Benign Breast Conditions

Ghaith Heilat, MD, MS, FEBS, FACS

Breast, Endocrine and General Surgeon
Faculty of medicine/ Yarmouk University

3/11/2021
Surgical Anatomy
• Overlying the second to the sixth-seventh
ribs and extending from the lateral border
of the sternum to the anterior axillary line.
• Relay on pectoralis major, serratous
anterior, external oblique and the cranial
part of rectus abdominis muscles.

• Breast volume determined by:

Glandular tissue. (15-20 lobes)
Fatty tissue
record

• The ratio of glandular to fatty tissue depend on age

• Young -< more glandular and less fat

• With age the glandular tissue will become atrophied and replaced
with fat
• Breast shape depends on the relationship between:
1. Glandular tissue
Most important is the ratio between them
2. Fatty tissue
3. Fascial-ligmentous system Ligament of cooper: extend
from the fascia to the skin
4. Skin envelop

• The lobule is the basic structural unit of the

mammary gland.
• From 10 to over 100 lobules empty via ductules
into a lactiferous duct, of which there are 15–20.

Glandular tissue consist from terminal duct lobular units(TDLUs) also

referred to as lobules, that is connected together with multiple ducts
(lactiferous duct)
• The ligaments of Cooper are hollow conical
projections of fibrous tissue filled with breast
tissue; the apices of the cones are attached
firmly to the superficial fascia and thereby to
the skin overlying the breast.(which help to
keep the shape of the breast)
• With age this ligament become more elastic
and elongated –< the breast become more
ptotic /sagging (‫)مترهل‬
• These ligaments account for the dimpling of
the skin overlying a carcinoma.
 Stimulation of the areola can
• The areola contains involuntary muscle arranged in result in puckers and wrinkles
concentric rings as well as radially in the subcutaneous which is normal reflux
tissue.
• The areolar epithelium contains numerous sweat glands and
sebaceous glands, the latter of which enlarge during
pregnancy and serve to lubricate the nipple during lactation
(Montgomery’s tubercles).
• The nipple is covered by thick skin with corrugations. Near
its apex lie the orifices of the lactiferous ducts (lactiferous
duct).
• The nipple contains smooth muscle fibers arranged
concentrically and longitudinally;(which help the sucking
baby during lactation) thus, it is an erectile structure, which
points outwards.
 Blood supply
Its important to know the blood supply in order to try
to avoid the arteries and mange the consequences
during surgery like necrosis of skin or nipple
• Blood supply by:
oInternal mammary artery (medial)
oLateral thoracic artery
o2nd-6th Intercostal artery perforators
oBranches from thoracoacromial, axillary
and subscapular arteries. (accessory artery)
• The venous blood flows towards the
axillary, internal mammary and intercostal
veins.
 Lymphatic
• The lymphatics of the breast drain predominantly into the axillary
and internal mammary lymph nodes(medially 15%-25%).
• The axillary nodes receive approximately 75-85% of the drainage
and are arranged anatomically in the following groups:
 Lateral(Axillary/humeral), along the axillary vein
 Anterior (Pectoral), along the lateral thoracic vein;
 Posterior(Subscabular), along the thoracodorsal vessels;
 Central, embedded in fat in the centre of the axilla;
 Apical, which lie above the level of the pectoralis minor tendon in
continuity with the lateral nodes and which receive the efferents of
all the other groups.

