Breast – History
Note: duration of symptoms to be established (lump may have been present for longer than women have known);
history of breast problems (cysts, abscess, trauma) may provide clues for current diagnosis; parity and age at 1 st
pregnancy may change likely diagnosis.
PC
Rationale
1. Pain: mastalgia
 Varies with menstrual cycle
 Physiological cause (premenstrual syndrome; fibroadenosis): responsive to
treatment
 Independent of menstrual cycle
 Not helpful in diagnosis
2. Lump in breast
 Hard
 What are the surface characteristics? Discrete mobile lump with smooth
surface if solid(fibroadenoma) but if fluctuant(fibroadenotic cyst). Ill-defined
margin and any suggestion of tethering to superficial/deep
structures(carcinoma)
 Firm, poorly defined/lumpiness
 Fibroadenosis, especially if outline difficult to distinguish from normal breast
tissue or if the breast is generally lumpy
 Soft
 Lipoma or a lax cyst
DD:
Lumpiness = various
names(fibroadenosis/ cystic
mastopathy/ fibrocystic disease/
cystic mastitis)
Discrete single lump; DD =
fibroadenoma; cyst; v localised
fibroadenosis
3. Skin changes
 Skin dimpling
 Sometimes subtle. Commonly carcinoma
 Visible lump
 Cyst(can appear quickly), carcinoma or phylloides tumour.
 Peau d’orange
 Over a lump = carcinoma due to tumour invasion of lymphatics causing
dermal oedema. May also be over an infective lesion
 Redness
 Usually infection, esp if skin is hot; maybe mammary duct ectasia
 Ulceration
 Neglected carcinoma in the elderly (often slow growing)
4. Nipple disorders
 Recent inversion
 Fibrosing underlying lesion(carcinoma; mammary duct ectasia)
 ‘Eczema’/rash involving nipple
 If unilateral = Paget’s disease of nipple = breast cancer
 Discharge:
 Pregnancy or hyperlactinaemia
 Milky
 Physiological
 Clear
 Perimenopausal; duct ectasia; fibroadenotic cyst
 Green
 ?carcinoma; intraduct papilloma
 Blood-stained
DD:
Mammary duct ectasia
Duct papilloma
Galactorrhoea
Worried!
 Previous Fx?
Age of onset:
Fibroadenoma: 10-30
Fibroadenosis: 20-50
Cystic fibroadenosis: 35-65; peak 50
Carcinoma: from 30 (peaks at 50, 65, 85)
HPC
Rationale
Cyclical pain
Site
Onset
Character
Early stages, may just be in outer regions of breast; later stages over all breast
Early phase of cycle that gradually worsens to reach peak just prior to menstruation; easing at
period.
Breast may feel engorged, heavy and tender; ?physical contact unbearable
Past Medical History
Any similar problems in the past?
Any hospital admissions?
Any investigations / operations?
Last menstrual period
Carcinoma
JADE, TAB, MARCH, thyroid function
Drug History
ALLERGIES (response?)
Contraceptive pill
HRT
OTC/homeopathic drugs
Rationale
Rationale
Post-menopausal women may have tender breasts as HRT keeps cells active
Social History
Rationale
Smoking (pack years)
Alcohol (units/week)
Diet
Exercise
Housing
Recreational drugs (IV)
Occupational exposure
Overseas travel
Contact with jaundiced person
Sexual orientation?
Hepatitis RF: alcohol, sex, drugs, piercings, tattoos, transfusions pre-’91, infection
Family History
Breast cancer
Ovarian cancer
Rationale
Sites of metastases:
Brain: headache, epilepsy, ataxia, paresis, parasthesia
Lung: usually asymptomatic
Pleura: effusion (SOB)
Liver: mass; jaundice; ascites
Long bones: skull; vertebrae; ribs; pelvis (pain, pathological fracture, spinal cord compression)
Breast - Examination
Introduce yourself, medical student, gel hands, confirm name and DOB of pt. I understand you’ve found (a lump), is
that correct? I’ve been asked to perform a breast examination which will involve, with a chaperone present, exposing
your chest, doing a few simple movements with your arms, and then me assessing for any lumps or irregularities.
Would that be OK? I’ll go and get a chaperone. Confirm consent. Ask pt to undress from waist up and put on a front
opening gown
General Inspection – patient and environment; ask pt to sit on edge of couch
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Hands down by sides
Lifting arms in to air above head – dimpling/puckering of skin usually more evident
Pressing hands on top of head
Hands pressed on hips and lean forwards – tests fixation of a lump to the chest wall = accentuates any lumps
Ask pt to lift breast up if large so you can see underneath (may see a scar if there have been implants)
Examine
Is the patient in any pain?
Size
Symmetry
Lumps
Skin tethering and dimpling
Rationale
Dimpling may be slight + cover carcinomas
Tethering = distortion of breast due to attachment of
breast lump to underlying tissues
Nipple deformity(retraction/deviation)
Nipple discharge/bleeding
Localised hyper vascular areas (surface erythema)
Oedema of the skin with dimpling (Peau d’orange)
Abnormal reddening, thickening or ulceration of the areola
(rash on areola)
Scars from previous surgery
Caused by infiltration of carcinoma + skin oedema;
inflammatory cancer?
Paget’s disease
Palpation – explain each step as you go along ‘I’m now going to examine…’
Patient should sit on examination couch at 45° and rolled slightly onto contralateral side. The arm on the side to be
examined should be elevated and placed on pillow behind. Cover exposed breast. Repeat with second breast.
Ask pt to identify any lumps they are worried about. Ask if they’re in any pain.
Palpate ‘normal’ breast first. Note that breasts may feel soft-nodular-hard; compare any physical signs with the other
breast (physiological and hormonally-induced changes tend to be symmetrical)
Nipple – concentric circles
outwards, ending in Axillary
tail/Tail of Spence
If PC is nipple discharge,
areola should be pressed
Axillary and supraclavicular
lymph nodes
Exam breast using flat of one hand and ‘kneed’ softly against the other.
Ask pt to squeeze own nipple. Or press areola in different areas (with 2 fingers) to
identify the duct from which it emanates and therefore the segment involved.
