Patologia Benigna Mama

17
Benign breast disease
Steven Thrush
J. Michael Dixon
Introduction Supernumerary nipples and

accessory breast tissue
Over 90% of patients presenting to a breast clinic
have normal breasts or benign breast disease.1 Accessory breast tissue is usually found in the ax-
An understanding of the aetiology, symptoms illa and supernumerary or accessory nipples are
and management will ensure correct treatment usually seen below the breast and above the um-
and patient satisfaction. The expectation that the bilicus. Accessory nipples vary and are usually just
breast surgeon's role is simply to diagnose or ex- rudimentary but can include glandular tissue (acces-
clude breast cancer has long disappeared. Benign sory breast). Accessory nipples in the bra line can be
breast disease causes considerable morbidity and excised if they cause irritation.
anxiety, and with increasing patient awareness Accessory breast tissue tends to become more
and expectations, the number of such patients at- prominent or obvious during pregnancy (Fig. 17.1).
tending clinics is increasing. Effective treatment Reassurance and an explanation of the cause of the
includes accurate diagnosis followed by adequate ‘lump’ are usually all that is required. Surgical exci-
explanation of the condition, provision of relevant sion should be reserved for those truly symptom-
information related to the diagnosis and how it is atic, as they are difficult to excise cosmetically and
best managed. This is a rewarding part of a breast surgery is associated with significant morbidity.2
specialist's workload. Liposuction during excision helps define the planes
Benign breast disease can be divided into congeni- between the accessory breast and the fascia of the
tal abnormalities, aberrations of normal breast de- axilla. As with normal breast tissue, both benign
velopment and involution (ANDI) and conditions and malignant conditions can develop within acces-
secondary to some extrinsic precipitatory factors sory breast tissue.3
(non-ANDI).
Congenital abnormalities Breast hypoplasia

Although not diseases as such, developmental ab- This is failure of one or both (rarely) breasts to develop
normalities of the breast can cause considerable fully and can be congenital or acquired. Genetic causes
concern and are not uncommon reasons for referral include Poland's syndrome and ulnar–mammary
to a breast clinic. syndrome. Poland's syndrome is a group of conditions
268
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breasts. A pedicled or free myocutaneous flap,

with or without an implant, can be used to recon-
struct any muscle defect and produce symmetry in
cases of severe hypoplasia or aplasia. Fat transfer
(lipofilling) has also been described as a technique
to correct or aid correction of breast hypoplasia
either alone or combined with a breast implant.5,6
Hypoplasia can also be associated with tubular
or tuberous breasts. This deformity can affect one
or both breasts and the breast shape is caused by a
constricting ring at the base of the breast, limiting
vertical and horizontal growth. The surgical man-
agement of this group of conditions is challenging
Figure 17.1 • Bilateral accessory breasts in axilla. and often unsatisfactory. Tissue expansion com-
bined with radial incisions on the deep aspect of
associated with the absence of hypoplasia of the pec- the breast to divide the constricting ring usually
toralis major muscle, the chest wall and varying de- improves contour. The large nipple–areola com-
grees of syndactyly.4 It is rare and usually only partial plex may need to be reduced in size. Lipofilling is
in nature. It is more common in men than in women. being used increasingly in such patients.6
Acquired abnormalities in breast development can be Macromastia is the excessive development of the
caused by iatrogenic trauma or radiotherapy. breasts. This tends to occur during puberty (juve-
Treatment of hypoplasia and Poland's syndrome nile hypertrophy) or with onset of lactation (gesta-
depends on the degree of deformity. Mild asym- tional). Prepubertal breast enlargement may occur
metry is a common problem and usually only re- very rarely in conjunction with a hormone-secreting
assurance is needed. If the asymmetry is marked, tumour. Juvenile hypertrophy results from exces-
augmentation of the smaller breast with or with- sive proliferation of ducts and stromal tissue but
out tissue expansion and/or reduction or aug- no lobule formation. Significant psychological and
mentation of the opposite breast may be required physical problems can be caused by macromastia
(Fig. 17.2). Tissue expansion is often required as and patients with significant breast enlargement
there are differing amounts of skin on the two benefit from breast reduction. This procedure is not
Figure 17.2 • Hypoplasia pre- and post-surgery with expansion followed by implant.
269
Chapter 17
ithout complications and should be performed by
w
an appropriately trained surgeon.7
Aberrations of normal breast

development and involution
Defining what represents breast disease and what is
normal is not a new problem. The ANDI classifica- Figure 17.3 • Fibroadenoma.
tion8 was developed to provide a framework to help
understanding of the pathogenesis and subsequent
management of benign breast disease. Most benign
diseases arise from normal physiological processes regular cytology. Phyllodes tumours may or may
and range from normality to mild abnormality (ab- not arise from fibroadenomas but contain stroma
erration) to severe abnormality (disease). The breast with much more marked cellularity and atypia.
passes through phases related to the levels of circu- Although phyllodes tumours cannot always be dif-
lating hormones and their effects on the ducts, lob- ferentiated on core biopsy with 100% certainty
ule and stroma. The phases are breast development, from fibroadenomas, it is usually possible to tell
cyclical change and involution (Table 17.1). whether phyllodes is likely and when the lesion is
a simple fibroadenoma. All discrete masses over
the age of 23 should have a core biopsy – multiple
Fibroadenomas
passes with three samples of the lesion. Although
A fibroadenoma is classified as an aberration of ultrasound can usually differentiate fibroadenomas
normal breast development and is made up of a from cancers and guidelines indicate ultrasound is
combination of connective tissue and proliferatory safe under 25, experience from medicolegal prac-
epithelium (Fig. 17.3).9 It is not a neoplasm or be- tice indicates the cut-off should be younger at 24
nign tumour as it does not arise from a single cell. or below.
