Case 11.4 – Benign Breast Conditions

Background - Cyclical Mastalgia:

Premenstrual nodularity and breast discomfort are so common that they are considered part of the normal cyclical changes. When premenstrual pain is severe, interferes with daily activities and influences quality of life, then this is classified as moderate or severe cyclical mastalgia.

• There is no association between cyclical breast pain and any underlying histological abnormality
• The cause of cyclical mastalgia is unknown
• Another common and significant problem is non-cyclical mastalgia

Management Approach:

• Need to establish cyclical / non-cyclical nature
• Differentiate breast pain from chest wall and muscular pain
• Determine effect of pain on daily activity (this may influence treatment)
• Assess risk factors for breast cancer

Management Algorithm for Palpable Breast Mass:

Step 1: Triple Assessment

Using clinical examination, imaging and core biopsy

Step 2: Classification Based on Results

A. MALIGNANT

• → Definitive treatment

B. SUSPICIOUS OR ATYPICAL

• → Repeat core or open biopsy

C. BENIGN (Definite Lesion)

• Option 1: Reassure unless radial scar
  • → Radial scar requires excision
• Option 2: Lesion adequately sampled + pictures of wire or clips in excision
  • → Discharge
• Option 3: Concern whether lesion hit or only 1 or 2 cores
  • → Repeat core biopsy

D. BENIGN (No Definite Lesion)

• → Reassure and discharge

Key Principle: All palpable breast masses require triple assessment to ensure accurate diagnosis and appropriate management.

Nature of Fibroadenomas:

Fibroadenomas are classified in most texts as benign tumours, but are best considered as aberrations of development rather than true neoplasms. The reasons are that:

• Fibroadenomas develop from a single lobule rather than from a single cell
• Show hormonal dependence similar to that of normal breast tissue
  • Lactating during pregnancy
  • Involuting in the perimenopausal period

Presenting Age:

• Fibroadenomas are most commonly seen immediately following the period of breast development and growth
• Typical age group: 15-25 years

Clinical Features on Examination:

• Well-circumscribed
• Firm
• Smooth
• Mobile lumps (sometimes called "breast mouse" due to mobility)
• May be multiple or bilateral

Natural History:

• Although a small number of fibroadenomas increase in size, most do not
• Over one-third become smaller or disappear within 2 years

Imaging Characteristics:

• Fibroadenomas have a characteristic appearance with easily visualized margins on ultrasound

Epidemiology:

• Approximately 7% of women in developed countries develop a palpable breast cyst at some time in their life
• Cysts constitute approximately 15% of all discrete breast masses
• They are distended, involuted lobules and are most frequently seen in the perimenopausal period

Clinical Features:

• Smooth discrete lumps
• Can be painful
• Sometimes visible

Mammographic Features:

• Characteristic haloes
• Easily diagnosed by ultrasonography

Management:

Symptomatic Palpable Cysts:

• Treated by aspiration
• Provided the fluid is not blood-stained, it is discarded
• If aspiration results in the disappearance of the mass, then the patient can be reassured
• Cysts that contain blood-stained fluid require excision to exclude an associated intracystic cancer
  • These cancers are rare and are usually evident on ultrasound

Asymptomatic Cysts:

• Most cysts are asymptomatic
• Provided they are appropriately investigated by ultrasound, do not need aspiration

Important:

• All patients with cysts should have mammography, preferably before cyst aspiration
• Between 1 and 3% will have a cancer, usually remote from the cyst, visible on mammography

Investigation Algorithm for Persistent Spontaneous Nipple Discharge:

Initial Investigations:

• Clinical examination
• Mammography

Classification of Results:

A. ABNORMAL Findings:

• → Investigate palpable mass lesion or mammographic abnormality

B. NORMAL Findings:

1. Single-Duct Discharge:

• Breastfeeding not an issue:
  • → Investigate palpable mass lesion or mammographic abnormality
• Wishes to preserve ability to breastfeed:
  • → Consider ductography +/- ductoscopy
  • → Microdochectomy +/- total duct excision
  • → Localized duct excision

2. Multiple-Duct Discharge:

• Distressing symptoms:
  • → Total duct excision
• No distressing symptoms:
  • → Reassurance

Ultrasound:

• Ultrasound is useful to assess for dilated duct(s) that may be responsible for nipple discharge
• Abnormal imaging findings require biopsy +/- excision

Lactating Infection

Timing:

• Infection usually develops within the first 6 weeks of breastfeeding
• Or, occasionally, during weaning

Presenting Features:

• Pain
• Swelling
• Tenderness
• Cracked nipple or skin abrasion

Causative Organisms:

• Staphylococcus aureus - most common
• Staph. epidermidis (occasionally)
• Streptococci (occasionally)

Pathophysiology:

• Drainage of milk from the affected segment is often reduced
• The resultant stagnant milk becomes infected

Non-Lactating Infection

1. Central (Peri-areolar) Infection

• Most commonly seen in young women (mean age 32 years)
• The underlying cause is periductal mastitis

Etiology - Smoking:

• Current evidence suggests that smoking is important in the aetiology of non-lactational infection
• 90% of women who present with periductal mastitis or its complications are smokers
• Substances in cigarette smoke either directly or indirectly damage the subareolar breast ducts
• The damaged tissue then becomes infected by either aerobic or anaerobic organisms

Clinical Presentation:

• Initial presentation is with peri-areolar inflammation, with or without an associated mass, or with an established abscess
• Clinical features include:
  • Breast pain
  • Erythema
  • Peri-areolar swelling and tenderness
  • Nipple retraction
• These occur in relation to the affected duct

2. Peripheral Non-Lactating Abscesses

• Less common than peri-areolar abscesses
• Sometimes associated with an underlying condition:
  • Diabetes
  • Rheumatoid arthritis
  • Steroid treatment
  • Granulomatous lobular mastitis
  • Trauma

Granulomatous Lobular Mastitis:

• Infection associated with granulomatous lobular mastitis can be a particular problem
• Strong tendency for this condition to persist and recur despite surgery
• Usually affects young parous women
• Develop large areas of inflammation with multiple simultaneous peripheral abscesses

Summary of Key Differences

Feature	Mastitis	Abscess
Definition	Inflammation of breast tissue	Localized collection of pus
Presentation	Pain, erythema, swelling, systemic symptoms	Fluctuant mass, more localized pain, may have systemic symptoms
Treatment	Antibiotics, continue breastfeeding/expression	Drainage (needle aspiration or surgical) + antibiotics
Progression	May progress to abscess if untreated	Represents progression from mastitis