Breast disease

Published on 11/04/2015 by admin

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Last modified 11/04/2015

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10 Breast disease

Breast symptoms are common but only one in ten patients referred to surgical clinics has a carcinoma. The remainder have a variety of conditions labelled benign breast disease. Many conditions are not truly pathological but aberrations of normal development that occur between puberty and old age.

Patients with breast symptoms are best assessed in a one-stop breast clinic where so-called triple assessment, i.e. clinical examination, fine-needle aspiration cytology and imaging (ultrasound or mammography), allows rapid diagnosis of most breast conditions.

Benign breast disease

Mastalgia (breast pain)

This is usually cyclical. Pain occurs early in the menstrual cycle and worsens to reach a peak just before menstruation, easing with the start of the period. Mild pain may affect the upper outer quadrants of the breast, causing minor symptoms. In severe cases, the breast may be engorged, tender and heavy.

Pain occasionally occurs in postmenopausal women, often related to hormone replacement therapy (HRT). Pain may be in one or both breasts. Clinical findings, apart from tenderness and occasionally nodularity, may be normal.

Management

Breast cancer is hardly ever painful and this reassurance may help. In women under 35 years, mammograms are of no diagnostic help since the breast tissue is too dense. Ultrasound may exclude a discrete lump.

A diary chart may determine if the problem is cyclical or non-cyclical. The most important aspect of management is reassurance. Patients with severe disease may be treated with gamma-linoleic acid (evening primrose oil), danazol or bromocriptine. Evening primrose oil is an essential fatty acid which may work by making the breast cells less sensitive to sex hormones. Sixty per cent of patients respond to the treatment if taken in a full dose (320 mg per day for 3–4 months). Danazol affects the action of oestrogen on the breast tissue. Side effects which are similar to those experienced in the menopause may make compliance low. Bromocriptine blocks the pituitary production of follicle-stimulating hormone (FSH) and luteinising hormone (LH).

Breast lumpiness and lumps

It is vital, but sometimes difficult, to distinguish whether a breast lump is part of a diffuse lumpiness or a discrete, isolated lump. The diagnosis may be influenced by whether the lump is painful and/or the age of the patient (Table 10.1).

Table 10.1 Likely diagnosis of discrete breast lumps at different ages

Young adult	Fibroadenoma
Middle-aged	Cyst
Elderly	Carcinoma

The triple approach (physical examination, mammography/ultrasound and fine-needle aspiration cytology) enables a diagnosis to be made in most patients. Mammography is unhelpful in women under 35 years of age because the breasts are frequently too dense for small lesions to be seen.

Lumpiness

Lumpiness is frequently associated with cyclical breast pain and is also known as fibroadenosis, cystic mastopathy, fibrocystic disease and cystic mastitis. These terms are now discouraged since their use suggests the breast condition is pathological, but in fact these changes are part of normal breast development throughout life which is more pronounced in some individuals. Lumpiness may be very localised and lead to difficulty in deciding whether a discrete lump is present.

Discrete single lump

The common benign causes are localised fibroadenosis, cyst, fibroadenoma and trauma.

Localised fibroadenosis

Usually the upper outer quadrants are affected or it may be unilateral. Patients are often young and the findings may be single or multiple lumps in either breast which may be tender premenstrually.

Investigation requires mammography in the over-40s combined with ultrasound and fine-needle aspiration cytology (FNAC). Treatment is by reassurance.

Fibroadenoma

This affects younger women. Fibroadenoma may remain of a small size but some regress or increase in size. Pain is not a usual feature. The lump is well-defined, rubbery or firm to hard, and may be mobile and difficult to find, hence the nickname ‘breast mouse’.

If triple assessment supports the diagnosis of fibroadenoma, small lesions may be left alone, but removal by excision should be advised for larger lesions in older women.

Breast cysts

Breast cysts occur at a later stage of life (35 through to the menopause). They may represent an involution of other cyclical breast changes. Multiple recurrent cysts may be associated with an increased risk of breast cancer.