Fibroadenomas arise from the hormone-dependent
terminal duct lobular unit and are influenced by Simple fibroadenomas
hormones, e.g. increasing in size during pregnancy. These are benign, extremely mobile, discrete, rub-
The stromal element of these tumours defines their bery masses that present symptomatically in young
classification and behaviour. A ‘simple’ fibro- women or are an incidental finding during breast im-
adenoma contains stroma of low cellularity and aging. They are a ‘frequent’ condition and are seen
most commonly at the time of greatest lobular devel-
opment in the late teens and early twenties. They are
Table 17.1 • Aberrations of normal breast development usually solitary findings but some women develop
and involution multiple lesions in one or both breasts. The aetiology
is unknown but has been linked to the oral contracep-
Age (years) Normal process Aberration tive and Epstein–Barr virus following immunosup-
<25 Breast development pression. They are highly mobile due to encapsulation
Stromal Juvenile and pliability of the breast tissue. This can make them
hypertrophy appear to be much more superficial on examination
Lobular Fibroadenoma than their true position, important to appreciate
25–40 Cyclical activity Cyclical mastalgia when embarking on removal under local anaesthetic.
Cyclical nodularity
(diffuse or focal) Fibroadenomas were observed for 2 years in
35–55 Involution women under 40 years of age: the majority did not
change in size (55%), some got smaller or resolved
Lobular Macrocysts (37%) and only a small number increased in size
Stromal Sclerosing lesions (8%), the majority of which were in women under
Ductal Duct ectasia the age of 20.10
270
In older women (>23 years of age) it is clearly es- Excision should be performed through a cosmeti-
sential to differentiate a fibroadenoma from breast cally placed incision, which includes a submammary,
cancer by triple assessment including core biopsy. axillary and circumareolar incision. Another option
Rapid growth of a fibroadenoma is rare but can is to remove fibroadenomas with a mammotome.13
occur in either adolescence (juvenile fibroadenoma) With larger lesions (>5 cm where histology has
or in the perimenopausal age group (Fig. 17.4). shown no suggestion that it could be a phyllodes
Tumours over 5 cm are termed ‘giant fibroadenoma’ tumour), it is safe to section the tumour in situ and
and are seen more commonly in African countries.11 remove it through a small incision below the breast
On macroscopic appearance fibroadenomas are dis- to improve cosmetic outcome. Large lesions are best
crete, bosselated, whitish tumours that appear to be removed cosmetically through an inframammary
bulge when cut through. Only rarely does cancer incision. Removal of excess skin is rarely required in
develop within a fibroadenoma but when it does it young women, particularly when removing a large
tends to be non-invasive and lobular in nature.12 juvenile fibroadenoma (Fig. 17.4). In some very large
lesions later revisional surgery is required but it is
Management
important to leave this for up to a year after the
The management of fibroadenomas depends on the
initial excision as skin retracts and the breast re-
patients' age and preference as well as the results
shapes itself over this period. Recurrence of a fibro-
of triple assessment. Core biopsy (multiple cores) is
adenoma can occasionally occur but is rare and it
now preferred to cytology to confirm the d iagnosis
may be due to undiagnosed adjacent lesions rather
of a fibroadenoma. In patients with lesions under
than incomplete excision.
4 cm, where histology confirms the diagnosis, the
patient can then be reassured and discharged. In
Tubular and lactating adenomas
women presenting with multiple clinical and ra-
A fibroadenoma consists of fibroconnective stroma
diological fibroadenomata, core biopsy should be
containing glandular structures. The glandular el-
undertaken of the largest lesions – either one from
ement is lined by a single or multiple layers of epi-
both breasts or two from the same breast.
thelial cells. When the entire lesion consists of glands
Excision is rarely indicated unless the fibroadenoma
with very little intervening stroma, this is termed a
is obviously symptomatic, it increases significantly in
tubular adenoma. Lactating adenomas are similar
size or causes significant distortion of the breast pro-
to tubular adenomas, but occur in the pregnant or
file. Lesions measuring over 4 cm in size are usually
lactating breast and are often multiple. Tubular ad-
removed, as should those with histological concern
enomas in non-pregnant women are clinically simi-
about stromal activity. Large fibroadenomas can be ob-
lar to fibroadenomas and are managed identically.
served providing they have been adequately sampled.
Mammographically punctuate microcalcification
Although it is important to take account of the wishes
within the acini may be visible. Lactating adenomas
of the patient when considering surgery, these are influ-
can be managed conservatively once a diagnosis has
enced by the manner in which the facts are presented.
been established through breastfeeding unless there is
All patients should be given written information,
clinical concern. They tend to regress following cessa-
which is available online from Breast Cancer Care.
tion of breastfeeding.
Hamartoma
Hamartomas are common benign breast lesions
and are composed of variable amounts of adipose,
glandular and fibrous tissues. They are usually
asymptomatic but may be palpable and feel like

soft fibroadenomas. Most occur in women over 35.