With your left hand, hold pt’s left wrist and examine left axilla using your right hand, and
vice-versa; support the weight of the pt’s arm at the elbow to relax their axillary muscle;
examining hand is held in a curve, pressing high into apex of axilla against chest wall
and draw downwards (hand will then ‘ride’ over any enlarged axillary nodes).
Apical, anterior, posterior, inferoclavicular, supraclavicular pectoral, subscapular
Lumps to be characterised: size(cm), site (use nipple as the centre of a clock face) – 12o’clock, 2cm from the nipple,
shape, tethered to underlying tissue?, texture – cyst/non-cyst, tenderness
Other organs
Palpate for liver edge, spine for tenderness and auscultate lungs => breast metastases?
Cover, thank, summarise
Invite the patient to get dressed and discuss your findings with her along with investigation proposals. Listen to her
concerns, give her time. If in doubt, and the imaging is normal repeat the examination again in 8-12 weeks.
Further investigations?
Invasive CA is most common type of breast ca accounting for over 70% of cases. Most breast cancers are invasive
but a few may be non-invasive or in-situ. 9 out of 10 lumps investigated in hospital setting is benign.
Diagnosis is performed by Triple Assessment:
1. Breast clinical examination
2. Appropriate radiological imaging
 <35: targetted USS of lump
 >35: targetted USS of lump PLUS bilateral mammogram
3. Histopathology: Core biopsy (Tru cut) of palpable lump
•
•
•
•
After Palpating the breast, any lump will be graded on a 5 point scale:
– P1 – normal breast tissue being felt
– P2 – benign feeling (eg fibroadenoma or cyst)
– P3 – abnormal but probably benign
– P4 – suspicious, probably cancer
– P5 – cancer
The Radiologist will use the same scheme:(R1-R5)
If FNAC, the Cytologist uses same scheme: (C1-C5)
If core Biopsy the histologist uses a similar scheme:
• It is similar (B1-B5) but note the different meanings for B1&B2:
• B1= Inadequate biopsy (no epithelium sampled, just fatty, or no lesion seen)
• B2= Benign lump (and it will usually say what lesion is identified)
So e.g. a lump may be P1, R2, C2, B2
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How common is it?
Who does it affect?
What causes it?
What risk factors are there (and how can they be reduced?)
How does it present? What symptoms should you look out for?
What signs may the patient have on examination?
Which other conditions might present similarly?
How would you investigate this patient?
What would you tell the patient and how would you explain the condition to them?
How do you think the patient/ and or family might be affected by the diagnosis? Will it affect their ability
to work/ care for themselves?
What questions are they likely to have?
What treatment(s) (surgical, pharmacological and non-pharmacological) would you discuss with them?
What risks and benefits of treatment are there?
What other health care professionals might be involved in their care?
Conditions we need to know
 Abscess
 Fibrocystic disease
 Ductal papilloma
 Breast carcinoma
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Breast lumps and carcinoma
All lumps require histo/cytological assessment.
Common lumps: fibroadenoma, cyst, carcinoma, fibroadenosis (focal or diffuse)
Rare lumps: periductal mastitis, fat necrosis, galactocoele, abscess, ‘non breast’ (lipoma, sebaceous cyst)
Benign: fibrocystic disease/condition, fibroadenoma, intraductal papilloma, abscess
Malignant: infiltrating ductal or lobular Ca, in situ ductal or lobular Ca, inflammatory Ca
Infiltrating ductal carcinoma is the most common malignant tumor; however, inflammatory carcinoma is the most
aggressive and carries the worst prognosis.
Triple assessment:
1. Clinical
2. Radiological:
 Ultrasound if < 35yo; Ultrasonography used for solid but discrete lumps to distinguish between cysts and a
solid mass.
 Mammography and ultrasound if > 35yo; In the presence of a palpable lump, mammography is up to 95%
diagnostic accurate; not good as a screening tool. Also not useful in women <35yo due to their normal dense
breast tissue.
 MRI ( Magnetic Resonance Imaging), in select cases.
 MBI (Molecular Breast Imaging), if available; not widely available at present, a type of computer
aided mammography delivering less radiation than traditional mammography.
3. Pathological:
 FNAC ( Fine Needle Aspiration Cytology), where a small amount of tissue is syringed out by a 22/23G needle
for examination under microscope. Fine needle aspiration cytology (FNA) – any lump, or any lump that is
indistinct on palpation but suspicious on imaging (US or mammography). A negative FNA does not exclude
carcinoma.
 Core biopsy in some cases for cellular examination (US-guided core biopsy best for new lumps)
 Sometimes sentinel node biopsy either to confirm or dismiss the suspicion of caner breast.
Cystic lump => aspirate
 clear fluid, discard and reassure pt
 bloody fluid, send to cytology
 residual mass, core biopsy
 Cysts contain yellow or green fluid, and after aspiration, should disappear. If it doesn’t or contains bloodstreeked fluid, then suspect carcinoma and send fluid to cytology. If cytology is unhelpful then excise the
lump. If mammography and US report lump as benign and following aspiration, the lump re-appears again,
aspirate and monitor.
Solid lump => core biopsy
 Malignant, plan prognosis
 Benign, reassure and treat mastalgia
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Any discharge for blood using urinalysis dipsticks. Smear on slides and send to cytology.
Scrapings from suspected Paget’s disease of the nipple can be sent for cytological analysis.
How common is it?
Breast cancer is the most commonly diagnosed cancer in women, after skin cancer, accounting for approximately 1
in 4 cancers diagnosed in US women.
Who does it affect?
 African American women have a higher incidence rate before age 40 and are more likely to die from breast
cancer at every age.
 White women have a higher incidence of breast cancer than African American women after age 40.
 1% of men.
 Women older than 40 years account for more than 95% of new breast cancer cases and 97% of breast cancer
deaths. The median age of diagnosis is 61 years of age.
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What causes it?
What risk factors are there (and how can they be reduced?)
 Risk factors for breast cancer include female sex, age older than 40 years, family history of a first-degree
relative with breast cancer, nulliparity, menarche before age 12 years, menopause after age 55 years, and
late pregnancy (>30 y of age).
