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Benign breast problems

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Woman and doctor

 

Most breast lumps are not breast cancer and will never develop into breast cancer. The safest approach to all breast lumps however is to always get a lump examined by a medical professional. In fact no matter how often you examine breasts as a doctor or check your own breasts as a patient, it can’t be assumed that the breast lump is of no concern. A clinical examination together with a simple non-threatening non painful investigation called an ultrasound or breast sonar (done by a radiologist, with a mammogram if over 35 years) is the easiest way to tell what the breast lump could be.

Many years ago we used to categorise breast masses according to the age groups where they occurred, but this can be confusing.  A far safer approach is to look at how breast masses are seen with ultrasound (breast sonar).  We want to emphasise that it is most important to determine that the lump is not a cancer.  The triple assessment of a clinical examination, either sonar and/or a mammogram should be obtained as well as a core needle biopsy if required.

Solid masses

Fibroadenoma

These are highly mobile round, smooth, firm lumps usually found in a young woman’s breast (the teenager and the girl in her early twenties). It is sometimes called the breast mouse because it is so mobile and ‘runs’ from the examining hand.  Sometimes they do occur in older women but not often. Fibroadenomas come from the lobules (milk tissue) and react to female hormones like the other breast tissue they develop from.

Most fibroadenomas get noticed around 1-2cm in size but they can grow to even more than 5 cm. Women who have one, often find more when they start looking and it’s not uncommon to find lots, and in both breasts. A fibroadenoma is quite innocent, and almost never related to cancer. Having a fibroadenoma doesn’t even increase your risk of cancer. If the doctor is sure your lump is a fibroadenoma (after confirming it on ultrasound and a core needle biopsy result because clinical exam alone can be wrong in half of all cases) it can be left well alone if it is not bothersome. It may disappear spontaneously.

If the fibroadenoma becomes painful, if it gets bigger than 3cm (that makes it a giant fibroadenoma) or if you are worried about it, it can be removed with surgery from a cut around the nipple. However remember that surgery leaves both scars on the skin and in the breast tissue and can make breast investigations later in life more difficult to read.

If you already have a fibroadenoma and are pregnant, during pregnancy and lactation you can expect the size may vary but they will not interfere with breast feeding or milk coming in.  Calcified fibroadenomas are sometimes found in the elderly women as a hard discrete mobile lump that can be easily seen on a mammogram.

 

Cystosarcoma Phyllodes (Phyllodes Tumour)

Phyllodes tumours (PTs) take their name from the Greek word phyllon which means ‘leaf’ because of their leaf-shaped growth pattern. They can also behave like plants which are difficult to root out, like a weed in the garden. Unlike fibroadenomas, when they grow in the breast, they don’t form a neat shell around the outside, but instead they grow into normal breast tissue. That means when they are removed with surgery, if a rim of normal breast tissue is not taken out too, little bits can be left behind. Like the roots of a weed, they will cause the lump to grow back, often more aggressively than before.

Phyllodes do have a risk of a recurrence even if they are benign (non-cancerous), but they also have a risk of spreading or recurring if malignant (cancerous). The type of tumour and its risk to recur or spread (metastasise) can only be determined once it has been removed and examined microscopically. Once the grade of a Phyllodes tumour is established, you’ll need to undergo a second surgical procedure to ensure you have clear margins of disease- free tissue of 1-2 cm, followed by reconstruction. The reconstructive options depend on many factors. If you’re large-breasted and the tumour is relatively small, reconstruction can be done in a similar way to a breast reduction. If the tumour is large and most of your breast needs to be removed, the reconstruction will be more extensive and involved.

Unlike ‘normal’ breast cancer there are no identified risk factors for having a Phyllodes tumour, nor does there seem to be a genetic predisposition. And unlike ‘normal’ breast cancer which arises from the glandular elements of the breast, these are tumours of the connective tissue within the breast tissue. Malignant Phyllodes tumours don’t spread like breast cancers to lymph glands and usually just recur locally, however the more aggressive tumours can spread to the lungs and liver. Some can be so large (up to 30 cm in size) that complete removal of the breast and part of the chest wall is required

Because doctors don’t encounter Phyllodes tumours all that frequently, they are often misdiagnosed as benign fibroadenomas, the most common kind of breast masses that occur especially amongst younger women. Breast masses should never be brushed off as ‘harmless fibroadenomas’ and that is why most diagnoses today should only be undertaken by a specialist radiologist with the use of an ultrasound.

