Breast

Published on 10/04/2015 by admin

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CHAPTER 10 Breast

Symptoms of breast disease 166

Benign breast disease 167

Carcinoma of the female breast 171

Other conditions of the breast 175

Conditions of the male breast 176

Whatever the presenting symptoms, the patient fears she may have cancer. A rapid, efficient and sympathetic approach, paying attention to psychological and emotional problems, is required in dealing with breast disease. The treatment of breast cancer is multidisciplinary involving surgeons, oncologists, breast care nurses, breast clinicians, specialist radiologists and pathologists.

Symptoms of breast disease

Patients with breast disease present with either a lump, discharge from the nipple, pain in the breast, abnormality of the nipple, or a change in size of the breast (→ Table 10.1).

TABLE 10.1 Presentation of breast disease

Breast lump

Carcinoma, cyst, localized area of fibroadenosis, fibroadenoma, breast abscess, fat necrosis, duct ectasia, lipoma, galactocele, phyllodes tumour, cyst of Montgomery’s glands, sebaceous cyst

Pain in the breast

Cyclical and non-cyclical breast pain
Carcinoma (85% are painless)
Duct ectasia (pain behind the nipple)
Infection:

• puerperal mastitis

• breast abscess

Fat necrosis
Costochondritis (Tietze’s disease)
Mondor’s disease (superficial thrombophlebitis of veins of the chest wall)

Nipple discharge Bloodstained (intraduct carcinoma, intraduct papilloma, Paget’s disease)
Serous (early pregnancy)
Yellowish, brown or dark green (benign nodularity)
Thick and creamy (duct ectasia)
Purulent (rarely in association with breast abscess)
Milky (late pregnancy, post-lactation, prolactinoma) Nipple abnormalities Retraction (congenital, duct ectasia, carcinoma)
Inflammation (eczema, Paget’s disease)
Destruction (Paget’s disease)
Mamillary fistula Breast enlargement Benign hyperplasia, pregnancy, cancer, giant fibroadenoma, phyllodes tumour, mammary lymphoedema

History

Take note of the following: the duration of symptoms, parity, age at menopause, age at menarche, breast-feeding, contraceptive pill and HRT, previous breast surgery, family history of breast cancer.

Examination

• Observe with patient sitting inclined at 45°, e.g. symmetry, masses, peau d’orange, skin dimpling, nipple retraction.

• Observe with hands raised above head, e.g. obvious skin tethering/dimpling/asymmetry.

• Examination of the nipples, e.g. nipple retraction, Paget’s disease, expression of blood from a duct.

• Palpate each quadrant and the axillary tail with the flat of the hand. With the patient in the akimbo position pressing hand on hip, test for deep fixation.

• Palpate axilla. Mobile or fixed nodes.

• Palpate supraclavicular fossa. Mobile or fixed nodes.

• General examination for distant metastases, e.g. chest – pleural effusion; hepatomegaly – liver metastases. Ascites. Spinous osseous tenderness.

Investigations

• Fine needle aspiration cytology (FNAC): a negative result does not exclude carcinoma

• Mammography: 90% accurate – unreliable under the age of 35 years because of the density of breast

• Core biopsy.

Triple assessment is the minimum standard of care for a mass or asymmetric density/thickening of the breast. Triple assessment includes examination, imaging and pathology. Imaging includes mammography + ultrasound. Pathology includes FNAC, core biopsy, vacuum assisted mammotome biopsy. As a core or mammotome biopsy offers the pathologist a sample of histological tissue with its surrounding architecture, it is more accurate for diagnosis than cells in suspension as in FNAC, and is therefore preferable.

Cases are discussed with the pathological and radiological findings at a multidisciplinary team meeting. The radiological size of a tumour and lymph node status, its histological type (e.g. ductal, lobular, mucinous) and hormonal receptor status (oestrogen receptor, progesterone receptor and HER2 protein receptor positivity) are reviewed with patients clinical and social history and a plan for both surgery and adjuvant therapy is made. The Nottingham Prognostic Index combines data of both stage and grade to offer a prognostic score, which enables the benefits of adjuvant therapies to be weighed against the risks (Table 10.2).

TABLE 10.2 Nottingham Prognostic Index*

Benign breast disease

This presents as breast nodularity; fibroadenoma; duct ectasia; fat necrosis; intraduct papilloma; breast abscess; related conditions such as Tietze’s disease or Mondor’s disease.

Benign nodularity/breast pain

This occurs between 20 and 45 years and settles after the menopause. It probably results from an abnormal response of the breast to changes in the hormonal environment. The terms fibroadenosis and cystic hyperplasia describe the pathological condition well. There is exaggeration of the fibrotic element (i.e. fibrosis), the epithelial element undergoes hyperplasia (i.e. adenosis), and there is a tendency to cyst formation. The condition may be extremely painful, especially premenstrually, hence the terms cyclical mastitis or cyclical mastalgia.

Symptoms and signs

Cyclical breast pain worse before period. Intermittent breast masses or areas of thickening with no discrete mass. Discrete mass, i.e. cysts, may be noticed by patient. Examination reveals nodular breasts with multiple thickened areas (usually upper and outer quadrant) that are usually tender. Lesions change in number and size during the menstrual cycle. If condition is suspected, examination should be repeated at different stages of the menstrual cycle. If there is a dominant mass, ‘triple’ assessment should be carried out.

Investigations

• Mammography to exclude carcinoma

• USS – fibroadenoma, cyst – ultrasound-guided or freehand core biopsy or FNAC. Aspiration may be diagnostic and therapeutic for a cyst.

Treatment

This condition may be exceptionally painful and cause severe distress to the patient. Keeping a breast pain diary to document severity and symptoms in relation to menstrual cycle helps distinguish between cyclical and non-cyclical breast pain and the efficacy of treatment. An explanation of the condition and treatment options should be clearly and sympathetically made; 90% of patients require no further treatment.

• Firm supporting bra to ‘rest’ the breast. This should be worn day and night when the patient is symptomatic.

• Evening primrose oil.

• Danazol is given for severe symptoms. Androgenic side-effects need to be explained to the patient. About 50% of patients cannot tolerate danazol.

• Anti-oestrogen therapy prescribed and monitored by a specialist (tamoxifen and goserelin are excellent treatment agents but are not licensed for use with breast pain). Short-course therapy only should be given.

• Rarely, some patients are so severely troubled they become suicidal. Subcutaneous mastectomy with or without reconstruction has been used in extreme cases.

• The condition occasionally responds to hypnotherapy and acupuncture.

Fibroadenoma

This occurs at age 15–35 years.

Symptoms and signs

Very mobile breast lump noted by patient. Non-tender. On examination there is a mobile, discrete, smooth, firm and rubbery swelling in the breast. It slips under the examining fingers, hence its name breast ‘mouse’. As with any discrete mass, triple assessment should be carried out to exclude carcinoma.

Treatment

Excisional biopsy if there is any doubt about the diagnosis. In young women in their teens, it is reasonable to observe. However, if observation is carried out FNAC or core biopsy should be undertaken.

Duct ectasia (periductal mastitis)

This occurs chiefly in the fifth decade. The aetiology is obscure but is associated with dilatation of the ducts behind the nipple and a periductal inflammatory reaction rich in plasma cells. The condition is sometimes called plasma cell mastitis.

Related

Churchills Pocketbook of Surgery