Mammographically they usually have a classical
appearance (circumscribed area consisting of both
soft tissue and lipomatous elements, surrounded
by a thin radiolucent zone). They also differ sub-
Figure 17.4 • Juvenile fibroadenoma right breast. tly on ultrasound and are often misdiagnosed as
271
Chapter 17
fibroadenomas. Management is similar to that of depending on the exact criteria used for classifica-
fibroadenomas. It is important when performing a tion. Treatment of metastatic disease is discourag-
core biopsy of a possible hamartoma to inform the ing, with no sustained remissions reported from
pathologist that the lesion may be a hamartoma as radiation, hormonal treatment or chemotherapy.
otherwise they are often reported as normal breast
tissue on core biopsy.
Nipple discharge
Phyllodes tumour and sarcoma
Nipple discharge accounts for 5% of referrals to a
The aetiology of phyllodes (leaf-like) tumours is un-
breast clinic,16 with up to 20% of these caused by in
known. They are less common than fibroadenomas
situ or malignant disease.17 The important features
(ratio of presentation 1:4014) and constitute about
to assess are whether the discharge is from a sin-
2.5% of all fibroepithelial tumours. The age of on-
gle or multiple ducts, is coloured or bloodstained,
set is 15–20 years later than fibroadenomas. They
is induced or spontaneous, and is affecting one or
can grow rapidly, sometimes producing marked dis-
both breasts. The frequency, colour and consistency
tortion and cutaneous venous engorgement, which
of the discharge should be noted. Blood-coloured
occasionally can lead to ulceration. The majority
discharge or discharge that contains significant
are benign in nature and feel like large fibroadeno-
amounts of blood on testing has been reported by
mas, and are diagnosed only following core biopsy.
some but not all authors to be more likely to arise
They are rarely fixed to skin or muscle. When cut
from a cancer than coloured discharge that contains
during removal they are more brownish in colour
no blood on testing.18 The sensitivity and specificity
than fibroadenomas and can have areas of necro-
of blood in the discharge is, however, not high.
sis within. Most diagnoses of phyllodes tumour are
Persistent discharge (≥2 per week) is also more
made before operation, on core biopsy, and the aim
likely to be associated with a significant causative
of surgery should be to remove the lesion with a
lesion (such as a papilloma or cancer). The aim is to
clear macroscopic margin.
differentiate between physiological causes and duc-
Differentiating benign from malignant phyllodes
tal pathology (Fig. 17.5). Discharge can be elicited
can be difficult and involves assessment of the size,
by squeezing around the nipple in 20% of women19
ratio of stroma and epithelium, the border of the le-
and is often noted following mammography. If dis-
sion, stromal cellularity and the number of stromal
charge is associated with a lump, then management
mitoses, and the presence or absence of necrosis.
is directed to the diagnosis of the lump.
Current classification identifies benign, borderline
and malignant phyllodes tumours.
Overall, phyllodes tumours recur locally in ap-
proximately 20% of patients. Most locally re-
current tumours are histologically similar to the
original lesions but occasionally benign phyllodes
recur as borderline lesions. Malignant phyllodes tu-
mours recur earlier on average than benign lesions.
For benign lesions, total excision with clear margins
(≥1 mm) is sufficient.15 For borderline and malig-
nant lesions a wider margin is recommended and
this may necessitate mastectomy with or without a
myocutaneous flap for skin cover or breast recon-
struction in large lesions. Regional lymph node
metastases are seen rarely in malignant phyllodes tu-
mours, with nodes being affected in approximately
5%. Metastatic spread, when it occurs, is similar in
pattern to that of sarcomas. Fewer than 5% of all Figure 17.5 • Multiduct physiological discharge. Note
phyllodes tumours metastasise and approximately the range of colours characteristic of physiological
25% of those classified as malignant metastasise, discharge.
272
Galactorrhoea should only be diagnosed if the dis- A number of techniques have evolved to deter-
charge is bilateral, copious, pale milky in colour and mine the aetiology and avoid unnecessary surgery.
from multiple ducts. Some women continue to pro- Ductoscopy, using a microendoscope passed into the
duce milk for many months after they have stopped offending duct, allows direct visualisation. There are
breastfeeding but galactorrhoea usually develops encouraging reports of its use (see Chapter 3), espe-
long after cessation of breastfeeding. Prolactin cially in directing duct excision at surgery23 and de-
levels should be checked and, if raised (>1000 tecting deeper lesions that may be missed by blind
mIU/L), the cause can be secondary to medication or central excision.24 Ductal lavage is a technique in
a pituitary tumour. If the serum prolactin is normal, which the duct is cannulated, irrigated with saline
then reassurance and a full explanation of the aetiol- and the subsequent discharge examined cytologically.
ogy are often all that is required. If there are persis- This technique increases cell yield by 100 times that
tent symptoms, the ducts underneath the nipple can of simple discharge cytology.25 Ductography (imaging
be ligated. of the ductal system) can identify intraductal lesions.
