1. 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

2. Case Study 1 – Miss X Age – 29 years Referred by GP “left breast lump” Husband noticed lump 2 weeks ago Doesn’t self examine, not sure how long it’s 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

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?

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 ?

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

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?

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

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

9. Fibroadenoma <25 y/o fibroadenomas can be diagnosed on USS alone >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

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

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

12. Miss Y - Examination BMI 37 Temp 37.5, HR 90, BP 141/74, sats 96% in air What are the options for management?

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?

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?

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?

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?

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

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

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

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

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?

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

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?

24. Histological Features Papillary lesion / PapillomaRadial Scar

25. Histological Features Columnar Cell Change with Atypia Atypical Ductal Hyperplasia / Atypical Intraductal Epithelial Proliferation

26. Histological Features Atypical Lobular HyperplasiaLobulare Carcinoma in situ

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

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

29. Questions?? Thank you