 The BRCA1 and BRCA2 genes are responsible for approximately 5% of all breast cancers and are inherited in
an autosomal dominant fashion. Women with mutations in either of these genes have a lifetime risk of
breast cancer of 60-85% and a lifetime risk of ovarian cancer of 15-40%.
How does it present? What symptoms should you look out for?
 Palpable mass, typically only in one breast
 Family history of breast disease, malignant and/or benign
 Menstrual and obstetrical histories are important.
 Associated symptoms of pain, nipple discharge, and skin changes (eg, dimpling or inflammation, nipple
inversion)
 Length of time present, speed of growth
What signs may the patient have on examination?
 Firm mass of variable shape and size
 Fifty percent of masses found in the upper outer quadrant of the breast
 May have associated pain with palpation, but most are painless
 Nipple discharge or inversion
 Skin retraction or tethering
 Axillary lymphadenopathy
 Inflammatory changes of the skin (ie, peau d'orange)
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Note, pay special attention to associated upper extremity neurologic motor or sensory abnormalities, as
these may herald invasion of the brachial plexus — an indication for emergent radiation therapy.
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Which other conditions might present similarly?
How would you investigate this patient?
What would you tell the patient and how would you explain the condition to them?
How do you think the patient/ and or family might be affected by the diagnosis? Will it affect their ability
to work/ care for themselves?
What questions are they likely to have?
What treatment(s) (surgical, pharmacological and non-pharmacological) would you discuss with them?
What risks and benefits of treatment are there?
What other health care professionals might be involved in their care?
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Breast cancer - suspected - Management
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Refer to breast cancer specialist team
Most cases are not cancer, but worth reminding pt that Tx and Px good as they will naturally be concerned.
Encourage all pts >50yo should be breast aware
Suggestive lumps of breast cancer: discrete, hard lump with fixation, with or without skin tethering. In
patients presenting in this way an urgent referral should be made, irrespective of age (be seen in <2 weeks)
Urgent referral in any woman > 30yo with a lump that present after menopause or persists after next period
Non-urgent referral in women <30yo (as rarely cancer and more often fibroadenoma) unless lump enlarges,
fixed and hard (other features of Ca), previous Fx
Urgent referral in any woman with previous Hx of breast Ca irrespective of age
Spontaneous bloody nipple discharge, nipple distortion with recent onset or unilateral eczematous skin or
nipple change that does not respond to topical treatment => urgent referral
Men: firm, unilateral sub-areolar mass if >50yo => urgent referral
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Other differential diagnosis for lumps
Fibrocystic breast disease/condition (FCC) also called fibroadenosis
Characterised by lumpiness and general discomfort in one or both breasts. Common and benign. Note the change to
condition not disease as most women tend to have some lumpiness in their breasts. Other names = mammary
dysplasia, chronic cystic mastitis, diffuse cystic mastopathy, and benign breast disease
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Spectrum of features includes development of cysts and fibrosis.
Lobules of the breast may dilate and form cysts of varying sizes, due to hormonal changes in the menstrual
cycle.
Rupturing of the cysts can cause scarring and inflammation that leads to fibrotic changes, which feel
rubbery, firm, or hard.
Adenosis = an increase in the number of glands.
How common is it?
FCC is most common cause of ‘lumpy’ breast and affects more than 60% of women. Cysts are found in about 1 in 3
women between 35 and 50 years old.
Who does it affect?
The condition primarily affects women between the ages of 30 and 50 and tends to become less of a problem after
menopause. The condition likely results from a cumulative process of repeated monthly hormonal cycles and the
accumulation of fluid, cells, and cellular debris within the breast. The process starts with puberty and continues
through menopause.
What causes it?
FCC involves glandular breast tissue = production of milk. This is surrounded by fatty tissue and support elements.
The most significant contributing factor to fibrocystic breast condition is a woman's normal hormonal variation
during her monthly cycle. Oestrogen and progesterone directly affect the breast tissues by causing cells to grow and
multiply. They also increase the activity of blood vessels, cell metabolism, and supporting tissue. All this activity may
contribute to the feeling of breast fullness and fluid retention that women commonly experience before their
menstrual period.
Prolactin, growth factor, insulin, and thyroid hormone are some of the other major hormones that are produced
outside of the breast tissue, yet act in important ways on the breast.
The breast itself produces hormonal products from its glandular and fat cells which can affect neighbouring breast
cells.
After menstruation is over these cells are removed by apoptosis during which the fragments of broken cells and the
inflammation may lead to scarring (fibrosis) that damages the ducts and the clusters (lobules) of glandular tissue
within the breast.
The amount of cellular breakdown products, the degree of inflammation, and the efficiency of apoptosis in the
breast vary from woman to woman. These factors may also fluctuate from month to month in an individual woman.
They may even vary in different areas of the same breast in a woman.
What risk factors are there (and how can they be reduced?)
 FCC is benign but may mimic lumps found in breast cancer so may need to rule it out.
 Atypical hyperplasia has a higher risk of breast Ca. This is because mutations have begun to accumulate in
cells that no longer respond normally to the signals that usually control cell growth and division. These cells
may also have an impaired ability to repair any genetic damage. As the atypical cells increase in number,
they accumulate additional genetic errors.
 Environmental, dietary, and metabolic toxins may also interact with a woman's complex hormonal system to
increase the risk of mutations and thus increase the risk of breast cancer.
How does it present? What symptoms should you look out for?
 breast pain (mastalgia)
 breast enlargement
 lumpiness of the breast (nodularity), particularly just before or during a period
 Uni or bilateral, but tends to be bilateral
 Symptoms can vary between women – annoying lumps to painful
 Breast discomfort: dull, heavy pain in the breasts, breast tenderness, nipple itching, and/or a feeling of
fullness in the breasts. These symptoms may be persistent or intermittent, especially appearing at the onset
of each menstrual period and going away immediately afterwards.
What signs may the patient have on examination?
May be difficult to diagnose as variable presentation:
 Very mild with minimal breast tenderness or pain. The symptoms can also be limited in time, usually
occurring only premenstrually. Lumps may not be palpable.