Coloured opalescent discharge, from multiple ducts, Although this investigation has only a 60% sensitivity
is common. It is usually physiological discharge. for malignancy, a filling defect or duct cut-off has a
In older women thick yellow discharge can result high positive predictive value for the presence of either
from duct ectasia. Serosanguineous and/or bloody a papilloma or a carcinoma.26,27 Ductography, how-
discharge from a single duct is more likely to be asso- ever, is a painful procedure and is not widely practised.
ciated with papillomas, epithelial hyperplasia, ductal At present, the major role of ductoscopy is as an
carcinoma in situ (DCIS) or an invasive carcinoma. adjunct to surgery; by using simple transillumina-
tion of the skin overlying the lesion during ductos-
Investigation copy, limited duct excision is possible. The role of
Assessment includes a careful breast examination to ductal lavage has been questioned due to large vari-
identify the presence or absence of a breast mass. ations in its sensitivity and specificity.28,29 During
Firm pressure applied around the areola can help to ductoscopy, visualised lesions can be biopsied and
identify the site of any dilated duct (pressure over a in one report 38 of 46 women with biopsy-proven
dilated duct will produce the discharge); this is help- papillomas were observed for 2 years with no re-
ful in defining where an incision should be made ported missed cancers.24 The role of ductoscopy
for any subsequent surgery. The nipple is squeezed in the assessment of nipple discharge is set to in-
with firm digital pressure and if fluid is expressed, crease as the quality of equipment improves and it
the site and character of the discharge are recorded. becomes more widely available. A benefit of both
Testing of the discharge for haemoglobin determines ductography and ductoscopy is that they allow
whether blood is present but this is of limited value, identification of the site of any lesion in younger
although bloodstained discharge is more likely to women, allowing localisation and excision of the
be associated with malignancy. Fewer than 20% causative lesion while retaining the ability to lactate
of patients who have a bloodstained discharge or (Fig. 17.6). A mammogram should be performed as
who have a discharge containing moderate or large part of the assessment of patients over 35 years of
amounts of blood have an underlying malignancy. age with a discharge. The sensitivity in this group
Age is said to be an important predictor of malig- of patients is low, at 57%.21 Digital mammography
nancy; in one series, 3% of patients younger than has been shown to have a greater pick-up rate than
40, 10% of patients between ages 40 and 60, and film mammography in women under 50 or with
32% of patients older than 60 years who presented dense breasts.30 Ultrasound can sometimes identify
with nipple discharge as their only symptom were papillomas and malignant lesions in the ducts close
found to have cancers.20 The absence of blood in to the nipple.31 Papillomas visualised on ultrasound
nipple discharge is not an absolute indication that can then be biopsied or removed using a vacuum-
the discharge is unrelated to an underlying malig- assisted core biopsy device.32
nancy, as demonstrated in a series of 108 patients If no abnormality is found on clinical or mam-
where the sensitivity of haemoccult testing was only mographic examination, patients are managed
50%. Nipple discharge cytology is of little use due according to whether the discharge is from a single
to its poor sensitivity.21,22 duct or multiple ducts (Fig. 17.6). Any patient with
273
Chapter 17
Investigations
Persistent spontaneous†
• Clinical examination Normal
nipple discharge
• Mammography
Abnormal
Single-duct Multiple-duct
discharge discharge
Investigate as for
mass lesion or Breast feeding Wishes to preserve Distressing No distressing
mammographic not an issue ability to breast feed symptoms symtoms
abnormality
Microdochectomy Consider ductoscopy Total duct

Reassurance
+/− total duct excision* or ductogram excision
*See indications section in total duct excision Localised duct

†
At least twice per week excision
Figure 17.6 • Investigation of nipple discharge.
spontaneous single-duct discharge should undergo hyperplasia, atypical hyperplasia and in situ carci-
surgery to determine the cause of the discharge if it is: noma. A solitary intraductal papilloma, which occurs
in a large duct (within 5 cm of the nipple), is the com-
• bloodstained or contains moderate to large
monest form and is the most common aetiology of
amounts of blood on testing;
a bloody nipple discharge. They are most frequently
• persistent (at least twice per week);
seen in the 30–50 age group and can be palpated in
• associated with a mass;
one-third of patients. As papillomas have a thin stalk,
• a new serosanguineous discharge in a
they have the potential to tort and necrose. Half of
postmenopausal woman.
women with papillomas have bloody discharge while
Aetiology the other half have a serous discharge.33
Duct ectasia Women with multiple intraductal papilloma syn-
This is benign dilatation and shortening of the ter- drome have many peripheral duct papillomas. There
minal ducts within 3 cm of the nipple. It is a com- has to be a minimum of five clearly separate papil-
mon condition and increases in incidence with age. lomas within a localised segment of breast tissue,
It should not be confused with periductal mastitis, usually in a peripheral location. These tend not to
which occurs in younger women and is secondary present as nipple discharge but as a palpable lump
to cigarette smoking. Duct ectasia can present as and usually occur at a younger age than single pap-
nipple discharge, nipple retraction (giving a slit- illomas. They are only associated with an increased
like appearance) or a palpable mass. It is usually risk of malignancy if they contain areas of atypical hy-
asymptomatic. The discharge is usually creamy and perplasia. Repeated excision of papillomas in patients
cheesy in nature. Bilateral multiduct green discharge with multiple intraductal papillomas can result in
is physiological and not related to duct ectasia. significant breast asymmetry. One option in such pa-
tients is to excise such lesions with a vacuum-assisted
Ductal papillomas core biopsy device. This provides sufficient material
There are three main forms: a solitary-duct discrete for the pathologist to assess that all excised lesions
papilloma, multiple papillomas or juvenile papilloma- are benign. Surgery to excise the affected duct system
tosis (Swiss cheese disease). Papillomas are character- with an oncoplastic procedure to reshape the breast
ised by formation of epithelial fronds that have both is preferential to mastectomy if biopsies show atypia.
the luminal epithelial and the outer myoepithelial Juvenile papillomatosis is a very rare condition
cell layers, supported by a fibrovascular stroma. The defined as severe ductal papillomatosis occurring in
epithelial component can be subject to a spectrum of young women <30 years old and usually presents as
morphological changes ranging from metaplasia to a painless, mobile mass (similar to fibroadenoma).
