Approach to breast masses, nipple discharges and breast pain

Introduction

It is easier to understand breast problems in terms of how they present. Breast problems present as follows:

• Pain

• Mass

• Nipple discharge

Physiology behind benign breast problems

Benign breast disorders may arise as a result of the cyclical hormonal fluctuations that occur in every woman before menopause or during the menstrual cycle. These disorders are in fact part of a spectrum that extends from a normal state, to overt benign disease.

The reader should not be overly concerned with this complex table.

What it basically means is that most of the conditions that result from the normal cyclical hormonal changes found in every woman, are just aberrations or slight deviations from normal. True disease is not that common in this setting (see the right hand column of the table). Symptoms of breast problems such as pain, nipple discharge or a mass should however prompt you to see your doctor

Breast masses

Developmental abnormalities in breast embryology

• The nipple may fail to evert, giving rise to an inverted nipple. Which is thus congenital (present from birth)? If a woman suddenly develops an inverted nipple in adulthood, this can have sinister connotations. It may be the first sign of breast cancer (Fig 3.5e).

Management of congenital nipple inversion can both be undertaken by manual techniques or surgery.

• Supernumerary or additional breasts or nipples may develop along the milk line or milk streak, a reminder of the embryology of the breast in more primitive animals (Fig 2.5a;b). During pregnancy and lactation this supernumary breast tissue and nipples may enlarge and even produce milk. If it is of concern to the patient surgical removal of the tissue can be undertaken.

• Breast absence or amasia. If something goes wrong with the embryological development, such as a genetic abnormality or if the pregnant mother is exposed to some poison (toxin, such as a toxic drug, or a virus), the breast may fail to develop. This can be managed by reconstructive surgery. The most important step is to ultrasound the normal breast to ensure all is well. No surgical removal of the normal breast must be done.

1. Breast enlargement in the baby. Occasionally, female sex hormone (oestrogens) crosses the placenta in increased quantities prior to birth. This results in a breast bud in the young infant. It is essential that these small breast buds are not squeezed or biopsied, as this can affect normal development of the breast. No treatment is required and the problem disappears within a few months after the birth.

2. Prepubertal breast development

This is a type of premature breast development, which often occurs on one side only. The breast will develop without any problems. Occasionally this is seen in young toddlers (See chapter 6 as well)

Management

No treatment is required except for firm reassurance that all is fine. Investigations may be done to ensure no other secondary sexual development is occurring. These breasts should NOT be biopsied without a specialist opinion. Open surgical biopsies will interfere with breast development. Breast masses can be divided into inflammatory masses and non-inflammatory masses. It is most important to determine that the mass is not a cancer. A triple assessment of a clinical examination, either' sonar and/or a mammogram should be obtained (depending on the age of the women) as well as a needle biopsy.

3. Fibroadenoma (Fig 5.t)

These highly mobile (breast mouse), round, smooth, firm masses in the young woman's breast, usually present in the teenager and the early twenties. Fibroadenomas arise from lobules and show hormonal dependence similar to the lobules from which they develop. Most fibroadenomas are 1••2cm in size and growth beyond 5 cm is unusual.

They may be multiple. These lumps are quite innocent and can be left well alone. They may disappear spontaneously. The clinical diagnosis of fibroadenomas may be incorrect in up to 50% of patients and it is for this reason that all patients with these masses should have a triple assessment of a clinical examination, an ultrasound and a needle biopsy.

If the patient is worried about the lump, a core biopsy will reassure her in most cases. If still worried (when there is a strong family history of breast cancer), the lump should be removed to allay her fears. Indications for surgery are:

• pain or other symptoms

• size greater than 3 cm

• cosmesis

When these tumours reach giant proportions (giant intracanalicular fibroadenoma), it is generally advisable to remove them, as they cause a lot of distress, and distort the breast simply due to their unwieldy size.

Fibroadenomas may increase in size (20%), decrease in size (30%) or remain the same size (50%). During pregnancy and lactation the size may also vary. Fibroadenomas in pregnancy should also be managed by sonar and needle biopsy.

They do not interfere with breast-feeding. Calcified fibroadenomas are sometimes found in the elderly as hard discrete mobile masses that are readily identified on mammography.

Surgical excision should always be done through cosmetic incisions with attention to moving around local breast tissue so as not to leave an unsightly dent in the breast.

