Maryam, a 21-year-old female law student, presented with a lump in her left breast that had been present for 3 months. On examination, a small, movable lump was found in the upper outer aspect of her left breast. No other abnormalities were noted. Investigations including imaging and biopsy were recommended to rule out any benign or malignant breast conditions and determine the appropriate treatment.

1. Benign Breast
Conditions
List of Presentation Authors

2. Maryam is a 21 year old unmarried female law student from
Muscat belonging to an upper middle socioeconomic status. She
came to the OPD with a chief complaint of a lump in the upper
outer aspect of her left breast since 3 months.

3. History

4. History
• Breast pain, swelling/lump or discharge.
• Site, onset, duration, progression.
• Hx of trauma.
• Association w/ menstrual cycle.
• Associated symptoms → skin retractions, dimpling, fever, weight loss, bone pain.
• Menstrual history.
• PMH/PSH.
• Medication → OCT, spironolactone.
• Family Hx.
• Social Hx → Alcohol and smoking.

5. Maryam is a 21 year old unmarried female law student from
Muscat belonging to an upper middle socioeconomic status. She
came to the OPD with a chief complaint of a lump in the upper
outer aspect of her left breast since 3 months.
The patient was apparently normal 3 months back when she first
noticed a small, movable lump on her left breast while taking a
bath. The lump remained the same size for the last 2 months and
increased in size in the past 1 month.
The lump is not associated with any pain normally or during
menstruation. She gives no h/o of previous pain around the same
area. No hx of trauma or fever. No discharge of any kind from the
nipple.

6. No hx of loss of appetite or weight loss.
No hx of back pain, shoulder pain.
N0 dyspnea or chest pain.
No jaundice or heaches.
No PMH of OCP or HRT.

7. Physical Exam

8. Physical Exam
• General examination + vitals + chaperone.
• Inspection
• Position 1 → sitting with arms by side.
• Symmetry, site, size, dimpling or skin changes.
• Position 2 → hands above the head.
• Make lumps prominent.
• Retractions or dimpling.
• Position 3 → standing and leaning forward.
• Fixation to chest wall.

9. Physical Exam
• Inspection
• Nipple → presence, size and location.
• Areola → size, color, nodularity, ulcer, and fistula.
• Palpation
• Clockwise palpation.
• Nipple palpation → discharge.
• Lump → site, size, shape, surface, consistency, margins, mobility and
fixity.

10. Physical Exam
• Axillary lymph node examination.
• Rt. Hand for Lt. LN’s and vice versa.
• Axillary LN’s and the infra/supra-clavicular LN’s.
• 3 positions:
• Arms hang loose.
• Hands on hips.
• Arms crossed behind head.
• Size, mobility, tenderness and firm.

11. Triple Assessment
• Clinical examination + radiological imaging + pathology analysis.
• H & P.
• Mammogram, U/S or MRI.
• Fine-needle aspiration cytology (FNAC) or core biposy.

12. Breast Pain

13. Mastalgia
• Breast pain or discomfort.
• Cyclical mastalgia → associated with menstrual cycle.
• Non-cyclical mastalgia → NOT associated with menstrual cycle.
• Extramammary pain → secondary breast pain.

14. Mastalgia → Cyclical
• Hormonal fluctuations during the luteal phase of menstruation.
• ↑Estrogen, ↑PRL, ↓Progesterone.
• Estrogen → breast growth (ducts).
• PRL → breast ductal secretions and lactation.
• Progesterone → breast growth (stroma).
• Oral contraceptives.
• Hormonal replacement therapy in postmenopausal women.

15. Mastalgia → Non-Cyclical
• Inflammatory breast conditions.
• Mastitis.
• Breast abscesses.
• Mammary duct ectasia.
• Breast lumps.
• Pendulous breasts.
• Previous breast surgery.
• Medications (OCTs and HRT)

16. Mastalgia → Extramammary
• Referred from extramammary locations.
• Costochondritis.
• Chest wall trauma.
• Shingles.
• Cardiac, oesophageal or pulmonary causes.

17. Mastalgia → Clinical features
• Cyclical mastalgia
• Bilateral and diffuse.
• Most severe in upper, outer quadrants of the breasts.
• Pain worsens a week prior to menstruation.
• Decreasing the day bleeding starts.
• Non-cyclical mastalgia
• Unilateral and localized.
• Sharp or burning pain.
• Extramammary pain.

18. Nipple Discharge

19. Nipple discharge
• Fluid that leaks from one or both nipples of non-pregnant and non-
breastfeeding women.
• Normal in → last weeks of pregnancy OR after childbirth OR during
breast-feeding.
• Hormonal fluctuations associated with the menstrual cycle.
• All nipple discharge in postmenopausal women is significant.
• All nipple discharge in men is significant.

20. Nipple discharge
• Physiological nipple discharge
• Lactation.
• Galactorrhea.
• Chronic nipple stimulation (e.g., piercings, tight clothing, etc.).
• Pathological nipple discharge
• Infections → abscess or mastitis.
• Intraductal papilloma.
• Mammary duct ectasia.
• Fibrocystic changes.
• Malignancies.

21. Nipple discharge → Clinical features
• Physiological nipple discharge
• Bilateral.
• Clear/milky appearance.
• Non-sticky.
• Occurring due to stimulation.
• Pathological nipple discharge
• Unilateral.
• May be bloody.
• Spontaneous.
• Associated with other symptoms → pain, swelling, fever, weight loss.

22. Nipple discharge
• Red flags concerning for malignancies:
• Unilateral.
• Persistent and spontaneous.
• Bloody or serosanguineous.
• Breast mass.
• Advanced age or +ve FHx for breast cancer.
• Postmenopausal.

