Breast disorders

Clinical features

• Complaints that vary with menses are often benign
• Cancers are often asymptomatic
• Radiation of pain to other body sites suggests cancer
• Presence of symptoms in contralateral breast reassuring for benign diagnosis
• Changes that patient notes on self-examination should be correlated with menstrual cycle
• Risk factors for malignancy:
  • First-degree relatives
  • Delay of childbearing to >30yo
  • Biopsy confirmation of atypical hyperplasia
  • Hx of chest irradiation
• Examine upper outer quadrant with particular care as 50% of breast carcinomas originate there

Disorders of lactating breast

• Abnormal lactation
  • Galactorrhoea usually due to hyperprolactinaemia
    • Physiologic – Sleep, stress, exercise, volume depletion, intercourse, orgasm, pregnancy, breast stimulation, seizures
    • Abnormal stimulation of chest wall – Herpes, surgery, trauma
    • Damage to pituitary stalk (lack of inhibitory dopaminergic stimulus)
    • Endogenous HPA signalling
    • Neoplasms – Prolactinomas, renal cell carcinoma, lymphoma, craniopharyngioma, bronchogenic carcinoma, hydatidiform mole
    • Medications – MAOi, SSRI, TCA, atenolol, methyldopa, reserpine, verapamil, antipsychotic phenothiazines, antihistamines, amphetamines, cocaine, opioids, marijuana
    • Systemic disease – Chronic renal failure, hypothyroidism, Cushing’s, acromegaly
  • History must include associated menstrual abnormalities, acne, hirsutism, infertility, libido changes, raised ICP and hypothyroidism
  • Should assess visual fields, breasts, skin, thyroid gland, pregnancy test, CT brain

• Complications of lactation
  • Breast engorgement 
    • 3^rd-5^th postpartum day with painful, hard, enlarged breasts
    • Warm showers, proper latching, manual massage and pumping can all be helpful
  • Nipple irritation
    • Common with poor latching/positioning
    • DDx includes trauma, plugged ducts, candidiasis or inflammatory skin disorders
    • Lanolin, analgesics and breast shields can help
    • May be some benefit of expressed breast milk on nipples
    • Reynaud’s phenomenon can be a cause and responds to topical nifedipine
  • Puerperal mastitis
    • 20% of lactating women (and 10% of these will suffer an abscess)
    • Severe pain, tenderness, swelling, redness +- fever, chills, myalgias
    • DDx – Marked breast engorgement, cogged milk duct and inflammatory carcinoma
    • USS can rule out abscess
    • S. aureus in 40%, E. coli and Strep also possible
    • DO NOT stop breastfeeding
    • Need frequent analgesia, breast emptying and antistaphylococcal antibiotics (augmentin is reasonable)
    • Bactrim is CI if infant <2mo and breastfed

• Risk factors for mastitis
  • Age >30
  • Gestational age >41 weeks
  • Prior hx of mastitis
  • Poor attachment
  • Cleft palate, short frenulum
  • Sore or cracked nipples

• Complications of lactation
  • Breast abscess
    • Seen in 3-10% of mastitis cases
    • US-guided drainage is first-line
    • Continue breasfeeding
    • Surgical drainage may be last resort if large multiloculated fluid collections not amenable to needle drainage but is relatively CI due to risk of milk sinus tract formation
    • Consider IV Vancomycin if risk of MRSA

Inflammatory breast conditions

• DDx
  • Infectious mastitis
  • Breast abscess
  • Ruptured breast cyst
  • Inflammatory neoplasm
  • Metastatic cancer
  • TB
  • Paget’s disease of the breast
• FAILURE to improve with antibiotics indicates urgent surgical consult +- biopsy to exclude inflammatory cancer

• Cellulitis
  • Rare in the breast and warrants surgical consult, USS +- biopsy
• Acute mastitis and abscess in non-lactating women
  • Periareolar vs. peripheral
  • Periareolar = Periductal mastitis
    • In younger women presents as cellulitis or recurrent subareolar abscesses
    • In older women present with nipple discharge, nipple retraction or subareolar mass
  • Empirical PO antibiotics include diclox/cephalex (consider MRSA though)
  • Empiric parenteral antibiotic options include Ceftriaxone, clindamycin, vancomycin, cipro or linezolid
  • Often polymicrobial and Pseudomonas is common
  • Smoking and diabetes are risk factors
  • MRSA is relatively common
  • Antibiotics should cover anaerobes
  • Surgical consult is advised with follow-up

