I. Fibrocystic Breast Change (FBC)
Fibrocystic Breast Change (FBC) encompasses several of the following pathologic features: stromal fibrosis, macro- and microcysts, apocrine metaplasia, hyperplasia, and adenosis (which may be sclerosing, blunt-duct, or florid).
- FBC is common and may present as breast pain, a breast mass, nipple discharge, or abnormalities on mammography.
- The patient presenting with a breast mass or thickening and suspected FBC should be re-examined in a short interval, preferably on day 10 of the menstrual cycle, when hormonal influence is lowest. Often, the mass will have diminished in size.
- A persistent dominant mass must undergo further radiographic evaluation, biopsy, or both to exclude cancer.
II. Breast Cysts
Breast Cysts frequently present as tender masses or as smooth, mobile, well-defined masses on palpation. If tense with fluid, its texture may be firm, resembling a solid mass. Aspiration can determine the nature of the mass (solid vs. cystic) but is not routinely necessary. Cyst fluid color varies and can be clear, straw-colored, or even dark green.
- Cysts discovered by mammography and confirmed as simple cysts by ultrasound are usually observed if asymptomatic.
- Symptomatic simple cysts should be aspirated. If no palpable mass is present after drainage, the patient should be evaluated in 3 to 4 weeks. If the cyst recurs, does not resolve completely with aspiration, or yields bloody fluid with aspiration, then mammography or ultrasonography should be performed to exclude intracystic tumor. Nonbloody clear fluid does not need to be sent for cytology.
Fibroadenoma is the most common discrete mass in women younger than 30 years of age. They typically present as smooth, firm, mobile masses.
- They enlarge during pregnancy and involute after menopause.
- They have well-circumscribed borders on mammography and ultrasound.
- They may be managed conservatively if clinical and radiographic appearance is consistent with a fibroadenoma and is less than 2 cm. If the mass is symptomatic, greater than 2 cm, or enlarges, it should be excised.
Most women (70%) experience some form of breast pain or discomfort during their lifetime. The pain may be cyclic (worse before a menstrual cycle) or noncyclical, focal or diffuse. Benign disease is the etiology in the majority of cases. However, pain may be associated with cancer in up to 10% of patients. Features that raise the suspicion of cancer are noncyclic pain in a focal area and pain associated with a mass or bloody nipple discharge. Once cancer has been excluded, most patients can be managed successfully with symptomatic therapy and reassurance; a well-fitting supportive bra is an important first step in pain relief. In 15% of patients, the pain may be so disabling that it interferes with activities of daily living.
A. Cyclic breast pain
Often described as a heaviness or tenderness and is usually worse before a menstrual cycle. It may be maximal in the upper outer quadrant and radiate to the inner surface of the upper arm. It resolves spontaneously in 20% to 30% of women but tends to recur in 60%. Many patients experience symptomatic relief by reducing caffeine intake or by taking vitamin E, although there is no scientific evidence supporting this.
B. Noncyclic breast pain
Described as burning or stabbing and frequently occurs in the subareolar area or medial aspect of the breast. It responds poorly to treatment but tends to resolve spontaneously in 50% of women.
C. Treatment of mastalgia
- Topical nonsteroidal anti-inflammatory drugs (NSAIDs) (diclofenac gel) have been proven in a randomized, blinded, placebo-controlled study to have significant efficacy with minimal side effects and should be considered first-line treatment (J Am Coll Surg 2003;196:525).
- Tamoxifen (an estrogen antagonist) has been shown to provide good pain relief in placebo-controlled trials with tolerable side effects (Lancet 1986;1:287), although concerns over increased risks of endometrial cancer limit long-term use.
- Danazol (a derivative of testosterone) has been shown to be efficacious and has been used historically for severe breast pain (Gynecol Endocrinol 1997;11:393), but significant side effects (hirsutism, voice changes, acne, amenorrhea, and abnormal liver enzymes levels) limit its use.
- Bromocriptine and gonadorelin analogs should be reserved for severe refractory mastalgia due to significant side effects.
- Evening primrose oil is often used but has been shown to have no benefit over placebo in clinical trials (Am J Obstet Gynecol 2002;187:1389).
D. Superficial thrombophlebitis
Superficial thrombophlebitis of the veins overlying the breast (Mondor disease) may present as breast pain. The thrombosed vein or “cord” may be palpated.
NSAIDs and hot compresses can provide symptomatic relief. Antibiotics are not generally indicated.
E. Breast pain in pregnancy and lactation
Breast pain in pregnancy and lactation can occur from engorgement, clogged ducts, trauma to the areola and nipple from pumping or nursing, or any of the aforementioned sources. Clogged ducts are usually treated with warm compresses, soaks, and massage.
F. Tietze syndrome or costochondritis
Tietze syndrome or costochondritis may be confused with breast pain. Patients are locally tender in the parasternal area. Treatment is with NSAIDs.
G. Cervical radiculopathy
Cervical radiculopathy can also cause referred pain to the breast.
V. Nipple Discharge
Lactation is the most common physiologic cause of nipple discharge and may continue for up to 2 years after cessation of breast-feeding. In parous nonlactating women, a small amount of milk may be expressed from multiple ducts. This requires no treatment.