Any features on ultrasound that are not typical should result in a core needle biopsy, which involves a small biopsy done under local anaesthetic.  ALL masses, irrespective of diagnosis, should be followed up 6 months later by an ultrasound. Furthermore any masses that grow, or are larger than 3cm, should always be excised

 

Fat necrosis

Severe injury to the breast (from a motor vehicle accident or being punched in the breast) can cause fat necrosis. It is also seen after some breast reduction operations. The problem is that fat necrosis feels like a hard irregular lump, which can feel a lot like a mimic breast cancer.  The only way to tell the difference is through a mammogram and core needle biopsy which will usually help tell the difference. There is no treatment required for this problem, surgery is not advisable, and once the investigations have confirmed that the lump is fat necrosis, reassurance and watching it doesn’t get bigger or change is all that is needed.

 

Breast hamartomas (Fibroadenolipoma)

This is not a common breast lump, and not the first thought of most doctors. Hamartomas of the breast are normally painless breast lumps which are softer and larger. They have been called a ‘breast within the breast’ because they contain all the different types of tissue found in a breast. This may account for some diagnostic confusion especially if an FNA is performed, as the cells are difficult to differentiate from abnormal cells. It is normally possible to confirm diagnosis with a core biopsy rather than an FNA. Even on a mammogram these lumps have a distinct picture showing an easy to see lump separated from normal breast tissue by a thin white margin. If clinical examination and core needle biopsy do not fully explain the lump, a surgical removal is recommended.

 

Fibroadenosis (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.

This is normally called ‘fibroadenosis’ but we think this term can be confusing and misleading sometimes because represents what is going on inside the breast at a tissue level but the process is normal. Breasts are uniquely different to palpation, some are smooth, some are nodular and the term should not be used as if this is abnormal or a disease of the breast.

All breasts have a certain amount of fibrosis (connective tissue) and adenosis (gland or milk tissue) 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.

 

Cystic masses

Breast Cysts

Breast cysts are masses that might look and feel like a lump but actually they are fluid-filled sacs within the breast. No one knows why they form but it can be due to the hormonal or structural changes in the breast that happen as you get older. Cysts usually occur in the premenopausal women in the years after childbirth and breast feeding (thirty-five to fifty years) and they develop in about 5% of women. They might be single or multiple, but often they are only picked up on mammogram or sonar. The most important information about pure breast cysts is that they do not cause cancer and they are no associated with cancer. They are easily diagnosed using sonar (ultrasound) and can be aspirated with a fine needle (FNA).  The fluid is usually yellow or greenish and there can be up to 20mls.

Provided there is no blood (red or black) in this fluid and that there is no residual 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 the residual mass if present under radiological guidance or to excise it surgically.

 

Galactocele

This is simply a cyst, found only in breast feeding women that contains retained milk but has no signs of bacterial infection.  It can be treated by needle aspiration of the cyst and suppression of milk. Uncommonly surgical excision can also be performed if necessary.

Gers_f1_?_Breast infections most commonly affected women from 18-50 years. They can be divided into infections related to breast-feeding and those that are not (non-lactational abscesses). It is important to treat any infection of the breast early and correctly to ensure they do not develop into deeper problems. As with all diseases of the breast it is also important to make sure a cancer is not missed.

Lactational breast abscess

This is a localised infection in the skin and tissue of the breast that is caused by bacteria which can enter the breast through a cracked nipple or fissure. It commonly occurs in the second to fifth week of breast feeding when a mother is still getting used to the whole procedure. Unsatisfactory breast feeding may cause milk retention and stasis which can make the problem worse. The breast becomes hard and swollen, completely or in one area, and it is painful to breast feed of even touch the breast. When the breast is swollen like this it is called mastitis. This can be adequately treated with antibiotics.  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.

Milk must be expressed from the infected breast (the one with the abscess) that is involved in the inflammatory process and the baby can continue to feed from the other breast. If the mother wants to stop breast feeding, lactation can be suppressed with fluid restriction and medications.