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Severe: the pain and tenderness are constant, and many lumpy or nodular areas can be felt throughout both
breasts.
Palpation: lumpiness most commonly found in the upper outer quadrant of the breast, are typically mobile
(not anchored to overlying or underlying tissue). Lumps usually feel rounded, have smooth borders, and may
feel rubbery or somewhat changeable in shape. Sometimes, the fibrocystic areas may feel irregular, ridgelike, or like tiny beads. These characteristics all vary from one woman to another.
Tends to be symmetrical (bilateral). A woman can have more fibrocystic involvement in one breast than in
the other. The less affected breast, however, often "catches up" over the years, and eventually both breasts
become almost equally fibrocystic.
Which other conditions might present similarly?
Cysts and fibrosis: Secretions are normally reabsorbed "downstream" in the ducts. However, when there has been
tissue damage and scarring (fibrosis) in the breast, these secretions may be trapped in the glandular portions of the
breasts, thereby leading to the formation of fluid-filled sacs called cysts. In some areas of the breasts, there may be
excessive fluid secretions due to stimulation by hormone-like substances. Cysts most commonly appear after 35yo.
Cysts vary in size. Some can be very tiny, while others can grow up to several centimetres in diameter. Single or
multiple cysts can occur in one or both breasts. Cysts often do not cause any symptoms, although some women may
experience pain, particularly if the cyst increases in size during the menstrual cycle. They do not significantly increase
the risk of breast cancer developing.
Hyperplasia and atypical hyperplasia of breast cells: With repeated stimulation from normal hormones, and
possibly the effects of many of the hormone-like substances produced in the breast, a few of the epithelial cells may
become hyperplasia.
Sometimes these proliferated epithelial cells may become atypical.
As other more normal cells continue to cycle, die and break down, these atypical cells can move in, spread out, and
accumulate. This extensive overgrowth and accumulation of atypical cells is called atypical hyperplasia.
How would you investigate this patient?
What would you tell the patient and how would you explain the condition to them?
How do you think the patient/ and or family might be affected by the diagnosis? Will it affect their ability to work/
care for themselves?
What questions are they likely to have?
What treatment(s) (surgical, pharmacological and non-pharmacological) would you discuss with them? What risks
and benefits of treatment are there?
 Treatments directed at individual components of the condition: symptomatic relief and correction of
hormonal irregularities.
Tenderness:
 Wearing bra at night or changing bra/support may be enough
 Anti-inflammatory medications
Hormonal irregularities:
 Irregular menstrual cycle may cause more severe FCC so establish regularity with oral contraceptives.
 Certain common hormonal (endocrine) abnormalities, such as diabetes or thyroid dysfunction, may
contribute to fibrocystic breast condition. Since these conditions may aggravate the symptoms of fibrocystic
breast condition, they should be diagnosed and treated.
 ?Short –term use of tamoxifen (anti-oestrogenic) or danazol (androgenic): reduce pain and nodule size but
there are side-effects.
What other health care professionals might be involved in their care?
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Fibroadenoma: ‘breast mouse’
 The most common cause of breast mass in female patients younger than 35 years is fibroadenoma;
infrequent after 40yo; rare variant in older women = phylloides tumour
 A benign, smooth, well rounded solid lump that sometimes develops outside milk ducts.
 Made up of fibrous and glandular tissue => rubber like texture and mobile (so difficult to find)
 Black women tend to develop fibroadenomas more often and at an earlier age than white women. The cause
of fibroadenomas is not known.
 These arise from the terminal duct lobular unit and appear clinically as singular, firm, rubbery, smooth,
mobile, painless masses ranging in size from 1-5 cm, well-defined borders
 Often don’t grow but may during pregnancy, thereby affecting the contours of the overlying skin and overall
shape of the breast.
 Ultrasonography reveals a well-defined hypoechoic homogeneous mass 1–20 cm in diameter.
 Fibroadenomas appear as multiple masses in 10–15% of patients.
 Fibroadenomas often get smaller after menopause (if a woman is not taking hormone replacement therapy).
Treatment
If a biopsy shows that the lump is a fibroadenoma, the lump may be left in place or removed.
The decision to remove the lump is made by the patient and the surgeon. Reasons to have it removed include:
 Abnormal biopsy results
 Pain or other symptoms occur
 Worry or concern about cancer
Sometimes, the lump may be destroyed without removing it, using freezing. This is called cryoablation.
Prognosis
Women with fibroadenoma have a slightly higher risk of breast cancer later in life. Lumps that are not removed
should be checked regularly by physical exams and imaging tests, following the doctor's recommendations.
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Abscess
How common is it?
Infectious complications occur in as many as 10% of lactating women.
Lactational mastitis is seen in approximately 2-3% of lactating women, and breast abscess may develop in 5-11% of
women with mastitis.
Mortality/Morbidity
 Recurrent or chronic infections, pain, and scarring are causes of morbidity.
 Mastitis is usually seen in lactating women, but the presence in a nonlactating woman should spur
evaluation for an inflammatory carcinoma or new-onset diabetes.
 Abscess formation complicates postpartum mastitis in fewer than 10% of cases.
 Neonatal mastitis usually occurs in term or near-term infants, is twice as common in females, and progresses
to development of a breast abscess in approximately 50% of cases.
Who does it affect?
Breast infection most commonly affects women aged 18-50 years; in this age group, it can be divided into lactational
and nonlactational infections. The process can affect the skin overlying the breast, where it can be a primary event,
or it may occur secondary to a lesion such as a sebaceous cyst as hidradenitis suppurativa.
What causes it?
Breast abscess:
 Staphylococcus aureus and streptococcal species are the most common organisms isolated in puerperal
breast abscesses. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and
anaerobes.
Mastitis:
 Mastitis occurs in 2-3% or more of lactating women, with its highest incidence in weeks 2-3 postpartum.
 Periductal mastitis comprises 3-4% of all benign lesions of the breast.
 S aureus is the most common cause. Streptococci, enterococci, Staphylococcus epidermidis,
Peptostreptococcus species, Prevotella species, and Escherichia coli are less common causes.
