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Okay. So hello everybody. I'm Doctor Cox. I'm retired breast position um in Cambridge in the UK. So today I'm talking about benign breast disease, which is very common. Um If you were with my lecture last week, I said about nine out of 10 people who come to a cute breast clinic will have benign disease rather than breast cancer. So, um it's very common and it's good to know the sorts of things that we see. So today I'm going, it's going to be a little bit interactive. I'll be asking you what, what you think things are. Um And uh so you can either reply by um uh talking or by uh typing in the chat. So, although the cases were going to discuss today are from uh real life, they are patient's I've seen in the clinic. They maybe amalgamation of several patient's, but they're all real scenarios. So I'm just going to share my screen now. Okay. So uh huh. Mhm. Uh So down to right. So just going to start by reminding you of the sort of timelines where we see things in terms of ages. Uh So when people are young, they tend to have benign conditions. Uh and then as they get older, uh the chances of cancer are much more likely rather than benign conditions. So I'm going to start with a male. Uh So this is a 22 year old who has a tender swelling behind the left nipple, which started at the age of 16. Um And four years before he was seen, he started bodybuilding using protein shakes. Uh and he noticed an increase in the size of the lump behind the left nipple. It's not on anabolic steroids and no other medication. And on examination, there was a left retro area ola firm tender mass and this is what it looked like. As you can see here, there's a swelling here in uh this left side and seen in profile. It might look like this. So what does anyone think this might be? Yes. Assad gynecomastia. Yes, very good. Um Does anyone know anything about gynecomastia? What uh what might cause it or what we might do about it? Yeah. To the level of uh estrogen arm estrogen hormone, high level of estrogen hormone. Yes. Yes. Yes. So if we have a look at some of the things about gynecomastia. Mhm So as you said, there's a disruption in the ratio between estrogen and androgen and uh so men have a little bit of estrogen and a lot of androgen and if that balance is changed, then you get gynecomastia. It's very common, particularly in adolescent So that's why he's started at the age of 16. Uh and very common in the over fifties. Um as the hormones begin to decline a little bit. Um But there are some other causes of gynecomastia which are important to know about. So the first one is testicular tumors. Uh So about 2 to 4% of gynecomastia comes in association with a testicular tumor. So that's very important to remember in the back of your mind if you see someone with gynecomastia, uh the other important thing is 25% of gynecomastia is related to medication, uh cardiac drugs in the older patient. Um And the PPI S. So that's important to take a history about medication. The other thing is what we might call recreational drugs and this is another big cause of gynecomastia. So the bodybuilding drugs, the anabolic steroids, uh and then marijuana, heroin and protein shakes that also go with the uh culture of body building. So it's important to ask about these. Uh I've also included in the slides, the uh all the other agents that might call cause gynecomastia um just for completeness. So, um any male between the age of 20 and 70 who has gynecomastia should have a testicular examination to exclude um testicular cancer, we then do a range of blood tests looking for other causes of going to calmus chur um And if no cause is found and the gynecomastia is very um prominent uh worrying the patient. Uh then there are two forms of treatment. The first is a drug called Tamoxifen, which is used for breast cancer, but is used in small doses for about three months to reduce the estrogen levels. And that can sometimes significantly help the gynecomastia. However, if the garda capacity has been there for a very long time, um then the only way to really get rid of it is by liposuction and in the UK, that would be done by plastic surgeons. Um but it's very difficult to get funding for that on the NHS. The patient may have to pay for that themselves. So, what about our patient? So, uh an ultrasound was done and that confirmed 20 millimeters of gynecomastia and all his blood tests were done and this actually showed that he had thyrotoxic osis. Um So what probably started as uh simple adolescent go in the commode Escher. Um Then I had um he then developed thyrotoxic osis, which made it more prominent but was also using protein shakes, which also contribute to gynecomastia. So there are several ways to help him uh get rid of his gynecomastia in. And just to note that the soya proteins in protein shapes can partially blunt serum testosterone levels. Um and that's what causes um the uh gynecomastia and going to capacity can be very uh two young men developing breasts. Um It can be very significant, their psychological health. So it's important to try and help them with their gynecomastia. Any questions about gynecomastia at this point? Okay. So moving on, I'm going on to the red breast. This