Breast

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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.

Symptoms and signs

Pain and periareolar erythema. Nipple discharge may be either thick and creamy or greenish brown. There may be a periareolar tender mass. The nipple may become retracted when healing occurs by fibrosis. Occasionally infection occurs with periareolar abscess formation.

Differential diagnosis

Carcinoma of the breast with nipple retraction.

Investigations

• Mammogram: opaque mass of dilated ducts and skin indentation may be apparent.

Treatment

• If infection is present aspiration should be carried out and antibiotics given.

• If an abscess is present surgical drainage may be required.

• A mammillary fistula may occur as a complication. If it does it should be laid open.

• With severe discharge or recurrent sepsis total duct excision should be carried out (mammadochectomy). The ducts are excised through a circumareolar incision, preserving the nipple.

Fat necrosis

This is due to trauma with rupture of fat cells and a consequent inflammatory reaction, which may become calcified.

Symptoms and signs

There may be a history of trauma, often minor. The partner’s teeth may be an aetiological factor and patients may be embarrassed to explain this possible cause. The lump may have decreased in size before the patient is seen in clinic. In the early phases, the lump is tender. In the later phases it is hard and irregular and tethered to the skin.

Investigations

Triple assessment to exclude carcinoma.

Treatment

Excision biopsy may be necessary ultimately to distinguish the condition from cancer of the breast. Ultimately, fat necrosis may evolve into an oil-filled cyst which can be aspirated.

Intraduct papilloma

The papilloma is usually in a solitary duct near the nipple in a young woman.

Symptoms and signs

Blood-stained discharge from a single duct on to the nipple. Occasionally a small mass may be palpable. Usually, however, no mass is palpable. Pressure over a certain spot, or the palpable mass will cause bleeding from a single duct orifice.

Investigations

Mammography may be required to exclude carcinoma.

Treatment

If the duct orifice from which the bleeding is coming can be identified, microdochectomy is carried out. If not, excision of the major nipple ducts is necessary. Histological confirmation is required to exclude in situ or invasive cancer.

Breast abscess

This most commonly occurs following suppuration of acute mastitis in the lactating breast. The infecting organism is usually Staphylococcus aureus. The early phase of acute mastitis may settle with appropriate antistaphylococcal antibiotics.

Symptoms and signs

Lactating breast. Patient generally unwell with painful, tender, red and warm swelling of breast. The swelling may become fluctuant and eventually the abscess points and discharges.

Treatment

The majority can be treated by aspiration and antibiotics. Aspiration may need to be repeated. Ultrasound guided drainage may be necessary. Loculation does not seem to be a major concern except for large abscesses. In the case of large abscesses, incision and drainage with breakdown of loculi may be required. Occasionally abscesses occur in the glands of Montgomery and appear as a boil-like lesion and should be treated as for a boil. Periareolar abscesses may occur with duct ectasia.

Related conditions

Patients may occasionally present with apparent pain in the breast, where the condition responsible for the pain is not within the breast.

Tietze’s disease

This is costochondritis and usually involves the second, third and fourth costal cartilages. The cause is unknown and radiographs are unhelpful. The condition is self-limiting, although NSAIDs and infiltration with local anaesthetic and steroids may be helpful if the pain is severe.

Mondor’s disease

(Superficial thrombophlebitis of the subcutaneous veins of the chest wall.) The cause is unknown and the condition self-limiting. The veins of the chest wall are felt as red, tender cords often extending on to the anterior axillary fold. The breast should be carefully palpated for underlying masses. Mammography is advised to exclude an underlying carcinoma. NSAIDs may help relieve symptoms.

Carcinoma of the female breast

This is the most common malignancy in the female. About 42 000 women and 300 men are diagnosed annually in the UK with carcinoma of the breast. Of the women diagnosed with breast cancer, 72% live for more than 10 years. The incidence of the disease appears to be rising. The cause remains unknown. Survival rate has improved significantly over the last 10–15 years. This probably reflects screening, awareness and earlier diagnosis, use of tamoxifen and better chemotherapeutic agents.