The findings are of a tense, discrete, mobile lump which then may be aspirated, yielding a straw-coloured fluid and causing collapse and disappearance of the lump. If the cyst does not completely disappear, repeat examination is advised and the lump evaluated by triple assessment. The aspirate is usually straw-coloured but a bloodstained aspirate (which may be traumatic) should be sent for cytological examination and possible excision biopsy. Multiple cysts may be treated with danazol, which helps reduce the incidence of clinical recurrence. Follow-up mammography is advised.

Trauma (fat necrosis)

Trauma to the breast is uncommon but may damage local blood supply and cause fat necrosis. This results in a hard, painful lump with irregularity over the overlying skin, mimicking a carcinoma. Triple assessment is required for diagnosis but no specific treatment is recommended.

Nipple discharge

Green or milky discharge is usually harmless. Clear or bloodstained discharge may indicate a duct papilloma and occasionally an underlying malignancy.

Mammary duct ectasia and periductal mastitis

The ducts adjacent to the nipple become dilated and engorged with breast secretion. Secondary infection and abscess may form. Subsequent fibrosis may cause nipple retraction. The condition mostly affects women in their 30s who smoke.

The discharge may be milky or dirty green and may be bilateral. Acute infection causes pain and swelling. The breasts may be lumpy. There may be a characteristic retraction of the nipple mimicking carcinoma. Untreated abscess formation may result in a mammary fistula.

Patients over 40 should have a mammogram and the discharge sent for cytology. If the discharge is very troublesome, excision of the duct system (Hadfield’s operation) may provide relief.

Duct papilloma

A serous or bloodstained discharge from a single aspect of the nipple is common. The breast may be clinically normal although pressure on a specific segment may reproduce the discharge.

A triple assessment and, in a bloodstained discharge, excision of the involved system and histological examination establish that a papilloma is present.

Galactorrhoea

This is a rare cause of milky discharge following lactation, caused by a persistent elevation of prolactin. It is treated by bromocriptine until the discharge subsides. Persistent discharge, despite treatment, may suggest a prolactinoma, but this is rare.

Breast abscess

This condition is a complication of breastfeeding caused by Staphylococcus aureus. The bacteria may get into the breast through cracks in the nipple during feeding. Initially a segment of the breast becomes inflamed with cellulitis. There is then a rapid build-up of pus with necrosis of local breast tissue, producing an abscess in a short space of time. A tender segment is found in the lactating breast, often with surrounding cellulitis. If detected early, antistaphylococcal antibiotics (e.g. flucloxacillin) may prevent abscess formation.

Once an abscess has formed, the pus must be released. It is usually possible to treat lactational breast abscesses by aspiration (repeated if necessary), though incision and drainage is sometimes required.

Breast cancer

Epidemiology and aetiology

Breast cancer was, until recently, the commonest cancer to affect women in the Western world. In the UK, there were 47 695 new cases in 2008.

There is variation within various ethnic cultural groups with American Jews and nuns having a higher incidence than, for example, Mormons and American Indians. Breast cancer incidence is increasing, with approximately one woman in eight in 2008 developing the disease in the UK.

The risk factors for breast cancer are listed in Table 10.2.

Table 10.2 Risk factors for breast cancer

Factor	High risk	Low risk
Age (years)	Greater than 50	Less than 35
Country of birth	Northern Europe, North America	Asia or Africa
First-degree relative affected	Yes
Age at first pregnancy	>30 years	<20 years
Nulliparity	Yes
Previous breast cancer	Yes
History of atypical hyperplasia	Yes

Age

Breast cancer is rare under the age of 35 (Fig. 10.1).

Figure 10.1 Age and risk of breast cancer.

Country of birth

Breast cancer is less common in the Far East compared to the West. Immigrants assume the same risk as the host community within two generations, suggesting there is a large environmental influence on cancer risk.

Genetic factors

Hereditary and familial breast cancer appears to be increasing (up to one-third of patients will have a family history of the disease).

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