274
Treatment is by complete excision. Patients with this Nipple adenoma

condition (and their close family) may be at some Nipple adenomas present as a non-discrete, palpa-
increased risk of subsequent breast cancer, especially ble growth of the papilla of the nipple (see Fig. 17.7).
if the lesion is bilateral and there is significant family There may be nipple discoloration and contour
history. Close clinical surveillance is indicated. change noted. Nipple adenomas tend to cause ero-
sion of the nipple tip and commonly present as a
Ductal carcinoma in situ
bloody discharge from the surface of the nipple.
Bloody nipple discharge with or without the pres- They are benign in nature and definitive treatment
ence of Paget's disease constitutes one-third of all is complete excision. It is caused by ductal hyper-
symptomatic in situ patients.34 Only rarely does an plasia of the lactiferous ducts and is seen most com-
invasive cancer cause nipple discharge in the ab- monly in women of between 40 and 50 years of age.
sence of a clinical mass. In most series, ductal car-
cinoma in situ (DCIS) is responsible for less than Surgery
20% of unilateral single-duct nipple discharge.19 Microdochectomy
The diagnosis is often made only following surgical A single duct can be removed by microdochectomy.
excision of the affected duct. This is performed through either a radial incision or
preferably a circumareolar incision. Expression of
Bloody nipple discharge in pregnancy the discharge should not be performed until the pa-
Bilateral bloody nipple discharge detected either tient is in theatre and fully draped in order to provide
visibly or on testing during pregnancy or lactation the best chance of identifying the offending duct. The
is common. In 20% of women who develop nipple discharging duct is cannulated and either a lacrimal
discharge during pregnancy, blood is evident on probe placed or methylene blue injected and an inci-
testing. The likely cause is hypervascularity of de- sion made. The probe aids identification of the rel-
veloping breast tissue; provided that the discharge evant duct and dissection of this from surrounding
is multiductal and/or bilateral it is benign, resolves ducts/breast tissue. A length of at least 2–3 cm should
spontaneously and requires no specific treatment.35 be removed. The excised duct should be opened to
Figure 17.7 • Nipple adenomas.
275
Chapter 17
ensure a cause for the discharge is present and the referred pain describe the pain as unilateral, associ-
distal remnant inspected to ensure that the entire di- ated with activity and reproduced by pressure on the
lated duct has been excised. If the residual duct is chest wall. Non-steroidal anti-inflammatory drugs,
dilated, then it should be split, opened and inspected. either taken orally or applied topically, can relieve
Microdochectomy should not damage surrounding such symptoms. True mastalgia is associated with
normal ducts and allows subsequent breastfeeding. swelling and nodularity of the breasts. It resolves
If performing a duct excision directed by ductoscopy, spontaneously in 20–40% of women but can recur.
then having identified an abnormality in the duct, the Due to the hormonal aetiology, true breast pain
light is used to direct the surgical excision. Once the is often worse before and relieved after menstrua-
excision has been performed, the nipple should be tion. Exacerbating factors include the perimeno-
squeezed gently to ensure that the discharging duct pausal state (where hormone levels fluctuate) and
has been excised. the use of exogenous hormones (hormone replace-
ment therapy or the oral contraceptive pill). The
Total duct excision or division
cause of cyclical mastalgia is unknown but studies
In women of non-childbearing age, total duct exci-
have implicated excess production of prolactin,38
sion is an option for a single-duct discharge. Current
excess oestrogen,39 insufficient progesterone,40 or
evidence suggests that total duct excision is more
increased receptor sensitivity in breast tissue caused
likely to result in a specific diagnosis and less likely
by a raised ratio of saturated fatty acids to essential
to miss underlying malignancy than microdochec-
fatty acids.41
tomy.36 Total duct excision can also be used for
multiple-duct discharge if the discharge is copious Assessment
and affecting quality of life, and is often performed
A full history and examination should be performed.
for periductal mastitis. The operation involves divid-
The patient should be rolled and the underlying
ing all the ducts from the underside of the nipple
chest wall – often the site of the pain – palpated. In
and removing surrounding breast tissue to a depth of
women over 40 years of age, mammography should
2 cm behind the nipple–areola complex.37 A circum-
be performed to exclude an occult malignancy (ap-
areolar incision is used. Patients should be warned
proximately 5% of women with breast cancer com-
that there is a small risk of nipple tip necrosis (<1%),
plain of pain,14 while 2.7% of women presenting
reduced sensation (40%) and nipple inversion asso-
with pain as their main symptom are diagnosed
ciated with this operation. Patients undergoing sur-
with breast cancer42). If a dominant lump or lumpi-
gery for periductal mastitis require total removal of
ness is palpable, then this will dictate further man-
all ducts from behind the nipple; leaving even small
agement. Most breast pain, and this includes many
remnants of ducts predisposes to recurrence. Because
women with cyclical breast pain, arises in the chest
the lesions of periductal mastitis usually contain
wall. Analgesia, a firm bra worn 24 hours a day and
organisms, patients should receive appropriate sys-
gentle stretching exercises such as swimming are ef-
temic antibiotic treatment during the operation and
fective treatments.