is a very common bird in the UK called that Robin has a lovely red breast. So the next patient is 57 female and she had several weeks of feeling unwell with low grade fever, body aches, painful right breast and pain in the axilla. She had a connective tissue disorder uh and was on methotrexate for that. She also had a family history of breast cancer. So she's been to the emergency department um and they hadn't given her any treatment. Um and then her GP referred her to the two week wait breast clinic. So what do you think might be going on here? What, what uh might be the cause of her red breast? So maybe we should look at some pictures. So, uh this is just a redness here with nothing else really to see. There'll be some sort of collagen vascular disorder. Physical. It could be um that is very unusual and very rare. Um uh but it could be, there are a few clues in the history. Uh She was feeling unwell and had a low grade fever and it was painful and with pain in the axilla. Um and, and does that help um coming to thought about what this might be? But it's still painful. It could be an abscess. Yes. Yes. So good. So it could be infection. Um So when we examined her, there were no masses, no lumps, but the breast was hot and red. There was no abscess formation. Uh There was a little bit of breast edema as well which had a very mild temperature elevation, but she'd taken paracetamol, had a bit of a rapid pulse. A white cell count was a bit elevated. Her CRP, which is an indicator of infection was very elevated. So we're beginning to think infection here. Um So uh called mastitis in the breast. It's common in breastfeeding women. Um um And this patient was on methotrexate. So she was immunocompromised. Um And so, um that's how she developed the infection in her breast. And uh our first line treatment for breast infection is flu clocks are Silin and if they've had that in the G P already or if they've had that and it doesn't work, then our second line antibiotic is co amoxiclav. So you mentioned abscess formation. So, here's, you can see with this infection uh that there is some swelling here. So what might we do if we have an abscess? How might the treatment differ? So we're going to give her antibiotics. Okay. Yep. But what else might we do? Uh I thought if the abscesses or will grow, you might dream it. Yes. And the actual pouch very good. So, drainage of an abscess uh really helps um healing. Um uh If you remove the pass, how might we drain the abscess. Um What are the ways of draining and abscess? Would it be an F N A? Yes. So, um uh that's the best way to do it so often. These are women who are breastfeeding and you don't want to bring them into hospital and uh disrupt the breastfeeding or their relationship with the baby and the family. So you want to try and do it as a, an outpatient. Um and so drainage uh of an abscess is a really good way to treat it. Um And uh um what we do is we use a very large needle if you did a sort of fine needle, aspirate, um the passes too thick to go up a fine needle. So you need to use a large needle and we tend to do it under ultrasound control because um the abscess is often in pockets. Um and sometimes you can't feel the pockets. So if you do an ultrasound, you can see where the pocket of passes and you can then drain the abscess. Uh and it may take several drainage is over several days to really get full resolution of the abscess. And we usually send the aspirate off to uh bacteriologist. So um to see if it's sensitive to the antibiotics, we have them on. So other causes of red breast. So here we have what we call inflammatory breast cancer. So this is much more like a sort of bloom or blush of redness. Here rather than that very distinct red breast. And I don't know, it's difficult to see in these photographs, but there is some distortion of the nipple here. So in a a mastitis, um you wouldn't get distortion of the nipples. So that's beginning to make you think that there is something other than infection going on here and inflammatory breast cancer. The breast is not hot like you would expect with an infection with mastitis and they don't have any systemic symptoms. They don't have the temperature and the fever and the aches and the feeling unwell. Often in inflammatory breast cancer, there's no associated breast lump. So you don't get that clue that this might be a cancer, but you do often get this per Doronjo. I'm going to show you a picture of this in a minute. So this is a French word. It's the French for orange, peel. So the skin of the breast looks like um an orange. Um often with inflammatory breast cancer, you can get hard auxiliary lymph nodes with mastitis. You may get uh auxiliary lymph nodes and they would often be tender and a bit rubbery, but these will be hard and not painful. Uh inflammatory breast cancer is in a rare and aggressive form of breast cancer. Um may not actually show on mammogram or ultrasound. Uh So you need to take biopsies of the breast uh and the skin. So this is a picture of the per day orange. So this um shows um a big, the pause of the skin are very defined and this is because the tissue between the pause is swollen with breast cancer. It's, it's a lot of very diffuse cancer. Any questions