4. Cystosarcoma phyllodes (phyllodes tumour)

There is a rare entity that may be confused with a fibroadenoma. This is called the cystosarcoma phyllodes. These are more aggressive than fibroadenomas. Because they have the capacity to recur after removal by lumpectomy, and also because around 10 - 20% show features of malignancy (rarely they can spread, more commonly they re-occur locally and more aggressively), a procedure involving wide local removal or a mastectomy and immediate reconstruction should be performed.

5. Galactocele - presents as a breast lump

This is simply a milk retention cyst, where no bacterial infection occurs. It can be treated by needle aspiration and milk suppression. Surgical excision can also be performed through reconstructive techniques.

6. Lactating breast abscess

Unsatisfactory breast-feeding may cause milk retention and stasis. Infection soon supervenes. This can be adequately treated with antibiotics early on (during the cellulitis or mastitis phase). During this phase frequent expression of milk will help prevent stasis and progressive infection. Cabbage leaves kept cold in the fridge also provide relief from the discomfort. Note that the baby must continue to feed on the contralateral breast to prevent a breast abscess developing there. Also, milk must be expressed from the ipsilateral breast (the one with the abscess) that is involved in the inflammatory process. The current recommended treatment is high dose antibiotics (amoxycillin/clavulinic acid is the drug of choice and safe in breastfeeding mothers) as well as repeated ultrasound guided aspiration (we seldom have to do surgical incision and drainage procedures).

If the mother or doctor wants to stop breast feeding, lactation can be suppressed with fluid restriction and bromocriptine (antiprolactin).

7. Non-lactating breast abscesses

Breast abscesses can occur in circumstances other than lactation. They can commonly be a complication of duct esctasia, or less frequently caused by an underlying malignancy, TB or HIVIAIDS. Superficial skin lesions (boils; sebaceous cysts and recurrent skin abscesses) can also occur.

Management

Antibiotics and ultrasound-guided drainage are the initial treatment modalities. This is followed in certain complicated cases by surgical drainage with biopsy of the abscess wall. An antibiotic must be used in the mastitis and/or abscess phase. Antibiotic of choice is amoxycillinlclavulanic acid if no penicillin allergy is present. Other options if the patient is allergic to penicillin are bactrim or a quinolone.

8. Breast cyst (Fig 5.2)

Usually occur in the premenopausal period (thirty-five to fifty, years). They maybe single or multiple. About 5% of women develop a breast cyst. They normally contain around 20ml of fluid. They are easily diagnosed using sonar (ultrasound). Treatment is by aspiration.

The, fluid is usually yellow or greenish. Provided there is no blood (red or black) in this fluid and that there is no residual fir 5.J lump remaining after the aspiration, no further treatment is necessary. If there is blood or a residual lump, further evaluation is mandatory. This takes the form of sending the aspirate for cytology (it is a good principle to send all aspirates for cytology) and then to biopsy a residual mass, if present, under radiological guidance or to excise it surgically.

9. Fat necrosis

Severe breast trauma (a motor vehicle accident or being punched in the breast) may cause fat necrosis, which can mimic breast cancer. A core biopsy will usually resolve the issue, if the clinician is worried about an underlying cancer. In a young woman with a history of trauma, all that is required is reassurance once investigations confirm that this is fat necrosis (masterly inactivity by the attending doctor).

10. Breast hamartomas (Fibroadenolipoma)

Hamartomas of the breast usually present as painless palpable masses. They are underestimated and not well recognised. They are larger and softer than fibroadenomas and may account for some diagnostic confusion when biopsied, as the cells are difficult to differentiate from atypical cells on FNA. A core biopsy is recommended for diagnosis. They have a distinct picture on mammogram showing a circumscribed density separated from normal breast tissue by a thin radiolucent zone. If clinical examination and investigations cannot be correlated, surgical excision is recommended.

11. Fibroadenosls (and cyclical breast pain)

Breasts alter cyclically with the different stages of the menstrual cycle. In the week prior to menstruation, the breast normally increases in size and sometimes becomes nodular, with pain. This can mimic a breast mass. The term fibroadenosis is confusing and misleading and represents what is going on inside the breast at a tissue level. Breasts are uniquely different to palpation, some are smooth, some are nodular and the term should not be used so as to imply a disease of the breast. All breasts have a certain amount of fibrosis and adenosis and disease should be attributed to a woman with breast symptoms. If concerned, a breast ultrasound can aid the clinician in determining whether this is a mass or just nodularity.