for 5 days after surgery. Options for antibiotic ther-
apy include amoxicillin–clavulanate or a combina- Treatment
tion of erythromycin and metronidazole. Reassurance that the symptoms are not related to
For patients having cosmetic nipple eversion, the an underlying malignancy is the most effective treat-
procedure can be performed through a limited inci- ment for mastalgia.43 Following this, the majority
sion and the ducts divided, ensuring that the nipple will require no further treatment.
everts naturally without the need for sutures. Evening primrose oil (EPO) is not effective, as
two double-blind, randomised, crossover trials
Mastalgia comparing EPO versus placebo showed no benefit
for EPO.44,45 The original work that advocated its
Most women at some point during their lives will use has never been published other than in abstract
suffer from breast pain. The aim for clinicians is to form.46 Other agents that have been shown to have
differentiate between true mastalgia (pain originat- some benefit include phyto-oestrogens (e.g. soya
ing within the breast) and referred pain. Women with milk)47 and Agnus castus (a fruit extract).48
276
Reducing fat intake to less than 15% of dietary Bromocriptine should not be used, due to its high
calories has been shown to improve symptoms in rate of adverse effects (80%).56 Selective serotonin
cyclical mastalgia.49 The patients who responded reuptake inhibitors have been reported as being of
showed changes in their serum lipid profiles but the some benefit in mastalgia as part of premenstrual syn-
study was not blinded so placebo effects cannot be drome;57 they also have effects on fatty acid profiles.
excluded and the diet is not easy to adhere to in the
long term.
In severe pain, medication can be used but compli- Breast cysts
cations of these treatments need to be outlined to
the patient. Treatment should be either tamoxifen Palpable breast cysts are a common presentation to
10 mg daily or danazol. Tamoxifen 20 mg daily was a breast clinic and affect 7% of all women.14 Small
superior to placebo in a double-blind, randomised, cysts have no significance except their potential to
controlled trial and pain relief was maintained in grow. Larger cysts present typically in the fifth de-
72% of women 1 year after use.50 Tamoxifen cade and are usually multiple in nature. Cysts can
restricted to the luteal phase of the menstrual cycle be divided into apocrine and non-apocrine, depend-
abolished pain in 85% of women. Recurrent pain at ing on the consistency of the fluid found within the
1 year was seen in 25% and the rate of adverse cyst. The only relevance of this classification is that
effects was 21%.51 Tamoxifen 10 mg daily has fewer apocrine cysts have a higher tendency to recur.58
side-effects and is as effective as 20 mg when com-
pared with danazol 200 mg daily.52 Imaging
Mammographically, breast cysts have characteristic
Tamoxifen is superior to danazol, with haloes but ultrasound is essential to the management
fewer adverse effects: 53% of patients receiving of cystic disease. Not only does ultrasound distinguish
tamoxifen were pain free at 1 year compared with between solid and cystic lesions, it also provides infor-
37% of patients receiving danazol. Tamoxifen 10 mg mation on the cyst wall and fluid consistency. It is also
daily or danazol can be given only during the luteal
an adjunct in ensuring accurate differentiation of sim-
phase of the menstrual cycle and results in similar
improvements in symptoms, but with a marked ple from complex cysts, as well as allowing complete
reduction in adverse effects.51,53 aspiration. A simple cyst has a smooth outline with no
internal echoes and posterior enhancement. Complex
Tamoxifen is not licensed for use in mastalgia. (or complicated or atypical) cysts are characterised
Toremifene, another selective oestrogen receptor by internal echoes or thin septations, thickened and/
modulator, has also recently demonstrated its ef- or irregular wall, and absent posterior enhancement.
fectiveness in treating mastalgia. In a randomised, Complex cysts are rarely malignant and require aspi-
double-blind trial of 195 women with persistent
ration or review with a follow-up scan several months
(lasting longer than 6 months) mastalgia, they as- later. If the cyst wall shows any projections into the
signed patients to toremifene 30 mg daily or a centre of the cyst, this may indicate the presence of an
matched placebo for three menstrual cycles. This intracystic papilloma or carcinoma and core biopsy of
demonstrated a significant benefit for toremifene the projected area is indicated.
but with no significant difference in adverse events
between the two groups.54 Management
A phase II trial using afimoxifene (4-hydroxy- Asymptomatic cysts should be left alone. Large,
tamoxifen) delivered locally to the breast as a trans- symptomatic or painful cysts should be aspirated
dermal hydroalcoholic gel daily over four cycles to dryness. If the fluid is bloodstained it should be
has shown statistically significant improvements sent for cytology; otherwise it should be discarded.
in signs and symptoms of cyclical mastalgia across If a palpable mass is still present after aspiration,
patient- and physician-rated scales, with excellent further imaging and biopsy are indicated. If the cyst
tolerability and safety. There is strong evidence that recurs, then repeat aspiration can be performed.
this tamoxifen metabolite is absorbed into the breast There is a slightly increased relative risk of develop-
tissue but does not have the systemic effects associ- ing breast cancer in women with cysts but this is not
ated with tamoxifen.55 It is not used in the UK. significant enough to warrant surveillance.
277
Chapter 17
Sclerotic/fibrotic lesions explains the cause of any localised mass is unwise.