As the infection develops, if untreated it can form a collection of pus which causes even more pain and sometimes a bulge in the breast. This pus will not resolve on antibiotics and needs to be drained. The current recommended treatment is high dose antibiotics (Co-amoxyclav is the drug of choice and safe in breastfeeding mothers) as well as repeated ultrasound guided aspiration (we seldom have to carry out a surgical incision and drainage procedure nowadays).

Thrush

Thrush can also affect the lactating breast, causing burning, shooting pains during breastfeeding and causing sore patches on the nipples (and a paler areola). The difficulty with thrush is that it can be passed from the baby’s mouth to the mother’s breast (causing the infection in the first place), and as the mother feeds the baby, it can be passed back again. It is very important to the mother and her baby at the same time, for long enough to ensure all infection is gone. Thrush can be treated with Fluconazole (difflucan) tablets and an anti-fungal cream for the nipples.

Non-lactational Breast Abscess

Breast abscesses can occur in women who are not breastfeeding. They may occur around the nipple as a result of chronic inflammation and active infection around the central ducts of the breast underneath the nipple. This is a result of duct ectasia, a widening and thickening of the ducts due to inflammation (and often smoking).

As the infection develops from mastitis, a collection of pus forms in the tissue along with surrounding swelling. The skin may thin over the abscess and it may become thin or flaky. Just like in lactational abscesses this pus collection will not resolve on antibiotics alone and management is high dose antibiotics (Co-amoxyclav is the drug of choice if no penicillin allergy is present) as well as repeated ultrasound guided aspiration. This is followed in certain complicated cases by surgical drainage with biopsy of the abscess wall.

Less frequently an abscess can be caused by an underlying infection such as TB and when you have HIV/AIDS this can be more likely. It is important to be treated in a specialist unit that can adequately diagnose and manage treatment of these infections, particularly in patients who have HIV

Breast cancer can also present looking like an abscess or mastitis. This is called Inflammatory Breast Cancer and it is the way 2-5% of breast cancers present. No infection should be ignored and all infections should be seen by a breast specialist who will be able to optimally diagnose and treat and unusual causes.

Superficial skin infections (boils, sebaceous cysts and recurrent skin abscesses) can also occur in the skin over the breast, but these are not related to the breast tissue.

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Pain in the breast is a frequent complaint.  All women will experience breast pain at some stage in their lives but some women are unfortunate enough to suffer from constant or repeated episodes of breast pain. When breast pain becomes excessive, it begins to interfere with the patient’s lifestyle such as being unable to wear seatbelts or having difficulty with sexual intercourse.  These women have what is referred to as mastalgia.

For most women breast pain is something that is experienced just prior to the menstrual period, or otherwise may be felt as an occasional twinge, but it does not feature heavily in our lives. Importantly, breast cancer only presents with pain in less than 10% of cases and will be a constant pain usually associated with a lump. Even if there is no mass but a constant localised pain a mammogram or sonar should be obtained. Only 2% of these cases will be due to cancer.

Trying to treat or cope with breast pain is often very frustrating. Most textbooks describe breast pain as cyclic or non-cyclic depending if it is related to the menstrual cycle. Two thirds of breast pain is cyclical and caused by the changes in hormones in our breasts. The rest is non-cyclical, of which one half is related to the bones and joints beneath the breast. Unfortunately it is difficult for women to differentiate these symptoms. All patients presenting with breast pain should have a thorough history and clinical examination with an ultrasound, and a mammogram if over forty.

But it is possible to approach pain according to the symptoms and type of pain. Sometimes women may have more than one type of pain. Sometimes it is only by treating the pain that it can be determined what the cause is.

When is a breast pain not a breast pain?…

… when it doesn’t come from the breast.

Nearly one fifth of all “breast pains” are actually due to non-breast causes such as:

  • cardiac problems (heart related), especially with left sided pressing breast pain
  • respiratory problems (lung problems such as pneumonia or pleurisy), often breast pain that is worse on breathing
  • gastro-intestinal problems (reflux heartburn), which might cause pain that wakes you at night or when you are lying flat
  • rib inflammation (costochondritis), which feels like pinpoint pain on either side of the breast
  • Shingles (Herpes Zoster infection), causing an incredibly painful rash from the back to the front.

What is breast pain then?

True breast pain can be dived into 4 types:

Lateral pulling pain

This is a pain that extends from the armpit down towards the nipples along the sides of the breasts. It is normally more common in big-breasted women.