The lymph nodes near the vein that drains in

Anterior + posterior + lateral drains in the central group
The central group drains in the Apical group
• The central group receives afferents from the (anterior, posterior,
lateral) lymph nodes
• Rotter’s nodes “interpectoral”, a few nodes lying between the
pectoralis major and minor muscles.
• Surgical wise the lymph nodes were classified (Berg’s) according to
their position to pectoralis minor muscle.
• Berg’s classification of the lymph nodes is in widespread clinical
practice as opposed to the anatomical classification.
• Berg defined three groups of axillary lymph nodes according to their
position relative to the pectoralis minor muscle.
Level I lymph nodes are located
laterally- inferior to the lateral margin of
the muscle. Anatomically correspond to
the anterior, posterior and lateral lymph
nodes.
Level II lymph nodes are located
behind the muscle. Anatomically
correspond to the central lymph nodes.
Level III lymph nodes are located
medially to the medial-superior margin
of the muscle. Anatomically correspond
to the apical lymph nodes.
If only level I is involved it have better prognosis than level I+II or
I+II+III
If lev III involved that’s mean that the cancer is more aggressive and the
risk of metastasis is high
 Triple assessment
Pain ,
• In any patient who presents with a breast lump or other symptoms secretion or
suspicious of carcinoma, the diagnosis should be made by a any other
combination of clinical assessment, radiological imaging and a tissue complain
sample taken for either cytological or histological analysis
Clinical

An accurate Careful
History Examination

Try to confirm or deny your

You put all the differential
differential (like 2-3)
diagnosis inside and try to
short your list into 4-5 for
example
Investigation to confirm which one
 Radiological
1. Mammography. X-ray.
• Is the primary imaging modality for the breast.
• The dose of radiation is approximately 0.1 cGy and, therefore, mammography is a very
safe investigation.
• Mammography is used for both screening and symptomatic diagnosis.
• Screening: looking for any abnormality in Asymptomatic pt
• symptomatic diagnosis: there is a complaint used for examination …the examiner may use
special tests like tomosynthesis , magnification compression or special view.
• For standard examination of the breast, two views of each side are obtained – craniocaudal
(CC) and medio-lateral oblique (MLO at a 45° angle).
 Record
• The breast putted between 2 plate that
compress the breast and the machine give a
beam from top to bottom or Medio lateral
oblique
• The beam enter the breast from one side and
exit from the other side where there is a film that
receive that beam and reveal what is inside the
breast
 Pectoralis major muscle it should
appear if you take good pic

There is a thin line The most condensations found behind the

that separate the nipple and whenever we go to the
breast and the periphery the pic become more clear
subcutaneous tissue (more fat)

Fat(if there is any lesion here its very easy to

pickup)
Mostly glands (its very hard to pickup
any mass if found here)
Accuracy and sensitivity of mammogram depend on the density of the breast tissue.
When the density increase the sensitivity decrease (appear as white picture)
The density depend on the ratio between the glandular tisse and fatty tissue inside the
breast which is mostly affected by the age

• The sensitivity of this investigation increases with age as the breast

becomes less dense. So, the sensitivity of it is age dependent. The
sensitivity of MMG is vary 50-95%.
• The more glandular tissue in the breast (as in young age), the higher the
density is and the more likely small lesions may be obscured by the
background and the sensitivity reduced.
• A normal mammogram does not exclude the presence of carcinoma.
• Digital mammography and tomosynthesis are being introduced, which
allows manipulation of the images and computer-aided diagnosis.
Elderly Young
Density/Age relationship
2. Ultrasound
• Ultrasound is particularly useful in young women with dense breasts in whom
mammograms are difficult to interpret, and in distinguishing cysts from solid
lesions.(diagnosis)
• Is a method using high-frequency acoustic waves. (sound waves that exit from probe
and reflect from the breast tissue to the same probe again –< the computer read these
reflections which make pic to this tissue )
• It carries practically no risk to the tissue and can be safely used in all groups of
patients, also during pregnancy and breastfeeding.
• It is an excellent method for guiding interventional procedures.(to locate the mass
while the biopsy is taken.
• It is not useful as a screening tool (cant detect if there is any calcification )
• and remains operator dependent.
 record
A : fibroadenoma …the internal shadow of the
mass is grey and round and its wider than taller

B: Cyst …very dark black shadow (fluid)

