COMMON BREAST PROBLEM


BREAST PAIN

NODULARITY

These are very common problems affecting the women and avokes lot of grief, anxiety and carries social stigma.

BREAST LUMP

NIPPLE DISCHARGE

BREAST PAIN

Cyclical breast pain Non-cyclical breast pain Approach Treatment

Breast pain (mastalgia) is the most common breast related complaint among women. Almost 80% of women experience pain in the breast/axilla, during there lifetime. But only 10 to 20% need treatment. Though 90% of breast pain is not due to breast cancer the woman should consult in the event of breast pain.

There are two main types of breast pain:

•  Cyclical

•  Non-cyclical

Breast pain (cyclical)

Breast pain (Non cyclical)

More common Less common
Related to menstrual cycles No relation to menses
Occurs in both breasts Pain is more localised
Occurs due to hormonal imbalance Pain is burning/dragging type
Main Complaint
- Heaviness and nodularity in breast which increased before menses
Mainly musculoskeletal
Poorly localised pain More common in middle and elderly age
Treatment helps Treatment not successful

Cyclical breast pain :

This type of pain has characteristic features, which varies from one woman to other, and is individualised. Typically there is feeling of heaviness in breast mostly bilateral (though patient may feel more pain in one breast than opposite), usually diffuse starts just before menstrual cycle or exaggerated if already continuous pain is present. Increase in pain is present during the period for 2-5 days and then subsides with end of cycle. The cause of this premenstrual pain is due to hormonal (estrogen and progesterone), Mediated water retention in the breast tissue and distension of the ducts and glands within breast. This pain may be associated with feeling of swelling or lumpiness, then it is termed as fibrocystic disease. This pain subsides after menopause. Though the pain is due to hormonal changes, many factors like stress, weight gain, diet and life style determine the pattern of pain particular person, which can only be clarified by monitoring pain chart monthly and treating the individual accordingly after ruling out cancer.

Non-cyclical breast pain :

This is a less common type of pain which may occur due to causes within breast or outside. Usually seen in middle or elderly women. It may also occur in younger women with history o f injury, operation on breast. This is typically localised to one part of breast and patient can often pinpoint the site. It may be tender to touch. It is not due to hormonal changes except in few postmenopausal women tking hormonal replacement therapy. It is not influenced by pattern of menstrual cycles and may persistent. A special and common type of Non-cyclical breast pain is Tietz syndrome (Costochondritis), due to inflammation (Arthritis), of Costochondral junction (junction of rib with cartilage), occuring >40 years. This pain is actually outside breast but is felt through breast. The other causes are increasing age, osteoporosis, poor posture, ill-fitting bra, biopsy and old trauma to chest.

Approach :

Once a woman is suffering from persistent breast pain she should consult a physician, who will evaluate the pain by detailed clinical history and examination, followed by mammography&/or ultrasonography supplemented by biopsy if needed, all these methods used according to the findings and need. After diagnosing and once breast cancer is excluded, the appropriate treatment is instituted after discussing with the patient.

Treatment :

Most of the women don’t need any specific treatment the form of drugs or surgery. Nearly 70% of women can controlled with reassurance and life style modification. Usually a step by step approach with increasing complexity is used depending on motivation and response of the women.

Re assurance --> Pain chart and life style modification -> Mild analgesics -> Primrose oil, Vitamin E ? -> Danazol -> Bromocriptine -> Amoxifen, Goserelin, Buserelin --> Surgery

The reassurance includes explaining the woman that the pain is not due to cancer or any surgical disease and is a benign condition without harm to life. Then motivating her to mark the severity and timing of pain on pain chart daily 3 times. This is red by the physician and advises the appropriate measures.

Minor life style modifications include:

•  Avoiding excess weight gain
•  Avoiding excess fat in diet
•  Avoiding smoking and alcohol intake
•  More of fresh fruits and vegetables with high vitamin content
•  Avoiding excess coffee and chocolates
•  Reducing high salt intake in diet
•  Occasional use of analgesics.

All these measures help in red uction of pain score in most of the patients. If it is still persistent then primerose oil is advised. Some physicians advie vitamin E and its role is doubtful. With reassurance, pain charting, adjustments in diet and habits most women respond.