 True fungal mastitis is rare and should prompt evaluation for coexisting diabetes mellitus.
 In infants, infections with Shigella, E coli, and Klebsiella species have been reported.
Pathophysiology:
The mammary glands arise along the milk lines that extend along the anterior surface of the body from the axilla to
the groin. During puberty, pituitary and ovarian hormonal influences stimulate female breast enlargement, primarily
due to accumulation of adipocytes. Each breast contains approximately 15-25 glandular units know as breast lobules,
which are demarcated by Cooper ligaments. Each lobule is composed of a tubuloalveolar gland and adipose tissue.
Each lobule drains into the lactiferous duct, which subsequently empties onto the surface of the nipple. Multiple
lactiferous ducts converge to form one ampulla, which traverses the nipple to open at the apex.
Below the nipple surface, lactiferous ducts form large dilations called the lactiferous sinuses, which act as milk
reservoirs during lactation. When the lactiferous duct lining undergoes epidermalization, keratin production may
cause plugging of the duct, resulting in abscess formation. This may explain the high recurrence rate (an estimated
39-50%) of breast abscesses in patients treated with standard incision and drainage (I&D), as this technique does not
address the basic mechanism by which breast abscesses are thought to occur.
Postpartum mastitis is a localized cellulitis caused by bacterial invasion through an irritated or fissured nipple. It
typically occurs after the second postpartum week and may be precipitated by milk stasis. There is usually a history
of a cracked nipple or skin abrasion. Staphylococcus aureus is the most common organism responsible, but
Staphylococcus epidermidis and streptococci are occasionally isolated. Drainage of milk from the affected segment
should be encouraged and is best achieved by continuing breastfeeding or use of a breast pump.
Nonlactating infections may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections
consist of active inflammation around nondilated subareolar breast ducts—a condition termed periductal mastitis.
Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with
an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis,
and trauma. Primary skin infections of the breast (cellulitis or abscess) most commonly affect the skin of the lower
half of the breast and often recur in women who are overweight, have large breasts, or have poor personal hygiene.
Breast masses can involve any of the tissues that make up the breast, including overlying skin, ducts, lobules, and
connective tissues.
What risk factors are there (and how can they be reduced?)
How does it present? What symptoms should you look out for?
Mastitis
 Localized breast erythema, warmth, and pain
 May have fever and chills
 May be lactating and may have recently missed feedings
 May progress to breast abscess
Breast abscess
 Signs of inflammation (mastitis)!
 Localized breast oedema (swelling), erythema (redness), warmth (fever), and pain
 History of previous breast abscess is common.
 Associated symptoms of fever, vomiting, and spontaneous drainage from the mass or nipple
 May be lactating
What signs may the patient have on examination?
Mastitis
 Localized breast erythema, warmth, induration, and tenderness
 May have associated fever
Breast abscess
 Localized breast erythema, warmth, edema, and tenderness
 Most frequently areolar or periareolar
 Fluctuance
 May have associated fever or axillary lymphadenopathy
 Nipple discharge or inversion
Which other conditions might present similarly?




Abscess
Breast Cancer
Cellulitis
Mastitis
How would you investigate this patient?
Breast abscess:
 FBC
 Aerobic and anaerobic cultures taken during surgical drainage
 US: used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage on
abscesses <3cm. Simple cysts are seen on sonograms as round or oval with sharply defined margins and
posterior acoustic enhancement. Complex cysts are characterized by a significant solid component,
septations, lobulations, varied wall thickness, and the presence of internal debris. Abscesses usually appear
as ill-defined masses and have central hypoechoic areas with either septations or low-level internal echoes,
and posterior enhancement.
What would you tell the patient and how would you explain the condition to them?
How do you think the patient/ and or family might be affected by the diagnosis? Will it affect their ability to work/
care for themselves?
What questions are they likely to have?
What treatment(s) (surgical, pharmacological and non-pharmacological) would you discuss with them? What risks
and benefits of treatment are there?
What other health care professionals might be involved in their care?
***********************************************************************************************
Intraductal papilloma (not on CKS, emedicine or ox handbook)
A benign (noncancerous) growth in a breast milk duct, often near the nipple. Usually a solitary papilloma 1-2cm
large. Sometimes they bleed or seep causing watery or bloody discharge from the nipple. Generally not at an
increased risk of Ca (but is associated with atypical hyperplasia which is ass with breast Ca). Multiple papillomas are
more often associated with atypical hyperplasia.
How common is it?
Who does it affect?
Breast duct papillomas are typically found in women between the ages of 35 and 55.
What causes it?
It is not known what causes a breast duct papilloma.
What risk factors are there (and how can they be reduced?)
The risk factors for developing a breast duct papilloma are not known.
How does it present? What symptoms should you look out for?
Nipple discharge with a lump next to or behind the nipple. Also ?breast enlargement or pain.
What signs may the patient have on examination?
Which other conditions might present similarly?
How would you investigate this patient?
What would you tell the patient and how would you explain the condition to them?
How do you think the patient/ and or family might be affected by the diagnosis? Will it affect their ability to work/
care for themselves?
What questions are they likely to have?
What treatment(s) (surgical, pharmacological and non-pharmacological) would you discuss with them? What risks
and benefits of treatment are there?


Surgery to remove the papilloma and affected ducts. The removed tissue will then be checked for the
presence of malignant (cancer) cells.
The outcome for patients with a solitary breast duct papilloma is excellent. However, patients with multiple
papillomas, or who develop a breast duct papilloma with certain changes in the appearance of the cells, may
have an increased risk of developing breast cancer.
What other health care professionals might be involved in their care?
Papillary adenoma of the nipple:
o Papillary adenoma is also known as erosive adenomatosis of the nipple, adenoma of the nipple,
florid papillomatosis of the nipple, and subareolar duct papillomatosis of the nipple.
o This is believed to originate in the terminal lactiferous ducts of the nipple and subareolar tissue.
o Incidence is highest among women in their 40s.
o It commonly presents with unilateral serous or bloody nipple discharge that increases before
menses.