The histological appearance has caused confusion
Stromal involution can produce areas of fibro- with mammary angiosarcoma, so immunohisto-
sis within the breast supporting tissues. Three chemical vascular markers may be required to dis-
different groups of such lesions are described: tinguish these two conditions.
sclerosing adenosis, radial scars and complex
sclerosing lesions (CSLs). Sclerosing adenosis can
present with a palpable mass and breast pain. Fibromatosis
Mammographically, it can be associated with
microcalcificaton. It differs histologically from Fibromatosis or desmoid tumour of the breast is
radial scars and CSLs in the degree of excessive an extremely rare entity. Fibromatosis is an infil-
myoepithelial proliferation seen together with the trative fibroblastic and myofibroblastic prolifera-
fibrosis. Radial scars and CSLs are considered to tion with significant risk for local recurrence, but
be part of the same process but are differentiated no metastatic potential. Fibromatosis is uncom-
on size (radial scar, ≤1 cm; CSL, >1 cm). Radial mon in the mammary gland and accounts for less
scars and CSLs are usually asymptomatic and dis- than 0.2% of all primary breast lesions. It prob-
covered as part of mammographic screening but ably arises from the fascia of the underlying chest
can rarely present as a palpable mass. Both lesions wall muscles rather than on the breast tissue it-
may serve as a background for the development of self. It may be indistinguishable from malignancy
atypical epithelial proliferations, including atypi- on ultrasound, mammography, physical examina-
cal hyperplasia and carcinoma in situ. Even in the tion and on gross evaluation. Fibromatosis is a
absence of atypia there is some suggestion that the spectrum of conditions from extremely indolent
presence of such lesions increases the individual's areas principally of fibrosis to a more prolifera-
risk of malignancy.59 All these lesions, though be- tive infiltrative lesion. Establishing the diagnosis
nign in nature, are difficult to distinguish from can be difficult on core biopsy and larger vacuum-
malignancy mammographically, macroscopically assisted needle biopsies provide more tissue for
and histologically. Percutaneous biopsy of these the pathologist to assess. Open biopsy may be
lesions with a large-gauge vacuum-assisted core necessary if a diagnosis is not evident on needle
needle is reliable, providing there is no associ- biopsy. Once it is established that the diagnosis is
ated atypia, at least 12 cores are performed and fibromatosis (this may involve sending the biopsy
there is concordance with radiological findings.60 for an expert opinion), then the initial treatment
Malignancy cannot be excluded reliably when is observation only. If the lesion increases in size
there is limited sampling, the presence of atypia and becomes symptomatic, particularly if it infil-
or discordance with the radiological appearance trates the chest wall and encases the intercostal
of the lesion. Then open excision is recommended. nerves, when it can cause marked discomfort and
pain, then surgical excision should be considered.
If the lesion recurs and becomes symptomatic or
Pseudoangiomatous stromal the initial excision involves removal of portions
hyperplasia of the breast (PASH) of the chest wall, then surgery should aim to re-
move all the disease with a 1-cm clear margin.
PASH is a benign myofibroblastic proliferation of There is little evidence of a benefit of chemother-
non-specialised mammary stroma. It is frequently apy or radiotherapy in recurrent or incompletely
a microscopic incidental finding in breast biopsies excised disease. Tamoxifen has been reported
performed for benign or malignant disease. It has to be of benefit but these lesions are oestrogen
been reported to form breast masses and some of receptor (ER) alpha negative, although reports
these have been reported to be sizeable. Whether suggest they are ER beta rich. Symptomatic re-
PASH is the cause of these masses or an epiphenom- currence is an issue only for a small percentage
enon, for instance extensive PASH is seen commonly of patients with fibromatosis following excision
within a juvenile fibroadenoma, is not clear. The and is often evident because of nerve entrapment,
aetiology is not known and assuming that PASH which results in local pain.
278
Non-ANDI conditions been shown to inhibit growth of Gram-positive bac-

teria, leading to an overgrowth of Gram-negative
Breast infections bacteria.65 This may affect the normal bacterial
flora and allow overgrowth of pathogenic aerobic
Infection is a common problem affecting the and anaerobic Gram-negative bacteria, and would
breast,61 and can be divided into lactational, non- explain the presence of these organisms in the le-
lactational and postsurgical. The skin overlying the sions of periductal mastitis. Microvascular changes
breast can also become infected either primarily or have also been recorded and it could be that ciga-
secondarily because of infection developing in an rettes cause some local ischaemia. The view is that
existing lesion such as an epidermoid cyst or as a the combination of damage due to toxins, micro-
consequence of a generalised skin condition such as vascular damage by lipid peroxidases, and altered
hidradenitis suppurativa. bacterial flora produces the clinical manifestations
Lactational infections of periductal mastitis.
Mastitis secondary to breastfeeding occurs in ap- Patients present with periareolar inflammation often
proximately 5% of puerperal women and is most associated with a mass or abscess. The organisms caus-
common during the first month or during weaning ing this infection are usually mixed and include anaer-
as the baby's teeth develop. Staphylococcus aureus obes. Periareolar sepsis has a high rate of recurrence.
is the usual organism and it enters the duct system Peripheral non-lactational breast abscesses are three
through the nipple. There is usually a history of times more common in premenopausal women than
a cracked nipple and/or problems with milk flow. in menopausal or postmenopausal women. The ae-
Patients initially present with pain, localised ery- tiology of these infections is unclear but although it
thema and swelling. If this progresses, the inflam- was reported that these are commonly associated with
mation can affect large areas of the breast and the diabetes, rheumatoid arthritis, steroid treatment and
patient can become toxic. Promoting milk flow trauma, this is untrue.66 The usual organism respon-
by continuing to breastfeed and the early use of sible is S. aureus. Very rarely, an infection is related to
appropriate antibiotics markedly reduces the rate underlying comedo necrosis in DCIS. For this reason
of subsequent abscess formation. Infections devel- a mammogram should be performed in women over
oping within the first few weeks may result from 35 years of age after resolution of the inflammation.