Risk factors

• Family history – first-degree relatives with early-onset disease

• Previous breast carcinoma (recurrence versus metachronous disease)

• Atypical hyperplasia on previous biopsy

• Nulliparous women

• Early menarche

• Age (the older the more likely).

Symptoms and signs

Symptoms include: painless lump in the breast; nipple retraction or discharge; skin dimpling; breast asymmetry; erythema over skin or nipple; symptoms of metastases, e.g. bone pain, headache, breathlessness, jaundice. Examination may reveal: hard irregular mass, fixed to skin or fixed deeply; erythema; Paget’s disease of nipple; peau d’orange; axillary glands mobile, fixed or matted; supraclavicular nodes palpable; signs of metastases – liver (jaundice, hepatomegaly, ascites), lung or pleural metastases (pleural effusion, consolidation), bone secondaries (bone tenderness or pathological fractures), brain secondaries (headache, fits, personality change, papilloedema).

Investigations

• Triple assessment (examination + imaging + pathology)

• Metastases screen – either (A) CXR, liver ultrasound, bone scan, LFTs and calcium, FBC or (B) CT thorax/abdomen, bone scan, LFTs and calcium, FBC. Frozen section is rarely performed nowadays as it is 35% inaccurate.

• CT scan of brain if symptoms, but not routinely performed. A mammogram of a patient with breast cancer is shown in Figure 10.1.

Figure 10.1 A mammogram showing a carcinoma of the breast. There is a dense mass with microcalcification. Malignant microcalcification requires careful examination of the film with magnification: it does not reproduce well in photographs.

Clinical staging

Two forms are in wide use (Tables 10.3, 10.4).

TABLE 10.3 Manchester Classification (modified)

Stage I	Lump <5 cm; not fixed deeply
Stage II	As for stage I but mobile, ipsilateral axillary nodes
Stage III	Lump >5 cm fixed to skin with fixed ipsilateral axillary nodes, or supraclavicular nodes, or peau d’orange, or arm oedema
Stage IV	Distant metastases

TABLE 10.4 TNM Classification

Primary (T)	Tis – carcinoma in situ T0 – no primary tumour located T1 – tumour <2 cm T2 – tumour 2–5 cm T3 – tumour >5 cm T4 – extension to chest wall
Nodes (N)	N0 – no nodal involvement N1 – mobile ipsilateral axillary nodes N2 – fixed ipsilateral axillary nodes N3 – ipsilateral supraclavicular nodes
Metastases (M)	M0 – no metastases M1 – distant metastases

Treatment

Surgery to the breast ranges from wide local excision (WLE) to mastectomy + oncoplastic or reconstructive options.

Important studies starting in the 1970s demonstrated that WLE with adjuvant radiotherapy produced comparable local recurrence and disease-free survival rates to mastectomy alone. WLE therefore became an option for women with smaller tumours in relatively larger breasts, i.e. where clearance is possible while still conserving the breast. Larger tumours in smaller breasts may necessitate mastectomy to achieve local control.

Adjuvant therapies include chemotherapy, anti-oestrogens (hormone) therapy and targeted therapies, e.g. trastuzumab (Herceptin) – a monoclonal antibody targeted against HER2 protein, bisphosphonates. Treatment options should be discussed with the patient. Preoperative counselling by the surgeon and a specially trained breast care nurse should explain the treatment options and prepare the patient for treatment. Recent trends are to more conservative management of breast cancer.

Alternative treatment modalities include neo-adjuvant chemotherapy (prior to surgery) which may ‘downstage’ a tumour to enable breast conservation in a patient with locally advanced disease that would otherwise require a mastectomy. Also, primary endocrine therapy for oestrogen receptor positive cancers can be offered as an alternative to surgery in patients who are at high risk of an anaesthetic, refuse surgery, or are assessed to be at a higher risk of mortality from another cause.

