a straw-colored nipple discharge and bilateral breast tenderness that fluctuates with her menstrual cycle.
        • Diagnosis : Fibrocystic changes. (MCQ)
        • Consider a trial of OCPs or NSAIDs. (MCQ)
      • Clinical scenario:
        • A 48- year-old female presents with breast pain that does not vary with her menstrual cycle with lumps in her nipple–areolar complex and a history of a nonbloody nipple discharge.
        • Diagnosis : Mammary duct ectasia. (MCQ)
      • Clinical scenario:
        • A 38- year-old female presents with a 1-month history of a spontaneous unilateral bloody nipple discharge.
        • Radial compression of the involved breast results in expression of blood at the 12 o’clock position. (MCQ)
        • Diagnosis : Intraductal papilloma. (MCQ)
      • Causes of gynecomastia:
        • Increased estrogen
          • tumors, endocrine disorders
          • liver failure, nutritional imbalances
        • Decreased testosterone
          • aging, testicular failure
          • primary or secondary, renal failure
        • Drugs (e.g., spironolactone)


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