If still pain is persistent then, prescription of medication is thought off. The breast pain is mostly influenced by psychology of the person. There is low threshold for prescription of the drugs, as the benefit with many drugs available for breast pain are marginal or temporary and are associated with many other serious side effects and are not cost effective for many women.

The drugs like danazol, bromocriptine are not well tolerated by many and associated with menstrul disturbances and fertility problems as their mechanism of action is by blocking the hormonal activity. Other drugs like Tamo xifen and LHRH agonists like Goserelin also act by interfering with hormone action at different site in the body, proved to be useful only in few patients nd thus not widely used for breast pain. Last resort that is surgery is attempted for cyclical pain only if pain associated with definite lump. Mastectomy (removal of breast breast) is rarely done as last attempt.

Non cyclical pain is usually treated with on the similar lines, but in addition analgesics are more frequently prescribed as they are localised and musculoskeletal in origin. Pain is also self limited and subsides after 2 -3 years and with postural adjustments. So metimes in severe pain such as costochondritis, local steroid injection is given. Rarely surgery is done but it is not advisable as it may exaggerate the pain after operation.

NODULARITY

Nodularity of breast is usually complained as lumpiness in breast. This is a benign d isease variously called as fibrocystic breast disease or fibroadenosis.

The features of this condition are :

•  Usually occurs in young women and between 20 – 35 years.
•  It is mostly seen in both breasts though symptoms predominate in one breast.
•  The patient may come with complaints of diffuse lumpy feeling in breast.
•  It is self limited and subsides after 6-8 weeks mostly.
•  Sometimes there will be lo calised lump.
•  Other way of presentationn is breast pain, in which clinical examination reveals nodularity in breast.
•  They are often slightly tender especially before menstruation.
•  Classically they are associated with Cyclical breast pain
•  Just before menstruation, due to estrogenic stimulation there is fluid retention in breast stroma and glandular acini with engorgement of both breasts usually felt by the womn as heaviness in breasts which is relieved spontaneously 3-5 days after menstruation.
•  Nodularity is more of a psychological problem as it is self-limiting.
•  Any persistent nodularity should be clinically examined to rule out cancer.

Approach :

After thorough clinical examination, the usual treatment advised is reassurance as in benign breast pain and kept under follow-up. But if there is persistent or localised nodularity or unilateral, then such cases should be submitted for TRIPLE ASSESSMENT.

Once malignancy is ruled out, then the treatment is just as in cyclical breast pain.

Treatment :

Most of the women don’t need any specific treatment the form of drugs or surgery. Neaarly 70% of women can controlled with reassurance and life style modification. Usually a step by step approach with increasing complexity is used depending on motivation and response of the women.

 Re assurance

 Pain chart and life style modification

 Mild analgesics

 Primrose oil, Vitamin E ?

 Danazol

 Bromocriptine

 Tamoxifen, Goserelin, Buserilin

 Surgery

The reassurance includes explaining the woman that the pain is not due to cancer or any surgical disease and is a benign condition without harm to life. Then motivating her to mark the severity and timing of pain on pain chart daily 3 times. This is read by the physician and advises the appropriate measures.

Minor life style modifications include ;

•  Avoiding excess weight gain

•  Avoiding excess fat in diet

•  Avoiding smoking and alcohol intake

•  More of fresh fruits and vegetables with high vitamin content

•  Avoiding excess coffee and chocolates

•  Reducing high salt intake in diet

•  Occasional use of analgesics.

All these measures help in reduction of pain score in most of the patients. If it is still persistent then primerose oil is advised. Some physicians advie vitamin E and its role is doubtful. With reassurance, pain charting, adjustments in diet and habits most women respond.

If still pain is persistent then, prescription of medication is thought off. The breast pain is mostly influenced by

psychology of the person. There is low threshold for prescription of the drugs, as the benefit with many drugs available for breast pain are mrginal or temporary and are associated with many other serious side effects and are not cost effective for many women.

The drugs like danazol, bromocriptine are not well tolerated by many and associated with menstrual disturbances and fertility problems as their mechanism of action is by blocking the hormonal activity. Other drugs like Tamo xifen and LHRH agonists like Goserelin also act by interfering with hormone action at different site in the body, proved to be useful only in few patients and thus not widely used for breast pain. Last resort that is surgery is attempted for cyclical pain only if pain asso ciated with definite lump. Mastectomy (removal of breast breast) is rarely do ne as last attempt.