***********************************************************************************************
Phyllodes tumor:
o Phyllodes tumor is also known as cystosarcoma phyllodes or giant fibroadenoma.
o Although generally benign, a malignant variant occurs in 10% of cases.
o Incidence is highest among women in their 40s or 50s.
o Most common presentation is that of a large (average size, 5 cm), solitary, firm, breast nodule.
***********************************************************************************************
US and Mammogram Images:
1. Ultrasonogram demonstrates a hypoechoic mass with smooth, partially lobulated margins typical of a
fibroadenoma.
2. Breast cancer, ultrasonography. Mediolateral oblique digital mammogram of the right breast in a 66-yearold woman with a new, opaque, irregular mass approximately 1 cm in diameter. The mass has spiculated
margins in the middle third of the right breast at the 10-o'clock position. Image demonstrates both the
spiculated mass (black arrow) and separate anterior focal asymmetry (white arrow).
3. Breast cancer, ultrasonography. Antiradial sonogram of the spiculated mass (shown in the image above)
demonstrates a hypoechoic mass with angular margins (black arrows). Cursors on the margins of the mass
were used to electronically measure its dimensions of the mass, which was 0.9 X 0.8 cm.
Schedule an outpatient mammography to further characterize the suspected breast mass. The sensitivity of
mammography ranges from 74-95%, and specificity ranges from 89-99%.[15, 16] Approximately 5-10% of
screening examinations are interpreted as abnormal, but 90% of women with abnormal results do not have
breast cancer.[15, 16] For more information, see Breast, Benign Calcifications, Breast, Fibroadenoma, Breast,
Nipple Discharge Evaluation, and Breast Cancer, Mammography.
4. Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of
the breast.
5. Spot compression mammogram of the outer part of the breast demonstrates a new mass as smooth,
margined, and oval. The findings are consistent with a fibroadenoma, a cyst, or a malignancy. In this patient,
the diagnosis was a rapidly growing fibroadenoma. Eggshell or rim calcifications (arrows) have walls thinner
than those of lucent-centered calcifications. This mass with associated large, coarse calcifications (arrows) is
a degenerating fibroadenoma.
Breast pain
Very common; 2/3 pre-menopausal women affected at some point in their lives
Cyclical pain
Breast pain that is part of a woman’s normal menstrual cycle
o Pain that varies in intensity from one menstrual cycle to another.
o Pain may be burning, prickling, stabbing or drawing-in pain; can affect one or both breasts, spread to
the axilla and to the scapula
o Discomfort or lumpiness in breasts a week or so before their period. Pain often disappears once
period started.
o Tender breasts without a discrete lump but with generalized swelling and lumpiness.
o Linked to changing hormone levels during menstrual cycle and affects those who haven’t gone
through the menopause (as menopause = ovaries stop working = no hormones). Women taking HRT
post-menopause may still experience cyclical pain because HRT keeps hormone levels at premenopausal levels.
o Exact cause unknown – drugs and stress may be a cause

Exclude:
o Pregnancy.
o Malignancy (refer urgently) suggested by:
 Women 30 years of age and older with a discrete lump that persists after the next menstrual
period, or presents after the menopause.
 Women younger than 30 years of age with a lump that enlarges, or has other features
associated with cancer (fixed and hard), or in whom there are other reasons for concern
(such as family history).
 Women who have previously had histologically-confirmed breast cancer, who present with a
further lump or suspicious symptoms.
 Unilateral eczematous skin, or nipple changes, or nipple distortion of recent onset.
 Spontaneous unilateral bloody nipple discharge.
o Infection, suggested by:
 Localized breast swelling, redness, warmth, and pain.
 Associated systemic symptoms such as fever, vomiting, and discharge from a lump or the
nipple
Note that some medications that may cause breast pain (although not often cyclical) include:
o Antidepressants, antipsychotics, and anxiolytics, including sertraline, venlafaxine, and haloperidol.
o Antihypertensive and cardiac medication including spironolactone, methyldopa, and minoxidil.
o Antimicrobials, including ketoconazole and metronidazole.
o Herbal medicines
Management:
 Reassurance it is entirely benign
 For women with moderate-to-severe pain, consider the use of a breast pain record chart to aid diagnosis.
o Include a daily pain score recorded on a visual analogue scale.
o Use the chart for at least 2 months to assess the severity and timing of breast pain.
o Analyse the chart for features indicative of cyclical breast pain
 Diet and lifestyle changes
o Reducing intake of caffeine, chocolate and red wine, increasing fruit and veg; relaxation therapy,
acupuncture and aromatherapy may help to reduce stress
o A better-fitting bra during the day.
o Soft support bra at night.
o If pain started when woman began taking contraceptive pill, possibly consider other forms of
contraception such as condoms or the diaphragm (cap)
 Anti-inflammatory meds
o Oral paracetamol and/or ibuprofen, as required. Creams and gels are good.
o Topical nonsteroidal anti-inflammatory preparation, as required.
 Hormone drugs
o

If pain severe and not improved with other methods; In general, continue treatment for 6 months
before considering second-line treatment.
o Ask the woman to keep a pain chart for a minimum of 2 months (if she has not already done so) to
evaluate the severity and timing of the pain, and its response to treatment.
o Consider referring to a specialist for other treatment options including:
 Danazol (an anti-gonadotrophin): only one licensed to treat breast pain but tamoxifen has
fewer side effects so often used first; blocks many hormones produced during menstrual
cycle; side effects = weight gain, amenorrhoea (no periods), facial hair growth and changes
to their voice
 Tamoxifen (an oestrogen-receptor antagonist): side effects = nausea and stomach upset
 Goserelin injections (a gonadorelin analogue inhibiting gonadotrophin release); hence stops
ovaries from producing oestrogen resulting in a temporary menopause; may cause side
effects of menopause such as hot flushes and vaginal dryness; used in conjunction with
hormone replacement therapy to relieve adverse effects.
 Bromocriptine: lowers prolactin levels; side effects = nausea, dizziness, headaches,
constipation so not usually prescribed
 Gestrinone (inhibits pituitary gonadotrophin).
 Toremifene (a selective oestrogen-receptor modulator).
Surgery in very rare and extreme cases
Which treatments are not recommended for cyclical breast pain?