C: galactocele

Malignant : irregular hypoechoic , taller than wider A B C

3. Magnetic resonance imaging MRI: Most expensive , no radiation , uses contrast , highly sensitive but it
have high false positive
• Is increasingly used in the characterisation
and diagnosis of breast pathology.
• Is being used with increasing frequency for
screening and diagnosis of breast cancer in
certain cases.
• There is no ionizing radiation to the patient
with MRI.
• Breast MRI uses application of contrast
media to detect pathology and assesses the
biological features of the lesions.
• MRI is not limited by breast density and is
an excellent tool for the screening of young
women.
• Is the most sensitive technique for detection of breast cancer, approaching
100% for invasive cancer and up to 92% for ductal carcinoma in situ
(DCIS), but it has a high false-positive rate.(due to increased sensitivity
which will increase the rate of biopsy and interventions)
• Interpretation is complex and requires skill, experience and time.
• Used to assessment the extent of lesions with LCIS and DCIS. (cancerous/
calcifications without mass)
• It is the best imaging modality for the breasts of women with
implants.(because the implants very hard to compress in mammogram and
give a shadow in imaging)

• Used as a screening tool (monitoring) in high-risk women (because of

family history). To detect in early stages
 Pathology/ Biopsy
FNA(fine needle aspiration) : thin syringe with US guided passed through the lump
with negative pressure
1. Cytology by FNA is obtained using a 21G or 23G needle and 10-mL syringe
with multiple passes through the lump with negative pressure in the syringe.
• Fine needle aspiration cytology FNAC is the least invasive technique.
• It is obtaining a cellular diagnosis.(cytology only: if there is cancer or not, but not
the type, grade, or receptors)
• It is a rapid test.
• False negatives do occur mainly through sampling error.
• Invasive cancer cannot be distinguished from in situ disease.
• Suspicious axillary lymph nodes may also be assessed with FNA during a breast
cancer staging evaluation. (to see if there is cancer cells inside the lymph node)
• FNA is also usefull in aspiration of cyst or abscess
2. Core needle biopsy(bigger beedle with blade that take a piece of tissue)
• It provides significantly greater sensitivity, specificity and positive predictive value than
FNA.
• Is the preferred method of evaluating an indeterminate or suspicious solid mass.
• A histological specimen taken by core biopsy allows a definitive preoperative diagnosis(we
can examine the whole tissue), differentiates between DCIS and invasive disease and also
allows the tumour to be stained for receptor status.(Estrogen , progesterone, HER-2)
• Cant be used in vital area like axilla or thyroid
3. Vacuum assisted biopsy/ Stereotactic Core Biopsy (mammogram with biopsy to identify
the border of the mass)
• VAB is a very successful method for improving the diagnostic accuracy of borderline breast
lesions and lesions at sites in the breast difficult to biopsy using other techniques.
4. Punch Biopsy for skin or NAC lesions.(biopsy with part of the skin and subcutaneous
tissue involved used with paget disease)
5. Surgical biopsy: Excisional (whole mass )or incisional(only part of the mass) biopsy.
BENIGN BREAST DISEASE BBD
• This is the most common cause of breast problems.
• Up to 30% of women will suffer from a benign breast disorder
requiring treatment at some time in their lives.
• The most common symptoms are pain or a lump.
• The aim of treatment is to exclude cancer and, once this has been
done, to treat any remaining symptoms.
• Breast tissue consists of a branching series
of ductal structures designed to channel the
flow of milk from the milk-producing units
of the breast, called the terminal duct
lobular units(TDLUs) also referred to as
lobules.
• This ductal and glandular structure is
supported within a stroma of fibrous tissue.
• BBD includes abnormalities of both
epithelial and stromal elements.
Congenital abnormalities
Amazia or Breast hypoplasia(no
breast tissue but there is nipple and
areola)
• Congenital absence of the breast
may occur on one or both sides.
• It is sometimes associated with
absence of the sternal portion of the
pectoralis major (Poland’s
syndrome).
• It is more common in males.
Polymazia
• Accessory breasts have been recorded in the
axilla (the most frequent site), groin, buttock
and thigh.
• They have been known to function during
lactation.(physiological increase in size during
lactation so it become more noticeable)
• Reassurance and an explanation of the cause of
the ‘lump’ are usually all that is required.
• Surgical excision or Liposuction are other
options for treatment. (if its too big or by the pt
request)
Injuries of the breast
Haematoma (after trauma or surgery . Mostly reabsorbed alone after while
but it could persist so it need aspiration or excision)
• Blood collection gives rise to a lump, which, in the absence of overlying
bruising, is difficult to diagnose correctly unless it is biopsied.
Traumatic fat necrosis
• Following a blow(seatbelt, hit from child or pet), or even indirect violence
(e.g. contraction of the pectoralis major), a lump, often painless, appears.
(hard lesion after trauma)
• This may mimic a carcinoma, even displaying skin tethering and nipple
retraction, and biopsy is required for diagnosis.
 Acute and subacute inflammations of the breast
1. Lactational mastitis The most common