 BREAST LUMP

Once a lump in the breast is identified during self-examination or clinical examination the primary concern is to exclude breast cancer. Though lump is the commonest symptom of cancer, most common lumps are due to Benign Breast disease. There are many varieties of benign breast lumps with distinct features, though underlying process is due to physiological cyclical hormonal fluctuations and phasic changes in physiology during menses, pregnancy, lactation all put together in term known as ANDI (Abnormalities in normal development and involution).

The many varities of benign b reast lumps are :

  •  Fibroadenoma

  •  Cysts

  •  Duct papilloma

  •  Epithelial hyperplasia

  •  Sclerosing adenosis

  •  Fibrosis

  •  Duct ectasia

Fibroadenoma :

The following are the features:

  • It occurs in younger women below 30 years.

  • The types of fibroadenoma clinically are usual one(<5 cm), Gaint fibroadenoma and phylloides  tumour(cystosarcoma pjhylloides).

  • Histologically 2 types – Intracanalicular and pericanalicular based on the distribution of acini and  fibrosis. In former the fibrosis is between acini and in later around them.

  • The are mostly painless and usually cause discomfort in breast around menses.

  • Larger fibroadenomas cause distortion of breast appearance and cosmetic problem

  • One-third of them subside without any treatment.

  • On examination it is firm to hard localised swelling within breast.

  • It is non-tender and freely mobile earning it the name – breast mouse.

  • Once malignancy is excluded by FNAC, it is followed up with mild analgesics and assurance.

  • The indications for surgical excision are for cosmesis in persistent and gaint fibroadenomas, phylloides tumour and patient preference.

  • Phylloides tumour is known for its frequent recurrences and grows to large sizes occupying whole  breast.

  • They are treated with surgery in first instance unlike in other fibroadenoma types.

  • In case of repeated recurrences , mastectomy is needed in phylloides tumour as it is known to  become malignant and metastasizes to Distant sites.

  • Fibroadenomas perse or excision of it does not predispose to breast cancer.

Cysts:

Simple cyst is a fluid filled, thin walled cavity within the breast tissue.

The features of breast cysts are :

  • They are seen usually after 30 years.

  • One third disappear spontaneously without treatment.

  • They may occur due to localised fluid retention in breasts due to estrogenic stimulation and later walled off by fibrosis and epithelisation due to inflammation.

  • Ultrasound is excellent way to detect cysts.

  • Clinically they are difficult to be distinguished from other benign conditions like fibroadenoma, fibrosis and sometimes cancers, due to its firm to hard to very hard consistency on palpation depending upon tenseness of fluid within and content type and duration of cyst.

  • Once detected on imaging, they are aspirated. They may completely disappear.

  • The results of cyst aspiration re resolution, partial collapse and later resolution, collapse and reaccumulation, no aspirate and repeated accumulations after 2 or more aspirations.

  • A cyst should be suspected as malignancy in following situations :

Bloody aspirate.
Some solid material on aspiration.
> 2 relapses.
Not uniform thickness of cyst wall.
Microscopic examination is suspicious of malignancy
Inconclusive microscopic examination.
In the above situations they are subjected to Excisional biopsy.

Duct papilloma :

They are not usually palpable but quite a common finding which is commonest cause of bloody nipple discharge. They are benign projections of ductal epithelium in to the lumen of lactiferous ducts. Occassionally multiple duct papillomas may present as nipple discharge from multiple ducts. The treatment approach for this duct pap illoma is excision of the concerned duct-acinar unit lodging it. For this the duct is cannulated with a lacrimal probe or a nylon thread from the nipple end of duct. Then with a circumareolar incision nipple-areola complex is raised and the probe is followed and the the duct system is excised (Microdochectomy). If multiple duct p apillomas are present, Macrodochectomy or in later premenopaussal ladies mastectomy done because of slight risk of malignancy.

Epithelial hyperplasia:

These are lesions found less commonly and if associated with features of atypia of cells , carry a high risk for breast cancer development. Then it is called Atypical epithelial hyperplasia. They are to be closely monitored after excision.

Sclerosing adenosis :

It is a rare benign breast disease usually occurs >35 years and is not premalignant.