about my mastitis or inflammatory breast cancer? So, moving on, there are some other forms of red breast. So, does anyone know what this red breast might be caused by? This is quite difficult answer. This one. This is the post post operator. Yes. Bert. Very good. Very good. So you can see here, his patient's had a scar here and that's a wide local excision scar. And often after a surgery, people can get a lymphedema and the lymphedema can look very red like this and occasionally the lymphedema can be infected. So you can get the two things at the same time. Um This has an added extra dimension. You could almost imagine that this was a square or a rectangle of redness around this breast. And this patient having had a wide local excision will actually have had radiotherapy. Um And this is a post radiotherapy uh redness which can also have an association with it, lymphedema or collection of lymph in the breast. Good to. So, uh post radiotherapy lymphedema is common at three months, maybe painful and may require antibiotics, but most was settled in time without treatment. And all lymphedema of the breast, whether it's radio radiotherapy or further down the line can be helped by cammiso taping. Uh This is what Cammiso tape looks like. So this is like the tape that elite athletes might wear if they've got a bit of lymphedema or um injury from there. Uh sport, very simple but can be very effective in helping reduce the blimp to Dhiman. So this is another form of infection, a very localized form of infection here, right on the nipple. Uh the areola edge here. Does anyone know what this one is called? Would it be like the stasis? Sorry, say that again. Sorry, I didn't hear you. I was saying just you started it. Go on, sorry, sorry. I was saying that uh this is my due to be a contact information. Yes, but Christie said stasis. Yes, this is could be also. Yes. So it could be a contact dermatitis. Um will come to that in a minute but it actually is a particular form of infection and, and that's called a peri ductal mastitis. Um I'll just sorry, just check that chat. Um So peri doctor Mastitis, gosh, sorry, I'm having trouble with my computer. Um So paradoxical mastitis is inflammation of the ducks under the nipple. And um if you've been able to examine this patient, you would have found that that area was hot and tender and there was a bit of an abscess underneath it. Um and you can get discharged from the nipple or actually a fistula forming um at the point where uh the nipple um the areola um junction with the ordinary skin of the breast. It's often in younger patient's and about 90% of paradox mastitis is in smokers, they need antibiotics and occasionally surgery. But the main treatment, the only treatment that's going to stop this happening on a regular basis um is um to stop smoking. Um So, um, that is the most important because actually this is caused by a uh damage to the small blood vessels around the ducts by smoking. Um And um uh often if you do surgery, it just makes things worse. So, um we see this quite commonly in the breast unit, but of course, it's incredibly difficult for patient's to stop smoking. So we often see them again and again. So moving on from the red breast, we'll have a look at some benign breast lights. Now. So we've got a 13 year old who had a lump on the left nipple, it was painful and tender and the other part of the breast became red, the redness of the breast settled without treatment, but the lump lump remained uh and was no longer read. So let's have a look. So this was the lump she was complaining about, do you know anyone know what that is? So this is actually a Montgomery's tube ical, which is a normal part of the areola. And I think uh our patient's case, it had become a little infected and that's why it became red. The infection settled by itself. Um And she was left with what she thought was an abnormal lump, but it was just a normal part of the areola. And the Montgomery's Ju Bickel is, is a sebaceous gland and its role is to lubricate the nipple and protect from infection. So it probably rubbed on her bra a little bit and uh infection got in that way. Um So moving on to another patient, a 39 year old who developed lump in the right breast for six weeks, it didn't change with her cycle and the lump was in the right breast in the upper outer quadrant. It was smooth, firm superficial with a visible punked own. A mammogram was normal. This is what it looked like. A little lump here with a punkt. Um on the top. Does anyone know what that is? Be an abscess? Again, it could be an abscess and in fact, often these do become infected and abscess. But the thing we must not forget in their breast is the skin over the breast is exactly the same as skin elsewhere. Um And this would it be an infected sebaceous gland and abstain? Yes. Good. Yeah. It's a sebaceous cyst. Actually, this one is not infected. Um And, but you're quite right, they can become infected um and often become an abscess and can need drainage. And if they're very uh if they become infected recurrently on, on a regular basis, then you may need to remove the sebaceous cyst all together and they're very easy to remove, uh, under a general anesthetic. They sort of, well, the surgeons tell me