The breasts hang on the pectoral muscle in a fine fibrous coating. Imagine the muscle as a coat hanger and the breast as a heavy jacket hanging on the coat hanger. The coat will drag on the hanger and just like that the breasts pull on the attachments below. This pain is usually worse at the end of the day and is related to breast poor fitting bras which will not support the breast adequately from below.

Burning, shooting pains

These types of pains, particularly around the nipple and associated with an itchy feeling can be due to duct ectasia. This is a dilatation on widening of the small milk ducts. These breast ducts are lined by fine hairs and inflammation in the ducts is similar to asthma or emphysema in the lungs. It causes debris to fill up inside and can increase the risk of infections. The causes of duct ectasia are smoking and pollution. Patients can experience burning discomfort in the breast and occasional shooting pains. Some complain of hot poking pains in the breast.

Topical antibiotics dabbed on the nipples may help for this type of pain.

 

Full, heavy uncomfortable breasts (feels like one needs to feed a baby)

This type of breast pain is hormonal and is most commonly caused by a change in the female hormone levels in the breast. It can be cyclical and related to the menstrual cycle, or non-cyclical and may be related to a hormone called prolactin. Most commonly the change in the breast tissue around the time of your period increases the amount of blood in your breast and the amount of water retained by the breast. This can make the breasts feel heavy and full, causing pain down the side of the breast, and throughout.

When the pain is not related to the menstrual cycle, it may be caused by stress (either physical (even chronic diseases), emotional or mental) which results in transient changes in the prolactin levels (a stress hormone). Women who are patients in Intensive Care Units also have raised prolactin levels. Prolactin is a fascinating hormone which is difficult to switch off once activated. Transient increases in prolactin may not reflected in blood levels tested but result in a full heavy discomfort in the breast. Women who have breastfed say the pain is similar to the discomfort experienced when the breast is full of milk. It is important to check thyroid function as an underactive thyroid causes similar breast discomfort, and consider any medication (such as some anti-depressants) which can affect prolactin levels as well.

No conventional pain medication works very well for this type of breast pain. Successful management of this breast pain is by understanding the cause, and trying evening primrose oils and Vitamin B6 combinations as the first line of treatment.

Fibroadenosis is not breast pain it is a lumpiness seen in the breast confirmed on a needle biopsy. However, a large number of women with lumpy breasts do have frequent breast pain.

 

Isolated medial and lateral pain on pressure (Chest Wall Pain)

This is known as costochondritis or as Tietze’s disease and accounts for 10% of breast pain. Men and women both suffer from this complaint but because the breasts are above these joints, most women perceive the pain as breast pain. The pain is localised to the breast and feels like particular tenderness over the costochondral junction (the ribs under the inner part of the breasts). The actual cause is often not known but may be due to a viral infection or may be related to or exacerbated by excessive muscle strain (sport).  Treatment is to abstain from doing the implicated sport for a few weeks and take NSAIDS (non-steroidal anti-inflammatory drugs).

Mondor’s disease is a rare and unusual cause of breast pain associated with a cord like structure running over the breast. It is the pain in the lower or lateral aspect of the breast from a thrombophlebitis (inflammation of a vein) crossing within the breast tissue.  Anti-inflammatory drugs (NSAIDS) and aspirin may give relief. This unusual condition can be associated with an underlying breast cancer so it is important to ensure appropriate breast investigations before treatment.

How can I treat this pain?

First determine what kind of pain it is. Treatments for most breast pains entail the following principles:

  • If your breast pain does not settle, please see a general practitioner or specialist with an interest in breast health.
  • Ensure that you have been for age appropriate investigations such as an ultrasound and/or mammogram and any blood tests.
  • If your breast pain is affecting your day to day life try recording your breast pain on a pain chart for four months. You can notice its variations over the menstrual cycles and it may help your treating doctor identify the cause.
  • Poorly fitting bras or old bras, combined with large breasts, result in pain under breasts and down the side of the breast, particularly as the day progresses and gravity takes its toll on the breast ligaments.
  • Medications that can be tried at home include Vitamin B6 (pyridoxine) and gamma linolenic acid (GLA, Evening Primrose Oil) should be tried first. GLA in particular tends to stabilize breast epithelial activity via hormonal metabolism. The dose of evening primrose oil is 2-6 capsules daily and B6 and evening primrose oil should be taken in combination. Treatment is continued for a minimum of 3 months. In some studies over 70% of patients had a good response.
  • If you are on the contraceptive pill or suitable for it, your doctor may suggest an alternative contraceptive pill after checking the relevant tests.