Fibrosis :

Fibrosis is not a specific entity, but is be found in all breast conditions in varying proportions. Sometimes a localized lump may wholly be composed of fibrous tissue with few scattered cells. This is not premalignant may need excision fr cosmetic reasons as it fibrotic process may distort breast form.

Ductectasia :

Duct ectasia occurs in >35 years age group and may persist for decades. It cause nodular lump, distortion of breast form and most importantly presents as nipple discharge. Characteristically, the nipple discharge is greenish in colour and may be mixed with blood. It is also called as Plasma cell mastitis due to histological features of macrophages and plasma cells surrounding degenerated duct remnants with ductal dilatation, the findings similar to bro nchiectasis in lung.

NIPPLE DISCHARGE

Nipple discharge is the third most common breast complaint for which women seek medical attention, after lumps and breast p ain. A woman's breasts have some degree of fluid secretion activity throughout most of the adult life.

The difference between lactating (milk producing) and non-lactating breasts is mainly in the degree or amount of secretion and to a smaller degree in the chemical compositio n of the fluid. In non-lactating women, small plugs of tissue block the nipple ducts and keep the nipple from discharging fluid.

The majority of nipple discharges are associated with non-malignant changes in the breast such as hormonal imbalances. However, any woman with a suspicious or worrisome nipple discharge should consult her physician.

Nipple Discharge is of Concern if it is:

1. bloody or watery (serous) with a red, pink, or brown color
2. sticky and clear in color or brown to black in color (opalescent)
3. appears spontaneously without squeezing the nipple
4. persistent
5. on one side only (unilateral)
6. a fluid other than breast milk

Causes of Nipple Discharge:

Suspicious nipple discharge is due to a malignant (cancerous) lesion just ten percent (10%) of the time. Discharge caused by a malignant condition is almost always on one side only (unilateral). Discharge that is coming from both breasts (bilateral) is usually benign. Papilloma usually causes discharge from a single breast duct.

Type of discharge

Common cause

Serous Duct papilloma, duct ectasia.
Milk Lactation, Prolactin excess states
Grummous Ductectasia
Bloody Duct papilloma, duct ectasia
Greenish Breast abcess

Examination for Nipple Discharge:

A blood test of prolactin levels is often made to determine hormonal causes of excessive milky discharge (galactorrhea). A hormone imbalance, pituitary tumor, and certain drugs such as sedatives, tranquilizers, hormone replacement or birth control pills may cause excessive prolactin levels. If there is a suspicious nipple discharge , Clinical breast exam (CBE) is first performed. If a discharge can be produced during the examination, some of the fluid may be collected and examined under a microscope to see if any blood cells or cancer cells are present. This test is called a nipple smear. The discharge may also be examined for signs of infection such as pus. Papillomas may be seen with microscopic examination of a nipple discharge, but this test may be inconclusive.

If the discharge is bloody or serous, a mammogram is often the first test to be performed. Even when no cancer cells are found in a nipple discharge, it is not possible to rule out breast cancer or other condition such as papilloma.

If a patient has a suspicious mass together with nipple discharge, evaluation of the mass should be performed using mammography, adjunctive imaging and biopsy as necessary. If these tests are negative and show no malignancy, nipple smear should be evaluated.

Treatment for Persistent Nipple Discharge:

The standard treatment for nipple discharge that has no hormonal involvement is duct excision (Microdochectomy).

Duct excision is usually performed on an outpatient basis with local anesthesia. The procedure is usually done through a small circular incision near the areolar border around the nipple. It is not uncommon for the pathology found to be so microscopic that it is invisible without the assistance of a microscope. Typically, nursing ability and nipple sensation are preserved after duct excision. Breast-feeding in the other breast should have no affect from the duct excision in the opposite breast. If multiple ducts are involved and in refractory cases excision of all major duct system is done which is known as Macrodochectomy. But with this nursing ability is lost and nipple sensation is lost partially.

Conclusion:

The above information details are general guidelines. If you have nipple discharge that is worrisome, please do not hesitate to contact your physician or healthcare provider about it. However, keep in mind that most nipple discharge is not caused by breast cancer.

Top

This Page Authored : Dr. P.R.K. Bhargava
S.R., Endocrine & Breast Surgery, SGPGIMS, Lucknow - 226014