they just shell out easily. So, yeah, that's a sebaceous cyst. Um, and, um, they're benign. They usually painless. They can discharge a foul cheese like material, as we said, they can become infected. And the giveaway is that central poor or punked? Um, that's very classic in a sebaceous cyst. Uh huh. So moving on the next patient, 18 year old with a six week history of a lump in the right breast, there was no change in her cycle. No nipple discharge, no family history. She was on the pill. She was told to stop the pill until she'd been to the breast unit. And on examination in the right upper outer quadrant, she had a smooth firm mobile nontender oval lump and she had an ultrasound. And here we see exactly as described, smooth outline, oval lump with a similar texture inside the lump to outside that lump. So very similar to breast tissue. Oh gosh, I've given it away. What do you think this might be? It's a fibroadenoma I've heard. Yeah, I've put it up here. That was a mistake. Does anyone know anything about fibroadenomas? It is a benign uh um you know, tissue which comes during the cycle. Is it estrogen dependent? It can be. Yes. Yes, because they will often grow bigger um during pregnancy. Um and during the cycle, as you say that it has the same um hormones have the same effect on fibroid enemas as on the normal breast tissue. So, um they're very, very common in women in their twenties and thirties. Um We can confirm the diagnosis on ultrasound. If the patient is over 30 we tend to biopsy um the fibrogen um as um to exclude this very rare condition called a fin Lloyds tumor. Uh for Lloyds tumor is a locally invasive tumor. So it doesn't go anywhere outside the breast, but it can be invasive within the breast. So they're always removed. Once you remove them, you may get other for Lloyds. But that um particular flock for Lloyds won't um it won't come back. So the natural history of fibroadenomas, a third will get smaller. A third will stay the same and a third will get bigger. So generally we leave them well alone unless they get very large. Um And uh and become a problem within the breast. Um And just to mention there was no need to stop the contraceptive pill while awaiting a two week wait appointment because all that will happen is that patient will get pregnant. So they can carry on using the pill until they get seen in the clinic. So I'm just going to mention one particular sort of fiber adenoma, which is a giant juvenile fiber fiber adenoma. This what it looks like when you remove it and cut it open. Um and a giant fiber adenoma, as you can see from this MRI scan is enormous and it can fill the whole breast and you can see the size of this breast compared to this one, uh the normal breast. And um uh this can often happens in a young adolescent patient um and can happen quite quickly. And as you can imagine, can be very distressing when you get such a difference in size between the two breasts. And uh they're not very common. Um as I say, they're usually in young people, but that big fibrogen ocma needs removal because it can affect the growing breast bud by pressure. Um And then that leads to non development of the normal breast of it. They can uh not develop properly on that side. So it's important to know about it and to remove it. So I'm not moving on now from benign breast lumps. Um I haven't mentioned breast cysts because I talked about a bit about them last week. Um uh So I'm moving on now to breast pain. Breast pain is very, very common um in the breast clinic. Um and it's a common part of what we have to deal with. So they're um I've got here to breast pain scenarios. The first one is a young woman who's 24. She's had 3 to 4 weeks of breast pain under her left implant. She had the implants fitted for cosmetic region reasons. Two years previously and she just taken up going to the gym and had started lifting weights and the pain felt like a pulled muscle. She'd taken some IV profin, a nonsteroidal anti inflammatory, which had helped, uh, and examining her, the left medial chest wall, there was tenderness underneath the implant. The implants were normal and intact. What do you think that breast pain might be? Of course, would it be a muscle strain? Yes. Very good. So that to relist major muscle, maybe. Yes. Yes. Very good. So, um that is actually the commonest cause of pain in the breast is pain coming up um, from a pulled muscle under the breast and it's not something that patient's easily recognize, but it's obviously important because the treatment is different to other forms of breast pain. Um, there are quite a lot of implant issues that can cause pain such as rupture of implants, but hear her implants were intact and the pain was because she started going to the gym and weightlifting and she pulled a muscle. So, um we also have a 40 year old who has bilateral cyclical breast pain. She's had it for four months. She's only got one week out of four with no pain. The pain eased towards the end of menstruation but gradually built up again to peak just before her period. She took paracetamol and Ibuprofen with some effect. And on examination, she had tender symmetrical nodular breast tissue bilaterally in the upper outer quadrant and it was the breast tissue