• Mastitis secondary to breastfeeding occurs in approximately 5%

of puerperal women
• Most are caused by S. aureus.
• Theories:
• Ascending infection from a sore and cracked nipple or child
mouth microflora may initiate the mastitis.
• Or the lactiferous ducts will first become blocked by epithelial
debris leading to stasis then organisms multiply.
• Patients initially present with pain, localised erythema and
swelling.
• The pain mostly during breast feeding but we should encourage
the mother to continue breast feeding or to use a pump despite
the pain to avoid fluid accumulation and stasis which can lead
to abscess formation
• If this progresses, the inflammation can affect large areas of the breast and the patient
can become toxic.
• Promoting milk flow by continuing to breastfeed and the early use of appropriate
antibiotics markedly reduces the rate of subsequent abscess formation.
• The patient should be advised to rest, continue nursing, and use warm compresses and
short acting non-steroidal anti-inflammatory agents for pain control
• Co-amoxiclav or flucloxacillin and erythromycin are the antibiotics of preference.
• Culturing the milk or any purulent nipple discharge for antibiotic sensitivities may
help.
• If not respond it might cause abscess, then you need to aspirate the pus and send it
for culture and you may need to change the Antibiotic accordingly.
• Incision and drainage is a final step in the management. Because there is risk of breast
injury or fistula between the milk inside and the skin.. but we can use this method in
case if recurrence
Tender erythema and swelling
Abscess that could perforate
 2. Non-lactational infections

• Non-lactational infections are grouped into peripheral or periareolar.

Periareolar area are seen in young women and are often secondary to
periductal mastitis (associated with heavy cigarette smoking).
• Substances in cigarette smoke may directly or indirectly damage and block
the wall of subareolar ducts and accumulate in the ducts.
• Smoking has also been shown to inhibit growth of Gram-positive bacteria,
leading to an overgrowth of aerobic and anaerobic Gram-negative bacteria.
• Patients present with periareolar inflammation often associated with a mass
or abscess.
• The organisms causing this infection are usually mixed and include anaerobes.
(most common bacteria is S. aureus)
• the pt could benefit from antibiotic or aspiration drainage but they have high risk
of recurrence
• Stop smoking is key of treatment.
• Aspiration of the pus and send it for culture to give the sensitive antibiotics.

Peripheral non-lactational breast abscesses

• Are three times more common in premenopausal women than in postmenopausal
women.
• The aetiology of these infections is unclear but although it was reported that these
are commonly associated with diabetes, rheumatoid arthritis, steroid treatment and
trauma, this is untrue.
 3. Granulomatous mastitis