 Treatments that should not routinely be used in treating cyclical breast pain include:
o Stopping or changing other medication, including combined oral contraceptives.
o Evening primrose oil (no evidence supporting it, though low gamolenic acid has been linked to pain)
o Progestogen-only contraceptives.
o Diets low in fat and high in carbohydrate, or low in caffeine.
o Antibiotics.
o Diuretics.
o Pyridoxine.
o Tibolone.
o Vitamin E.
Non-cyclical pain:
Two types:
 Breast pain that comes from the breast but is not related to the menstrual cycle
 Extra mammary pain that is felt in the area of the breast but is actually coming from elsewhere; eg may be
referred musculoskeletal pain
Both types will cause intermittent or constant pain, affecting women before and after the menopause. The pain may
be in the whole breast, a specific area or both breasts. Causes of pain often unknown but may be due to previous
surgery, specific benign breast conditions or underlying conditions not related to the breast
Management: pain often resolves by itself mind
 Diet and lifestyle changes as above
 NSAIDs
 ?hormones
Pain from elsewhere:
Inflammation of the chest wall: costochondritis or Tietze’s syndrome. The pain comes from the costal cartilages; pain
is worse if pressure is put on it.
DD = mammary duct ectasia; periductal mastitis; trauma; Tietze’s disorder (tenderness over costochondral joints)
Mammography if older pt as 10% have carcinoma (if lump present too)
Breast screening - Management
View full scenario
WHAT ARE THE BENEFITS AND HARMS OF BREAST SCREENING?
 Inform women of the associated benefits and harms of breast screening to allow them to make an informed
choice.
 The benefits include:
o Breast screening saves lives, with the greatest reduction in mortality in women 50–70 years of age.
o Increased early detection of breast cancer has led to more breast-conserving treatment and a
reduced rate of interval cancer.
 It has been estimated that up to 1400 women in England are saved each year from death,
following detection of breast cancer at screening.
 The harms include:
o Over diagnosis leading to unnecessary treatment.
o False-positive mammograms leading to unnecessary further investigations.
o False reassurance due to missed cancer and incorrect diagnosis.
o Pain and discomfort due to mammography.
o Psychological distress.
o Radiation exposure which may increase the risk of breast cancer.
 It has been estimated that if 2000 women are screened regularly for 10 years, one woman
will avoid dying from cancer, but 10 healthy women will be treated for breast cancer
unnecessarily, and about 200 women will experience a false alarm.
Basis for recommendation
 These recommendations are based on expert opinion in reviews [Blamey et al, 2000; Dixon, 2006], trial
evidence [Vainio and Bianchini, 2002], and a Cochrane Review [Gøtzsche and Nielsen, 2006].
 Available evidence indicates that breast screening reduces mortality from breast cancer in women of 50–
70 years of age. It is a point of controversy whether this benefit is outweighed by the harm caused by
screening.
 Benefits of screening:
o Reduced mortality:
 The evidence for this is based primarily on two meta-analyses [U.S Preventive Services Task
Force, 2002; Vainio and Bianchini, 2002].
 The first was an intention-to-treat analysis of 10 randomized controlled trials, which
suggested that up to 1400 women in England are saved each year from death, following
detection of breast cancer at screening [Vainio and Bianchini, 2002].
 The second was a meta-analysis of seven trials, six of which were also included in the
Cochrane Review, which estimated a pooled reduction in breast cancer deaths of 22% in
women older than 50 years of age after 14 years of regular screening. To prevent one death,
838 women would need to be screened [U.S Preventive Services Task Force, 2002].
 The estimate of the number of women whose life is prolonged varies from one in every 2000
women screened in a 10-year period [Gøtzsche and Nielsen, 2006] to five in every 2000
women screened in a 10-year period [Advisory Committee on Breast Cancer Screening,
2006].
o Increased breast-conserving treatment and reduced rate of interval cancer:
 Other support for screening is obtained from information published by the Advisory
Committee on Breast Cancer Screening. They estimate that 7 out of 10 women diagnosed
with breast cancer during screening had breast-conserving therapy compared with 5 in 10
outside the screening program [Advisory Committee on Breast Cancer Screening, 2006].
 Interval cancers are breast cancers diagnosed in the period between screenings, and thus
can be defined as occurring only in women who have been screened. Interval cancer rates
are inversely related to the screening-detected cancer rates, and have decreased overall
over time indicating the increased sensitivity of screening programmes in detecting breast
cancer [Advisory Committee on Breast Cancer Screening, 2006].
 Harm from screening:
o Over diagnosis leading to unnecessary treatment:
 Over diagnosis refers to the detection of breast cancers through screening that would not
have been diagnosed without screening and would not have threatened the lives of the
women concerned. Once diagnosed through screening these cancers have to be treated;
without screening they would not. The evidence for harm due to over diagnosis is based
primarily on a Cochrane Review of six randomized trials.
 The review estimates that, for every one prevented breast cancer death in 2000 women
screened over a 10-year period, 10 healthy women will be unnecessarily treated with
invasive investigations and surgery [Gøtzsche and Nielsen, 2006].
o False-positive mammograms:
 Around 5% of women screened are recalled for further tests (which may include clinical
examination, more mammograms, breast ultrasound, and needle biopsy) because they are
judged to have abnormal mammograms or, less often, to have suspicious signs or symptoms.
Of these women, 85% do not have breast cancer and would not have required further tests
had they not attended for screening. Only around 15% of women recalled (0.6% of women
screened) prove to have breast cancer. False-positive mammograms are an inevitable and
unavoidable aspect of breast screening [NHS Breast Screening Programme, 2007].
o False reassurance:
 There is evidence from a single study that false-negative interpretation of mammograms
occurs. However it must be noted that this study does not reflect current screening practice
in the UK which has changed significantly since the study was published [Harvey et al, 1993].
 There is limited evidence to suggest that, in women who have been previously screened for
breast cancer, false reassurance has no significant effect in terms of delaying presentation of
symptoms to the GP [de Gelder et al, 2008].
o Pain:
 There is evidence to indicate that mammography causes breast discomfort and pain.