that was painful this time and mammogram was normal. So, what do you think this breast pain is that mastitis uh to east regenerated or is it cyclical related pain? Yes. Yes. So, this is a cyclical breast pain. Uh The better word for it perhaps is moustache algia rather than mastitis. We tend to reserve mastitis for um infection. So, nostalgia meaning breast pain and this is a hormonal cyclical breast pain. So, these are the two uh main sorts of breast pain that we see. The true breast pain, which is a cyclical nostalgia, occasionally, not cyclical but mostly cyclical. Um and then the extra memory pain, which is musculoskeletal and is the commonest cause of breast pain seen in our to equate clinic. Um And as you can see someone did a bit of an audit and this was in a two week wait clinic. This was the number of patient's who come with breast pain in whom the uh it was muscular skeletal. Uh And this was uh the true breast pain and this was other courses. So you can see how common the cause of breast pain is muscular skeletal. And when you're examining the patient with breast pain, it's important to roll the patient on their side here so that you can examine the rib cage underneath the breast. Uh and then you will find a tender pinpoint trigger points um confirming that this is a muscular skeletal breast pain. So muscular scalito, breast pain tends to be lateral. Whereas true breast pain tends to be more uh here in the upper outer quadrant of progressed. Uh and this nicely sums up the causes and the treatments. So, um anything uh can cause chest wall pain from lifting toddlers and heavy Children, heavy shopping bags, gardening uh work is used. So it's important to find out what their work is. And also it's part of um working the issues, the muscular skeletal issues that can arise from working on a computer all day. So the famous, the more common ones are the wrist, um and shoulder and elbow problems from working on a computer. But there is also a chest wall pain. And once you have made the diagnosis, you can be very um um reassuring about chest wall pain. You can treat with topical nonsteroidal anti inflammatories. Um, heat and rest can often help as well. True breast pain. However, uh also can be helped by the same sorts of analgesia, the nonsteroidal gels and paracetamol. But also uh some people get some relief from evening primrose oil, which is a tablet or star flour oil, um and a comfortable bra. Um sometimes uh getting rid of the cycle with hormonal contraceptives can help. Um And um uh sometimes all that's needed is just reassurance. So I'm just going to check the chat sometimes if hormonal breast pain gets very severe. Um then um you can treat with tamoxifen. We've seen tamoxifen is a treatment for breast cancer and for gynecomastia. But you can actually use tamoxifen um to treat very severe uh mesalamine jah used in half the dose that we use for breast cancer and we use it for just 3 to 6 months. And what that does is get rid of the estrogen um and allow the breast tissue to um not have that estrogen effect, which causes the pain back again. Um So people often worry about breast pain and breast cancer, but actually, breast pain is a rare presenting feature of breast cancer. Breast cancer is usually painless um and usually presents with a lump. Um So, um as you can see here, undetected breast cancer is found in only 227% of patient's with pain as they're only complaint. So, uh pain with breast cancer is very uncommon. There are some drugs which can cause breast pain, particularly hormone replacement therapy, which people taking the menopause. Um And um uh as we said, reassurance is often all that is required to reassure them that there is nothing serious going on. Okay. So, another big area of problems which we've touched on briefly is nipple problems. So, uh here we have a 55 year old patient who has four weeks of dry itchy red patch of skin on her nipple that occasionally uses um and she washes with a particular so called Xanax and uses her own brand of organic moisturizer, which makes up herself and of interest she's had in the past X more on her hands. So this is what her nipple might look like. And see this uh rough read a scaling um area here. What do you think that might be? Is that an eczema as well? Yes. Yes. Very good. So, this is an X HMA of the nipple. Um So as I said earlier, the skin on the breast is just the same as any skin anywhere else. Uh And um uh it can get eczema or psoriasis or, or any other skin condition um in exactly the same way. Um nipple Isma is very common. Um And my, my theory about that I can't bucket back it up with uh scientific evidence. But I think that women who wear a bra which is the normal in in the UK um the skin is touching the bra all the time. Um and that can irritate the skin. Um And it's often what the bra is washed in that can irritate the skin. So, biological washing powders can be very uh irritating to skin that is prone to asthma. So the treatment of this you can uh so one of the important things is to avoid irritants. And I usually suggest the bras are washed in a non biological washing powder that doesn't have these biological enzymes. Um and that they use an extra rinse cycle for the bra to wash out the washing