Surgery for ductal carcinoma in situ, Tis (DCIS)

Forming 25–30% of screening-detected tumours, ductal carcinoma in situ represents an area of dysplasia reaching, but not invading the basement membrane. It can be low, intermediate or high nuclear grade and has a variety of histological subtypes. It represents a point in the evolution between atypia and malignancy. Microcalcification may be present on mammography and it may occupy a small area of the breast or be widespread. Core biopsies positive for DCIS, may not be a true reflection of the mass which may contain areas of invasion. Surgery with clear histological margins is the primary aim which, in widespread DCIS may require mastectomy. If histology confirms invasion then the axilla will require staging (see below), and adjuvant therapy is offered accordingly.

Surgery for early breast cancer (T1, T2)

• Wide local excision: removal of the lump with a margin of normal breast tissue. If the lesion is impalpable such as those detected by screening, a wire is passed to the tumour localized under ultrasound or mammographic guidance, offering the surgeon a guide to locate the tumour. Specimens are oriented with marker sutures and clips and an X-ray taken to assess clearance of margins. Surgery is now routinely performed with a view to preserving the volume and contour of the breast (oncoplastic technique).

— Neighbouring breast tissue can be mobilized to fill the resulting defect (tissue displacement), whereas larger defects can be replaced with nearby tissue, e.g. latissimus dorsi muscle (tissue replacement) sometimes after a delay to confirm complete excision.

— Fat injection harvested by liposuction from the abdomen or thighs is becoming increasingly popular in addressing partial defects.

— In larger breasts, the wide local excision can be performed as part of a bilateral breast reduction (therapeutic mammaplasty).

• Simple mastectomy either with immediate or delayed reconstruction. Most common mastectomy operation is modified Patey procedure, i.e. pectoralis minor is preserved (Auchincloss mastectomy).

• Whichever excision technique is used, the nodal status of the axilla should be staged formally, either by sentinel node biopsy, axillary node sampling or axillary clearance according to local protocol. Patients with positive nodes on sampling would normally proceed to formal clearance of all the axillary lymph nodes or radiotherapy. Devices enabling the intraoperative assessment of sentinel nodes/node samples for evidence of cancer spread are currently being introduced.

Patients with early breast cancer should be considered for systemic adjuvant treatment, i.e. chemotherapy and/or anti-oestrogen therapy. Anti-oestrogen therapy should only be used in those who are oestrogen receptor +ve. Oestrogen blockade (tamoxifen) or oestrogen deprivation therapy with aromatase inhibitors (anastrozole, letrozole, exemestane) may be used according to local protocol. Ovarian oestrogen production can be stopped with oophorectomy, radiotherapy or goserelin injections. Primary tamoxifen therapy without surgery may be used in elderly/unfit patients.

Surgery for advanced breast cancer (T3, T4)

• Locally advanced disease (no systemic disease) – neoadjuvant therapy – chemotherapy/radiotherapy/surgery

• Salvage mastectomy

Palliation (stage IV)

• Local palliation (e.g. radiotherapy for fungating lesions)

• Radiotherapy to localized bony metastases

• Aspiration of pleural effusions and instillation of cytotoxic agents

• Hormonal manipulation, e.g. tamoxifen

• Chemotherapy.

Extensive surgery may be required for chest wall defects requiring grafting with myocutaneous flaps, e.g. latissimus dorsi flaps.

Recurrent disease

Local recurrent disease may be treated by radiotherapy if this has not been given to the area before. Systemic disease may be treated by hormonal manipulation or chemotherapy.

Follow-up

• Routine self-examination of operation site and other breast

• Follow-up is in accordance with local protocols but should be continued for 5 years – patients who are disease free then should be discharged

• Mammography to contralateral breast every other year and to ipsilateral breast, if conserved, every year.