23. Inflammatory
Conditions

24. Mastitis
• Epidemiology
• Lactating, Why?
• Clinical features
• Tender, firm, swollen,
erythematous breast
(generally unilateral)
• Reactive lymphadenopathy
• Complications?
• Diagnostics
• Clinical.
• If no response to empiric antibiotic
therapy for mastitis, consider: Breast milk
cultures, breast imaging, biopsy.
• Management
• Puerperal mastitis: Supportive therapy
(breastfeeding on demand, analgesics,
cold compresses).
• If no improvement after 12–24 hours of
supportive therapy: empiric antibiotic
therapy for mastitis (e.g., dicloxacillin).
• Nonpuerperal mastitis: Initiate empiric
antibiotic therapy for mastitis.

25. Breast abscess
• Epidemiology
• Complication of puerperal
mastitis
• Clinical features
• Breast pain, erythema, and
edema
• Fluctuant tender mass
• Systemic signs (e.g., fever,
chills, nausea)
Figure 1: Title

26. Breast abscess
• Diagnostics
• Clinical, US, FNAB and
culture.
• Management
• Abscess drainage (two types).
• Empiric antibiotics for breast
infections.
• Analgesics.
Figure 1: Title

27. Fat necrosis
• Epidemiology
• Trauma
• Clinical features
• Irregularly defined breast
mass.
• Often peri-areolar in location.
• Skin retraction, erythema,
and/or ecchymosis.

28. Fat necrosis
• Diagnostics
• US or mammography, biopsy.
• Management
• No need.

29. Mammary duct ectasia
• Epidemiology
• Perimenopausal
• Clinical features
• Unilateral, non-milky grey,
greenish, or bloody discharge.
• Nipple inversion.
• Firm, tender subareolar mass
may be present.

30. Mammary duct ectasia
• Diagnostics
• US or mammography, biopsy
(if concerning).
• Management
• No need.
• Surgical duct excision for
persistent symptoms or to
rule out malignancy.

31. ABERRATION of
normal
development and
involution (ANDI).

32. Normal breast development and involution

33. ABERRATION of normal development and
involution (ANDI).

34. Benign breast
tumours

35. Fibrocystic changes
• Epidemiology
• Most common Premenopausal
• Clinical features
• Premenstrual breast tenderness
• Multiple breast nodules bilaterally
• Diagnostics
• US or mammography, biopsy (concern)
• Management
• Symptomatic
• Proliferative with atypia: surgical excision
followed by close surveillance for breast cancer

36. Intraductal papilloma
• Clinical features
• Solitary lesions
• Bloody or serous nipple discharge
• Palpable breast tumour close to or behind
the nipple or areola
• Multiple lesions : Usually asymptomatic
• Diagnostics
• US or mammography, biopsy confirm
• Management
• No atypia: surveillance or surgical excision
• With atypia: surgical excision to rule out
associated malignancy

37. Fibroadenoma
• Clinical features
• Solitary, well-defined, nontender,
rubbery, and mobile mass
• Typically 1–2 cm in size
• Generally do not increase in size
• Diagnostics
• US or mammography, biopsy
confirm
• Management
• Expectant management or surgical
excision.

38. Phyllodes tumor
• Epidemiology
• Rare
• Clinical features
• Painless, smooth, multinodular lump
• Variable growth rate
• Diagnostics
• US or mammography, biopsy confirm
• Management
• Surgical excision
• High risk of recurrence after excision

39. Gynecomastia

40. Etiology
• Increased estrogen/testosterone ratio
• Physiological gynecomastia
• Neonatal (Placental), Pubertal, Senile ..
• Pathological gynecomastia
• Estrogen excess (malignancies, liver cirrhosis, hyperthyroidism)
• Decreased testosterone (Klinefelter, CKD, testes, hypogonadism,
hyperprolactinemia, starvation)
• Drug induced

41. Gynecomastia
• Diagnostics
• Clinical, if pathological.
• Management
• Physiological gynecomastia:
reassurance
• Pathological gynecomastia: Treat the
underlying cause.
• Persistent symptom:
• Medical therapy (off-label): selective
estrogen receptor modulators
• Surgery (subcutaneous mastectomy)

42. Back to our case
RULE OUT?

43. Maryam is a 21 year old unmarried female law student from
Muscat belonging to an upper middle socioeconomic status. She
came to the OPD with a chief complaint of a lump in the upper
outer aspect of her left breast since 3 months.
The patient was apparently normal 3 months back when she first
noticed a small, movable lump on her left breast while taking a
bath. The lump remained the same size for the last 2 months and
increased in size in the past 1 month.
The lump is not associated with any pain normally or during
menstruation. She gives no h/o of previous pain around the same
area. No hx of trauma or fever. No discharge of any kind from the
nipple.

44. Investigations

45. Investigations
CALCIFICATION?

46. Management

47. Treatment
• Screening
• <2cm, asymptomatic
• Breast exam, imaging (age appropriate)
• Surgical excision
• >2cm or rapidly growing, suspected malignancy, bothers Sx cosmetic
• Minimally invasive procedures
• An alternative to surgical excision for patients with biopsy-proven
fibroadenomas
• Thermal ablation
• Vacuum-assisted percutaneous excision

48. References
• Mastalgia - StatPearls - NCBI Bookshelf (nih.gov)
• Breast Nipple Discharge - StatPearls - NCBI Bookshelf (nih.gov)
• Salzman B, Collins E, Hersh L. Common Breast Problems. Am Fam
Physician. 2019; 99(8): p.505-514. pmid: 30990294.
• Practice Bulletin No. 164: Diagnosis and Management of Benig... :
Obstetrics & Gynecology (lww.com)

49. Thank
You
Questions?