powder entirely uh emollient, which is a moisturizer is very important um and to moisturize the skin. Um and often soap is drying and makes the eczema worse. So, washing with an emollient, uh it's such as a quiz cream or E 45 is very helpful. And then we can use just as any other part of the body with Isma, we can use steroid creams, either very low dose steroids such as hydrocortisone or a higher dose. If it's not responding to hydrocortisone with betamethasone, and they usually respond very nicely to uh to that sort of treatment for nipple extima. So uh people doctors worry that this could be uh something else um which looks like eczema. So this is what looks like Isma around the nipple. So, the important thing in this one is it doesn't involve the areola. Unlike the other picture, if we go back that that involves really the areola and not the nipple. In this one, it's virtually all nipple. Does anyone know what this condition is? Inverted? Nipples? Yes, the nipple is inverted and looks very odd, doesn't it? There's a particular um condition that presents like this with this scaly x Malike rash on the nipple. Does anyone know what that? It's not sorry as this of the nipple? No, it's not sorry psoriasis. Um Anything else it might be? So this is a condition called Paget's disease of the nipple. Um So Paget's disease of the nipple um always involves the nipple, not just the areola as I show showed you X may usually just involves the areola and the importance of picking up Paget's disease. The nipple is that 90% of women who have Paget's. It's will also have breast cancer either as pre cancerous changes. Doctor cost no more insight ship or invasive breast cancer. It's rare. So only 1 to 2% of people with breast uh disconnected. They're under the microscope. Just check that chant. Sorry doctor. I think you disconnected for a second there. Could you please repeat yourself? Yes. OK. So it's Paget's disease of the nipple. Uh So Paget's disease, the nipple always involves the nipple, not just the areola as we saw in the picture. Extima usually just involves the areola as we saw in the xmas picture. Uh And the reason we have to think about Paget's disease is that 90% women who have Paget's disease will also have breast cancer either as ductal carcinoma in sight you which is a pre cancerous changes or actually invasive breast cancer. It's rare. So only 1 to 2% people with breast can't swill have Paget's disease. Um And um uh what we see when we look at it under the microscope are these distinctive tumor cells called Paget cells present in the epidermis of the nipple. And if you haven't seen cancer on the mammogram or even if you do, it's good to confirm that this is Paget's disease or even uh to help us distinguish between X MMA and Paget's disease of the nipple. Um by taking a punch biopsy where we take a biopsy of that area of the nipple. Um and uh look at it under the microscope and then you see these distinctive pageant cells. Um Finally, I'm just going to talk a little bit about nipple discharge, another common um uh problem in uh we see in the clinic. So, um there are two really two types of nipple discharge. There's the spontaneous bloodstained nipple discharge. Um uh And when you examine the patient, um you can reproduce this profuse single duct, bloodstained nipple discharge. The other sort is a nipple discharge that only occurs on squeezing the nipple can be multicolored, um is not spontaneous. So it can be brown, green, white, yellow, any combination of that. And when you examine the nipple, there's general who's from several ducts. Um and uh brown, those from several ducks rather than one duct. Uh So the importance of looking at nipple discharge is a papilloma. So a papilloma is a water lesion that forms in the duct. And about 10% of papillomas can be associated with pre cancerous changes. And papillomas tend to present as a bloody watery, serious spontaneous profuse single duct discharge. The other sort of discharge is duct ectasia which is usually green, brown, yellow, creamy white, it's multi duct, it doesn't mean infection. So the important thing is that they don't really need antibiotics. And what happens is as you get older and it's a normal process of aging on the ducts. The ducts uh uh start collapsing. Uh And um uh when the ducks collapse, this sort of natural secretion can collect in the duct. And then when you squeeze the nipple, it can come out through the duct. And the answer to this is don't squeeze the nipple, the more you squeeze, the more you will get discharge, the less you squeeze the discharge will all settle down. Um So it's important to educate the patient uh into how to, to deal with this sort of issue. So this is benign. Um And this one is potentially associated with pre cancerous changes. So I'm going to stop there. Are there any questions um if you get a copy of my slides, um then you will see there were other things in the talk, but uh there's never enough time to do the whole talk, but there may be some other things you can learn from the further slides there. Um Any questions anyone would like to ask? Okay, good. Well, thank you very much for listening. Um And good luck with the rest of your studies. Thank you, ma'am. Could you share this?