• Characterised by non-caseating granulomas and microabcesses confined

to a breast lobule.
• The most common species isolated was the newly described
Corynebacterium.
• Patients present with a firm(hard) irregular mass (which is often
indistinguishable from a carcinoma) or multiple or recurrent abscesses.
• Because we suspect cancer we should do biopsy if there is a any abscess
associated with a mass to rollout inflammatory breast cancer
• The mass can be extremely tender (painful).
• Young parous women are most frequently affected and there is no
association with smoking.
Swelling with abscess
and signs for multiple
previous abscess
• As it mimic cancer a carful triple assessment is a must with tissue biopsy
confirmation of Granulomatous mastitis.
• It is sensitive to penicillin and tetracycline.
• Steroids and other immunosuppressive agents(methotrexate) have been used
with varying reports of their efficacy.
• It resolves spontaneously over a period of 6–18 months (highly chronic) but it
might reoccurs after 4-5y.
• Treatment is supportive and is aimed at treating associated infection and
abscesses(aspiration). … we try to avoid surgical excision because its very
diffuse and multiple. Except if the case is very complicated and not responsive.
 Apocrine infection -< blockage especially hair which
4. Hidradenitis suppurativa
may lead to pain , discharge , fole smelling.

• Hidradenitis is a condition affecting the apocrine glands of the skin,

including the axillae, perineum and/or breast areas.
• It is much commoner in smokers, bad hygiene ,diabetic pt.
• Treatment in the acute phase comprises management of any
infection/abscesses by appropriate antibiotics and aspiration or
drainage of any abscess.
• Excision of the affected area with skin grafting has been reported.
• Smoking cessation is also beneficial.
5. Mondor’s disease Inflammation of superficial veins, and mostly autoimmune

• Mondor’s disease is thrombophlebitis of the superficial veins of the

breast and anterior chest wall, although it may also occur in the arm.
• The pathognomonic feature is a thrombosed subcutaneous cord,
usually attached to the skin.
• The only treatment required is to restrict arm movements. The
condition usually subsides within a few months (self limited) without
recurrence, complications or deformity.
Aberrations of normal development and involution
• Breast development start at birth and continue to the final stage after lactation
• If the female doesn't lactate then her breast didn’t reach to the final maturation
• The breast passes through phases related to breast development, cyclical changes
and involution.
• So, some conditions are considered as aberration(‫ )انحرافات‬rather a disease.
Fibroadenomas its not cancer only aberration from normal development
• Is made up of a combination of connective tissue and proliferatory
epithelium.made up from all the tissue (stroma +glands)
• It is not a neoplasm or benign tumor as it does not arise from a single cell.
• Highly connected with estrogen and progesterone -< change in size with
woman menstrual cycle or pregnancy
• Fibroadenomas arise from the hormone-dependent terminal duct lobular
unit and are influenced by hormones, e.g. increasing in size during
pregnancy.
• Is extremely mobile, discrete, rubbery masses ,round ,mostly painless but
rarly can be painfull that present symptomatically in young women or are an
incidental finding during breast imaging.
• They are seen most commonly in the late teens and early twenties.
• They are usually solitary findings but some women develop multiple lesions
in one or both breasts.
• The aetiology is unknown.
• Rapid growth of a fibroadenoma is rare but can occur in either adolescence
(juvenile fibroadenoma) or in the perimenopausal age group.
• Tumours over 5cm are termed ‘giant fibroadenoma’ and are seen more
commonly in African countries.
• It is clearly essential to differentiate a fibroadenoma from breast cancer by
triple assessment including core biopsy after age 23 years.
• The management of fibroadenomas depends on the patients' age and
preference as well as the results of triple assessment.
• Has very low risk transforming into cancer
• A fibroadenoma does not require excision (especially if the size is less than
2-3cm) unless associated with suspicious cytology(FNA showed Atypia), it
becomes very large, sudden increase in size or the patient expressly desires
the lump to be removed.
Phyllodes tumour ..can be classified into benign , malignant, and borderline
• The aetiology of phyllodes (leaf-like) tumours is unknown.
• They contain stroma with much more marked cellularity and atypia.
• They are less common than fibroadenomas.
• The age of onset is (40s-50s).. 15–20 years later than fibroadenomas.
• They can grow rapidly, sometimes producing marked distortion and
cutaneous venous engorgement, which occasionally can lead to ulceration.
• The majority are benign in nature and feel like large fibroadenomas, and are
diagnosed only following core biopsy.
• They are rarely fixed to skin or muscle. (doesn’t invade them)
• They present as a large, sometimes massive, tumour with an unevenly
bosselated surface.
• Most diagnoses of phyllodes tumour are made before operation, on core
biopsy, and the aim of surgery should be to remove the lesion with a clear
macroscopic margin.
• Current classification identifies benign, borderline and malignant(close to
sarcoma) phyllodes tumours.
• Overall, phyllodes tumours recur locally in approximately 20% of patients.
• For benign lesions, total excision with clear margins (≥1mm) is sufficient.
• For borderline and malignant lesions
a wider margin is recommended and
this may necessitate mastectomy.
• Very low potential invading lymph
node or metastasis
• Regional lymph node metastases are
seen rarely in malignant phyllodes
tumours. mostly due to local
invasion
• Metastatic spread, when it occurs, is
similar in pattern to that of
sarcomas.(malignant)
Hamartoma
• Hamartomas are common benign breast lesions and are composed of
variable amounts of adipose, glandular and fibrous tissues. Can be
only differentiated by core needle biopsy
• They are usually asymptomatic but may be palpable.
• Most occur in women over 35.
• Management is similar to that of fibroadenomas.
Macromastia huge breast
• Macromastia is the excessive development
of the breasts.
• This tends to occur during puberty (juvenile
hypertrophy) or with onset of lactation
(gestational).
• Significant psychological and physical
problems(neck pain, shoulder frozen pain,
kyphosis, back pain) can be caused by
macromastia and patients with significant
breast enlargement benefit from breast
reduction.
Size reduction surgery