Prognosis

• Stage I: 80% 5-year survival

• Stage II: 50% 5-year survival

• Stage III: 15% 5-year survival

• Stage IV: 5% 5-year survival.

Complications of mastectomy

Wound seromas, stiffness of the shoulder. Lymphoedema of the arm is a complication of axillary node clearance. The main problems are psychological and should be managed both preoperatively and postoperatively by expert counselling and support.

Breast reconstruction

Following mastectomy, many patients are well rehabilitated with an external prosthesis that fits in a bra. Others, however, wish breast reconstruction. This may be performed immediately at the time of the initial surgery or at a later date. Reconstruction after mastectomy can be achieved using implant-based or autologous tissue according to patient choice, size of breast, fitness for surgery. Autologous transfer imports healthy tissue via pedicled or microsurgical free tissue transfer which makes it a superior choice if the chest wall has been irradiated.

Tissue can be recruited from:

• The back – pedicled latissimus dorsi muscle with overlying skin and fat based on the subscapular vessels.

• The abdomen – skin and fat with the underlying rectus abdominis muscle based on the superior epigastric vessels can be rotated into the mastectomy defect about this vascular pedicle (pedicled transverse rectus abdominis musculocutaneous flap – TRAM). The free microsurgical TRAM is based on the deep inferior epigastric vessels and a variant of this, the deep inferior epigastric perforator flap (DIEP) spares the rectus abdominis muscle.

• The buttocks – skin and fat can be harvested based on perforators from the superior or inferior gluteal vessels (SGAP or IGAP)

• The inner thigh – The free transverse upper gracilis (TUG) flap. A paddle of skin and fat is elevated with the underlying gracilis muscle based on the medial circumflex femoral vessels.

Breast screening

This is based on the premise that early detection of breast cancer improves the prognosis. Current screening in the UK invites women in the 50–70 age group to have two-view mammography every 3 years. By 2012, this age group will be extended to 47–73. Of the screened women, 5% are recalled for further investigation. Suspicious lesions on mammography are biopsied by image-guided core biopsy or mammotome biopsy – >90% preoperative diagnosis is expected by this technique. If screening biopsy does not produce a result concordant with the imaging findings, then open biopsy is required: in impalpable lesions this may be performed using a wire-localization technique (see above). If malignant, appropriate treatment is undertaken.

Other conditions of the breast

Phyllodes tumour

This is a rapidly growing highly cellular variant of a fibroadenoma. It rarely metastasizes, but it recurs locally after an inadequate incision. It should not be shelled out like a fibroadenoma but should be excised with a rim of normal breast tissue.

Pseudolipoma

This is a soft lobulated swelling of the breast that resembles a lipoma. It is caused by an underlying carcinoma causing retraction of the suspensory ligaments of the breast resulting in bunching of the fat between the skin, septae of the breast, and the carcinoma. Beware the diagnosis of lipoma of the breast, especially in the older patient. Mammography is advised.

Conditions of the male breast

Gynaecomastia

Gynaecomastia is benign hypertrophy of duct and connective tissue elements of the male breast. It may occur in the following instances:

• At birth (maternal oestrogens crossing placenta)

• At puberty, where it may be unilateral or bilateral (embarrassing to the patient; it may resolve or may need surgery)

• Because of drugs (cimetidine, spironolactone, digoxin, methyldopa, oestrogens)

• Because of liver failure

• Association with testicular tumours.

Carcinoma

This is rare and usually occurs over the age of 50 years. It presents with a unilateral, hard, painless mass.

Treatment

This is by mastectomy with or without axillary node clearance. Tamoxifen is given if oestrogen receptor +ve (most male breast carcinoma is oestrogen receptor +ve). The prognosis of male breast cancer is now thought to be identical to that of the female type when compared stage for stage, but the male tends to present with skin infiltration more often than the female and therefore is seen at a later stage.

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