 An estimated one in three women having their first mammogram experienced discomfort
[Rutter et al, 1992; Gøtzsche and Nielsen, 2006; Miller et al, 2008].
o Psychological distress:
 There is limited evidence that false-positive interpretation of mammograms can lead to
psychological distress for many months afterwards [Lerman et al, 1991; Gøtzsche and
Nielsen, 2006].
 Despite the possible psychological distress there is also evidence of no significant reduction
in participation in subsequent breast screening programmes between women with a falsepositive test and women with a negative test [Andersen et al, 2008].
o Radiation-induced breast cancer:
 There is limited evidence of a small risk of radiation-induced breast cancer. The estimates for
radiation exposure-induced breast cancer averages at 0.07 per 1000 women of 50–70 years
of age [Advisory Committee on Breast Cancer Screening, 2006].
WHAT INFORMATION DO I GIVE WOMEN ABOUT BREAST SCREENING?
 Inform women awaiting breast screening that:
o An invitation will arrive by post giving the date, time, and place to attend. If the time and place are
inconvenient, the appointment can be changed by telephoning the screening unit.
o Screening is done using mammography (radiography) of each breast.
o The screening unit may be mobile, hospital-based, or permanently based in a convenient location
such as a shopping centre.
o The visit to the screening unit should last approximately 30 minutes.
o Mammography requires removal of clothes from the top part of the body, including the bra if the
woman is wearing one.
o Each breast is placed in turn on the machine and gently but firmly compressed with a flat, clear,
plastic plate.
o Some women find mammography uncomfortable, and even painful, as the breasts have to be held
firmly in position and pressed to get a good image.
o The pain due to mammography usually only lasts for as long as the procedure, although in a small
number of women it may continue for some time afterwards.
o Women should avoid the use of talcum powder or spray-on deodorant on the day of breast
screening as this may affect the mammogram.
o Women with breast implants can receive breast screening but usually have to go to the hospital
screening unit for this.
o
They should await contact from the breast screening service about the test results and any follow up
required. Results should arrive within 2 weeks, and after this time the woman can contact the
screening unit directly for results.
o Additional information about the UK Breast Screening Programme can be obtained from
www.cancerscreening.nhs.uk.
Basis for recommendation
 These recommendations are based on expert opinion in reviews [Blamey et al, 2000; Dixon, 2006; Knutson
and Steiner, 2007].
WHO IS ELIGIBLE FOR NATIONAL SCREENING FOR BREAST CANCER?
 Inform women younger than 50 years of age, who are not an increased risk of breast cancer, that they are
currently excluded from the screening programme.
o The incidence of breast cancer and the effectiveness of mammography are lower among women in
their forties than in women 50 years of age or more.
o Mammography results in less absolute benefit and greater absolute risk for women in their forties
than for women 50 years of age or more.
o The Cancer Reform Strategy 2007 announced a policy of extending the range of women eligible for
routine breast screening to 47 years of age, but this is not yet in place.
 Women at increased risk of breast cancer (e.g. with a strong family history of breast cancer) are eligible for
breast screening before 50 years of age. Women who may be at increased risk can be referred to have their
risk formally assessed and their management options, which include screening, discussed. For more
information, see the CKS topic on Breast cancer - managing FH.
 Advise healthy women of 50–70 years of age that they are eligible for routine breast screening.
o Because the programme is a rolling one which invites women from GP practices in turn, not every
woman will receive an invitation as soon as she is 50 years of age; but she will receive her first
invitation before her 53rd birthday.
o Routine screening is repeated every 3 years.
 The breast screening service provides additional support for certain groups of women including those with a
degree of:
o Physical disability.
o Mental impairment.
 Resources are available to assist women with learning difficulties to learn more about breast
screening. For more information see www.cancerscreening.nhs.uk.
 Advise women older than 70 years of age that they are currently excluded from the screening programme.
However, if they wish to continue to receive breast screening they can do so by contacting their local NHS
Breast Screening Service directly, either by phone or letter.
o Local breast screening centres will also accept GP- or self-referral for an appointment for women
older than 70 years of age.
o The decision to screen women older than 70 years of age should be based on consideration of any
comorbidities that may limit life expectancy and hence reduce the benefits of any treatment.
o The Cancer Reform Strategy 2007 announced a policy of extending the range of women eligible for
routine breast screening to 73 years of age, but this is not yet in place.
 Refer the woman to a breast clinic if she has worrying breast symptoms.
Basis for recommendation
 These recommendations are consistent with the Advisory Committee on Breast Cancer Screening [Advisory
Committee on Breast Cancer Screening, 2006; NICE, 2006] and are based on expert opinion in reviews
[Blamey et al, 2000; Dixon, 2006; Knutson and Steiner, 2007].
 Mammography in women less than 50 years of age who are not at increased risk is not currently advised:
o There is only limited evidence that screening women of 40–49 years of age reduces mortality from
breast cancer.
o Any reduction in mortality for women who are screened from 40 years of age onwards may be due
to cancer detected after 50 years of age.
o There is difficulty in interpreting results due to increased breast tissue density in this age group,
which may affect the mammogram [Advisory Committee on Breast Cancer Screening, 2006].
o Screening is available as an option for women less than 50 years of age who have been formally
assessed as being at increased risk [NICE, 2006].
o However, the NHS Breast Screening Programme is due to include women from 47 years of age by
2012. This is likely to commence in 2009 in a number of screening units.


Women with physical disability:
o Mammography is a procedure that requires a high degree of cooperation between the radiographer
and the woman.
o Extra support can be provided in the form of additional facilities and increased duration of
appointment.
o If a mammogram is not technically possible at a particular time due to the disability, the woman
should still remain in the call and recall programme, as any increased mobility at a future date may
make screening easier.
Women with impaired mental capacity:
o Permanent mental incapacity should not normally be a barrier to screening.
o The decision to undertake breast screening in the event of lack of consent due to permanent mental
incapacity should take into account the local policy of the screening unit and the views of the
woman's medical practitioner and family.
o Some people may have fluctuating mental capacity, in which case, the decision about screening
should be delayed until the woman is able to decide for herself.
o