Very useful technique

after mass excision
also
Discharges from the nipple

• Discharge can occur from one or more lactiferous ducts.

• Management depends on the presence of a lump (which should always be
given priority in diagnosis and treatment) and the presence of blood in the
discharge or discharge from a single duct.
• The important features to assess are whether the discharge is from a single
or multiple ducts, is coloured or bloodstained, is induced or spontaneous,
and is affecting one or both breasts. And also if there is any associated pain
or mass
• Cytology may reveal malignant cells but a negative result does not exclude
a carcinoma or in situ disease.
• The fluid that is physiologic can range in color
from white to yellow, to green, to brown, to blue-
black.
• About two-thirds of nonlactating women have a
small amount of fluid secreted from the nipple on
manual expression.
• The secretion usually is seen in multiple ducts.
• Nonspontaneous, bilateral, nonbloody secretion
that is physiologic requires no treatment.
• Duct ectasia and benign papillomas ,
infections, galctocele are the commonest
causes of nipple discharge in young women.
• Carcinoma is more common in older women.
• Age is an important predictor of malignancy
in a patients presenting with nipple discharge
as the only symptom.
• A blood-stained discharge may be caused by duct ectasia, a duct
papilloma or carcinoma.
• A duct papilloma is usually single and situated in one of the larger
lactiferous ducts. It is sometimes associated with a cystic swelling
beneath the areola.
• The evaluation of nipple discharge begins with a history, physical
exam, and breast imaging.
• Diagnostic ductography can be used for spontaneous unilateral single
duct nipple discharge.
• Treatment must firstly be to exclude a carcinoma by occult blood test
• In duct ectasia or papilloma Simple reassurance may then be sufficient
but, if the discharge is proving intolerable, an operation to remove the
affected duct or ducts can be performed.(Microdochectomy vs Total
major ducts excision)
• Galactorrhoea may be diagnosed if the discharge is copious, pale milky in
colour and from multiple ducts.
• Mostly bilateral but can be unilateral
• Some women continue to produce milk for many months after they have
stopped breastfeeding but galactorrhoea usually develops long after
cessation of breastfeeding Like 6 months
• Prolactin levels should be checked, If raised (>1000 mIU/L), the cause can
be secondary to medication or a pituitary tumour.
• If the serum prolactin is normal, then reassurance and a full explanation of
the aetiology (mostly galactocele) are often all that is required.
• Duct ectasia
• A benign dilatation and shortening of the terminal
ducts within 3cm of the nipple -< nipple retraction
• It is a common condition and increases in incidence
with age.
• Duct ectasia can present as nipple discharge, nipple
retraction (giving a slit-like appearance) or a palpable
mass.
• It is usually asymptomatic.
• The discharge is usually creamy and cheesy in nature.
• Bilateral multiduct green discharge is physiological
and not related to duct ectasia.
• Ultrasound or ductoscopy to confirm
• Asymptomatic duct ectasia requires no treatment.
• Antibiotics may be needed when there are signs of infection.
• Duct excision is recommended when nipple discharge is persistent
and troublesome and a periareolar abscess requires drainage.
• Lactation after total duct excision is very hard but seems to be not
affected after single duct excision