 

Previously breast pain was treated with strong hormonal manipulative medication such as Danazol or Bromocriptine. Often, however, the side effects of these drugs (weight gain, growing facial hair) often outweigh the benefit.

Breast pain that does not respond to supplements may be treated with low dose anti-oestrogen medicines such as Tamoxifen or Fareston (although these do not have FDA approval in the USA for this use). Tamoxifen taken orally at very low doses is incredibly useful in premenopausal women. Alternatively some studies suggest crushing these SERMS and mixing them in KY jelly and applying them topically to the breast tissue. In post-menopausal women, a related drug called raloxifene (Evista) works in a similar way and may help decrease breast pain. This medication may have the added benefit of decreasing risk of breast cancer as will Tamoxifen.

Would surgery help?

Breast pain that does not respond to any treatment should never be treated with surgery. A doctor does not treat a headache by chopping off the patients head and even after surgery 50% of women who have breast surgery for breast pain have continuous pain post-surgery. The only type of breast pain that is improved by surgery may be lateral pulling pain in large breasted women where a breast reduction is helpful.

Remember that breast pain with an associated normal mammogram is almost never a breast cancer.

It is estimated that 80% of women are wearing the wrong bra. Are you one of them?

Wearing the wrong size bar can lead to increased pain in the neck and shoulders as the breasts are inadequately supported. One of the most common causes of breast pain is poor support and women are often shy to look for the correct size of bra. As a result their bust is unsupported from below and all the support comes from the shoulder straps which causes welts and indentations in the shoulders.

This lack of support can also lead to large breast hanging down on the skin below the breast causing an area of warm moisture through the day. This results in a fantastic breeding ground for bacteria and funguses to grow- often seen as a white or red discolouration under the breasts and eventually leading to darker discolouration in dark skins. An inappropriately tight bra can also cause problems. There is constriction of the respiratory muscles (the muscles that helps us breathe well) causing breathing problems, and back and should aches too.

So what is the wrong bra and how do you find the right one for you? Look in the mirror with your bra on and see if it fits

Every woman is different in her personality, her looks, her shape… and her breasts. Most of these differences are very normal but occasionally a child can be born with an abnormality of the breast. Most do not require treatment and will resolve alone.

Nipple inversion

The nipple may fail to evert at puberty, giving rise to an inverted nipple. This is a common condition and not abnormal. It is most often bilateral. If there are no symptoms, no treatment is needed. Women can even still breastfeed with inverted nipples but may require a nipple shield. If it does become a problem, or if you are unhappy with it, management of congenital nipple inversion can both be undertaken by manual techniques or surgery.

If a woman suddenly develops an inverted nipple in adulthood however, it needs to be investigated because it may signify an underlying problem such as a cancer.

Accessory breasts

This is a very common condition, and if you look carefully maybe you have it! (One in five women does).

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. They follow in the path of a line going from under the arm, over the nipple and down to the groin. In practice breast tissue or nipples most commonly develop above the waist.

During pregnancy and lactation this extra breast tissue may enlarge and even produce milk if a nipple is present. The tissue can also become painful around the period because it is stimulated by the same female hormones that control the breast.  If this type of tissue causes concern, it can be removed surgically.

 

Amazia (absent breast)

If something goes wrong with the embryological development, such as a genetic abnormality or if the pregnant mother is exposed to some dangerous factor such as a toxic drug, or a virus, the breast may fail to develop. This can be managed by reconstructive surgery when the girl is old enough. It is very important to ultrasound the normal breast and to ensure that there are no masses making that side seem bigger. No surgical removal of the normal breast should be carried out.

 

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 which may even produce milk (called witch’s milk).

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.

 

Prepubertal breast development

This is a type of premature breast development which often occurs on one side only and it is occasionally this is seen in young toddlers.  The breast will develop without any problems in the future so no treatment is required except for firm reassurance that all is fine. Open surgical biopsies will interfere with breast development. Investigations should be done to check for other signs of secondary sexual development occurring early and to find a reason why.