Galactorrhea is milky discharge unrelated to breast-feeding. Physiologic galactorrhea is the continued production of milk after lactation has ceased and menses resumed and is often caused by continued mechanical stimulation of the nipples.
- Drug-related galactorrhea is caused by medications that affect the hypothalamic-pituitary axis by depleting dopamine (tricyclic antidepressants, reserpine, methyldopa, cimetidine, and benzodiazepines), blocking the dopamine receptor (phenothiazine, metoclopramide, and haloperidol), or having an estrogenic effect (digitalis). Discharge is generally bilateral and nonbloody.
- Spontaneous galactorrhea in a nonlactating patient may be due to a pituitary prolactinoma. Amenorrhea may be associated. The diagnosis is established by measuring the serum prolactin level and performing a computed tomography (CT) or MRI scan of the pituitary gland. Treatment is bromocriptine or resection of the prolactinoma.
C. Pathologic nipple discharge
Pathologic nipple discharge is either (1) bloody or (2) spontaneous, unilateral, and originates from a single duct. Normal physiologic discharge is usually nonbloody, from multiple ducts, can be a variety of colors (clear to yellow to green), and requires breast manipulation to produce.
- Pathologic discharge is serous, serosanguineous, bloody, or watery. The presence of blood can be confirmed with a guaiac test.
- Cytologic evaluation of the discharge is not generally useful.
- Malignancy is the underlying cause in 10% of patients.
- If physical examination and mammography are negative for an associated mass, the most likely etiologies are benign intraductal papilloma, duct ectasia, or fibrocystic changes. In lactating women, serosanguinous or bloody discharge can be associated with duct trauma, infection, or epithelial proliferation associated with breast enlargement.
- A solitary papilloma with a fibrovascular core places the patient at marginally increased risk for the development of breast cancer. Patients with persistent spontaneous discharge from a single duct require a surgical microdochectomy, ductoscopy, or major duct excision.
a.Microdochectomy: Excision of the involved duct and associated lobule. Immediately before surgery, the involved duct is cannulated, and radiopaque contrast is injected to obtain a ductogram, which identifies lesions as filling defects. The patient is then taken to the operating room, and the pathologic duct is identified and excised, along with the associated lobule.
b.Ductoscopy utilizes a 1-mm rigid videoscope to perform an internal exploration of the major ducts of the breast. Once a ductal lesion is identified, this single associated duct with the lesion is excised.
c.Major duct excision may be used for women with bloody nipple discharge from multiple ducts or in postmenopausal women with bloody nipple discharge. It is performed through a circumareolar incision, and all of the retroareolar ducts are transected and excised, along with a cone of tissue extending up to several centimeters posterior to the nipple.
VI. Breast Infections
A. Lactational mastitis
Lactational mastitis may occur either sporadically or in epidemics.
- The most common causative organism is Staphylococcus aureus.
- It presents as a swollen, erythematous, and tender breast; purulent discharge from the nipple is uncommon.
- In the early cellulitic phase, the treatment is antibiotics. The frequency of nursing or pumping should be increased. Approximately 25% progress to abscess formation.
- Breast abscesses occur in the later stages and are often not fluctuant. The diagnosis is made by failure to improve on antibiotics, abscess cavity seen on ultrasound, or aspiration of pus. Treatment is cessation of nursing and surgical drainage.
B. Nonpuerperal abscesses
Nonpuerperal abscesses result from duct ectasia with periductal mastitis, infected cysts, infected hematoma, or hematogenous spread from another source.
- They usually are located in the peri/retroareolar area.
- Anaerobes are the most common causative agent, although antibiotics should cover both anaerobic and aerobic organisms.
- Treatment is surgical drainage.
- Unresolved or recurring infection requires biopsy to exclude cancer. These patients often have a chronic relapsing course with multiple infections requiring surgical drainage.
- Repeated infections can result in a chronically draining periareolar lesion or a mammary fistula lined with squamous epithelium. Treatment is excision of the central duct along with the fistula once the acute infection resolves. The fistula can recur even after surgery.
Gynecomastia: hypertrophy of breast tissue in men.
- Pubertal hypertrophy occurs in adolescent boys, is usually bilateral, and resolves spontaneously in 6 to 12 months.
- Senescent gynecomastia is commonly seen after age 70 years, as testosterone levels decrease.
- Drugs associated with this are similar to those that cause galactorrhea in women, for example, digoxin, spironolactone, methyldopa, cimetidine, tricyclic antidepressants, phenothiazine, reserpine, and marijuana.
- Tumors can cause gynecomastia secondary to excess secretion of estrogens: testicular teratomas and seminomas, bronchogenic carcinomas, adrenal tumors, and tumors of the pituitary and hypothalamus.
- Gynecomastia may be a manifestation of systemic diseases such as hepatic cirrhosis, renal failure, and malnutrition.
- During the workup of gynecomastia, cancer should be excluded by mammography and subsequently by biopsy if a mass is found. The cause of gynecomastia should be identified and corrected if possible. If workup fails to reveal a medically treatable cause or if the enlargement fails to regress, excision of breast tissue via a periareolar incision can be performed.