• Ductal papillomas : benign lesion originate from ducts
• Papilloma of the nipple has the same features as any cutaneous
papilloma and should be excised with a tiny disc of skin.
• There are three main forms: a solitary-duct discrete papilloma,
multiple papillomas or juvenile papillomatosis (Swiss cheese disease)
• A solitary intraductal papilloma, which occurs in a large duct (within
5cm of the nipple), is the commonest form and is the most common
aetiology of a bloody nipple discharge.
• They are most frequently seen in the 30–50 age group.
• Ductal papillomas are only associated with an increased risk of
malignancy if they contain areas of atypical hyperplasia (seen after
biopsy)
• Repeated excision of papillomas in patients with multiple intraductal
papillomas can result in significant breast asymmetry.
 Mastalgia
Mastalgia (breast pain)
• Most women at some point during their lives will suffer
from breast pain.
• True mastalgia is associated with swelling and nodularity
of the breasts.
• It resolves spontaneously in 20–40% of women but can
recur.
• Due to the hormonal aetiology, true breast pain is often
worse before and relieved after menstruation. Cyclical
(due to engorgement and fluid retention)
• Exacerbating factors include the perimenopausal state
(where hormone levels fluctuate) and the use of
exogenous hormones (hormone replacement therapy or
the oral contraceptive pill)
• Noncyclical : due to musculoskeletal , bra due to
compression.
• A full history and examination should be performed.
• The patient should be rolled and the underlying chest wall – often the
site of the pain – palpated.
• In women over 40 years of age, mammography should be performed
to exclude an occult malignancy.
• If a dominant lump or lumpiness is palpable, then this will dictate
further management.
• The mainstay of treatment is reassurance
that there is no serious underlying cause
for the pain.
• Analgesia, a soft supporting bra 24
hours a day and gentle stretching
exercises such as swimming are
effective treatments.
• Evening primrose oil (EPO) for 3
months may has some benefit.
• In severe chronic pain the best option is
Tamoxfin
 Breast cysts

• Palpable breast cysts are a common presentation to a breast clinic.

• Small cysts have no significance except their potential to grow.
• Larger cysts present typically in the fifth decade and are usually
multiple in nature.
• Ultrasound is essential in diagnosis and treatment.
• Not only does ultrasound distinguish between solid and cystic lesions,
it also provides information on the cyst wall and fluid consistency.
• A simple cyst has a smooth outline with no internal echoes and
posterior enhancement.
• Complex (or complicated or atypical) cysts are characterised by
internal echoes or thin septations, thickened and/or irregular wall, and
absent posterior enhancement. (harder to aspirate)
• Complex cysts are rarely malignant and require aspiration or review
with a follow-up scan several months later.
• Asymptomatic cysts should be left alone. No need for treatment
• Large, symptomatic or painful cysts should be aspirated to dryness.
• If the fluid is bloodstained or debris it should be sent for cytology;
otherwise it should be discarded.
• If a palpable mass is still present after aspiration, further imaging and
biopsy are indicated.
• If the cyst recurs, then repeat aspiration can be performed.
• There is a slightly increased relative risk of developing breast cancer
in women with cysts but this is not significant enough to warrant
surveillance
• Thank you