• Hidradenitis suppurativa
  • Often presents with recurrent subcutaneous abscesses, sinus tracts, scarring of breast folds/axillae/groin/perineum
  • Chronic inflammatory disease due to obstruction of sweat glands and polymicrobial colonisation (mostly S. aureus and Streptococcus)
  • Often present with superficial cutaneous abscesses that are painful and require surgical drainage for relief
  • I&D is often adequate but should be avoided if at all possible
  • Chlorhex or antimicrobial body wash is helpful
  • PO clindamycin or rifampicin are sometimes used by dermatologists/surgeons for prophylaxis and control of symptoms in the long-term
  • No cure

Inflammatory breast cancer

• Highest mortality and longest delay from presentation to diagnosis
• Indistinguishable clinically from infection
• Prompt mammography and biopsy ensures diagnosis
• Always consider if antibiotic response is inadequate in presumed infection or if abscess fails to completely resolve

Mastodynia

• Breast pain
• Irritation of intercostal nerves T3-5 can cause pain in breast or nipple
• Pain is bilateral and usually more severe in upper outer quadrants
• Uncommon symptom of breast cancer
• Cyclic mastodynia is usually worst in pre-menstrual phase and resolves following menstruation
• Reassurance, supportive bras and GP follow-up for imaging of any palpable nodules (likely fibrocystic changes) is all that is required

Nipple discharge

Purulent – Infection, periductal mastitis

Milky – Causes of galactorrhoea

Serous/serosanguinous – Intraductal papilloma, ductal ectasia, cancer

Watery – Papilloma, cancer

Green/grey/black – Duct ectasia or periductal mastitis

Nipple discharge

• Bilateral, occurs with nipple manipulation and expressed from several ducts is not suggestive of cancer
• If single breast, emanates from single duct, is clear/pink/bloody/serosanguinous carries increased risk of malignancy
• GP follow-up for mammography and fluid analysis is required always
• Intraductal papillomas
  • Present with unilateral bloody nipple discharge in women 20-40yo

Mondor’s disease

• Thrombophlebitis of the superficial thoracoepigastric vein
• Cordlike mass in breast with dimpling
• May be due to localised trauma or inflammatory condition
• Usually present with breast pain and cordlike mass in superficial subcutaneous tissue
• Benign and self-limited
• USS confirms superficial thrombophlebitis
• Rx – Thrombophilia screening and LWMH with haematology consult

Nipple irritation

• May be repeated friction or atopic dermatitis, erosive adenomatosis, Paget’s disease
  • Can try petroleum jelly protection or protective pad in bra for friction
  • If doesn’t respond, refer to breast surgeon to rule out more concerning diagnosis
• Erosive adenomatosis is benign proliferation of lactiferous ducts presenting as eczema
  • Refer to breast surgeon as needs surgical excision
• Paget’s disease
  • Weeping, eczematoid lesion of the nipple
  • Almost always underlying breast carcinoma and usually diagnosed in postmenopausal women
  • 6-12 month delay to diagnosis is usual as may respond to antibiotics initially
  • Need urgent bilateral mammography and surgical follow-up

Fibrocystic disease of the breast

• Breast nodularity, breast tenderness occuring in cyclic pattern
• Does not include
  • Skin thickening
  • Oedema
  • Discolouration
  • Nipple retraction
  • Nipple discharge
• All should have USS/mammography/MRI performed regardless of age
• If recurrent/severe, skin changes, solid masses, nipple abnormalities or anxiety – refer to breast specialist
• Other red flags include lymphadenopathy, skin ulceration, mass fixed to chest wall, fixed axillary nodes and presence of ipsilateral arm oedema
• Delayed diagnosis and poor outcomes associated with:
  • Low SES
  • Unmarried
  • Normal or false negative mammogram results
  • Nipple lesions
  • Axillary mass
  • Younger age at diagnosis

Breast trauma

• Any avulsion of breast tissue or expanding haematoma needs surgical consult
• Significant isolated breast injury should prompt consideration of abuse or cancer
• Long-term sequelae
  • Architectural changes in breast and persistent microcalcification
  • Fat necrosis can present later with a palpable mass, skin dimpling and retraction and be confused with carcinoma
  • Any persistent mass after trauma must be evaluated for possible cancer and referral to breast surgeon is required

Post-operative complications

• Breast haematoma
  • Up to 1.5L of blood can accumulate within a single breast
  • Expanding haematoma usually require evacuation or ligation of bleeding vessels
  • Later presentations are usually managed conservatively with analgesia, compressive bra and correction of coagulopathy
  • Aspiration of any haematoma is usually ineffective
  • Infected haematomas require percutaneous/open surgical drainage + IV antibiotics
• Wound infection
  • Oral cephalexin if no abscess, systemic toxicity or immunocompromise
  • If deterioration, purulent drainage or above – inpatient IV antibiotics

Last Updated on October 6, 2021 by Andrew Crofton