organisms transmitted in hospital and may be re-
sistant to commonly used antibiotics. Over half
Postsurgical infection
Infections can present in the acute postsurgical period
of organisms that cause breast infection produce
or after the wound has healed. There was formerly
penicillinase.62 Co-amoxiclav or flucloxacillin and
conflicting evidence of the benefit of prophylactic an-
erythromycin are the antibiotics of preference.
tibiotics during clean breast surgery, although studies
Tetracycline, ciprofloxacin and chloramphenicol
have now shown a small but consistent benefit from a
should not be used to treat infection in breastfeed-
single perioperative dose of a broad-spectrum antibi-
ing women because these drugs enter breast milk
otic such as co-amoxiclav.67 The most common organ-
and may harm the child.
isms causing early infection include normal skin flora,
Non-lactational infections S. aureus or organisms derived from the terminal
Non-lactational infections are grouped into periph- ducts.68 Most surgeons give antibiotics routinely to
eral or periareolar. Those infections in the periare- patients having implants inserted. Patients having
olar area are seen in young women and are often surgery for periductal mastitis are at increased risk of
secondary to periductal mastitis (associated with postoperative infection and all these patients should
heavy cigarette smoking).63 Substances in cigarette have intraoperative and postoperative antibiotics that
smoke may directly or indirectly damage the wall cover the range of organisms isolated from this condi-
of subareolar ducts. Accumulation of toxic metabo- tion. ‘Seromas’ are frequent and can become infected
lites, such as lipid peroxidase, epoxides, nicotine following aspiration or as a result of reduced resis-
and cotinine in the breast ducts has been demon- tance to infection during chemotherapy. Radiotherapy
strated to occur in smokers within 15 minutes of a interferes with both the blood and lymphatic flow
woman starting to breastfeed.64 Smoking has also to the breast, and its effect is to increase rates of
279
Chapter 17
infection in the treated area; when infection occurs, that few if any breast abscesses require incision
prolonged and high-dose antibiotic therapy may be and drainage under general anaesthesia.75 All ab-
required in such pateints. Redness and oedema of scesses should be assessed by ultrasound and if
the breast following breast-conserving surgery are pus is present the surgeon or radiologist aspirates
not uncommon (especially after radiotherapy). This this, usually under ultrasound guidance (Figs 17.8
usually occurs between 3 and 12 months following and 17.9). Patients are reviewed every 2–3 days
surgery. This is unresponsive to antibiotics and has an and any further collections aspirated until no fur-
incidence of 3–5% in patients following radiotherapy ther pus forms. Drainage of pus by making a small
for breast-conserving surgery.69 It appears to be re- stab incision in the skin under local anaesthesia
lated to obstructed lymphatic flow and responds to is performed in patients where the overlying skin
manual lymphatic drainage. is thinned or necrotic (Fig. 17.10). The incision to
If an implant becomes infected, intensive antibi- drain any breast abscess should be just large enough
otic therapy is occasionally effective but usually the to allow the pus to drain (1 cm or less), which mini-
prosthesis has to be removed. Replacing an infected mises later scarring. Ultrasound provides a simple
implant following thorough lavage has been re- method for differentiating an abscess from celluli-
ported to be effective but is rarely performed.70 It is tis, allows assessment of any loculation, which is
not uncommon for implants to become infected after rare, and permits complete aspiration of all pus.
a minor surgical intervention (such as dental work) Experience in the Edinburgh Breast Unit of using
or during chemotherapy given as adjuvant therapy ultrasound to assist aspiration of breast abscesses is
or as treatment for metastatic disease. Prophylactic that it is quick and simple to learn and use. Local
antibiotics should be considered for patients with anaesthetic (1% lignocaine with 1:200 000 adrena-
implants undergoing major dental work. line) is injected into non-inflamed skin away from
the abscess and along the needle track and is then
Treatment
irrigated into the abscess cavity. Aspiration is then
The basis of treatment for all breast infections is
relatively painless and the local anaesthetic helps if
use of a broad-spectrum antibiotic and draining any
the pus is thick by diluting the pus to allow aspira-
collections of pus.
tion. Periareolar non-lactational abscesses can be
treated and cured by repeated aspiration. Due to
Due to the difficulty of predicting the presence
the recurrent nature of periareolar infection, recur-
of pus within an inflamed breast, ultrasound with or
without aspiration should be performed.71 The need
rent abscess formation is common and in such pa-
for open drainage in breast abscesses has been tients when all signs of acute infection have settled,
superseded by the use of aspiration.72–74 which takes at least 6 weeks, careful surgical exci-
sion of any residual abscess and affected ducts is
This has allowed management of breast infection often required. A mammary duct fistula (a connec-
to become outpatient based. Protocols validated tion between the infected and damaged duct and
within the Edinburgh Breast Unit have demonstrated the skin, usually at the edge of the areola) develops
a b
Figure 17.8 • Aspiration of abscesses under ultrasound guidance. (a) Ultrasound view of a breast abscess. (b) The
needle can be seen entering the abscess on the right, allowing aspiration to be performed.
280
a a
Figure 17.9 • (a) Lactating abscess: skin red but normal at presentation. (b) Lactating abscess following aspiration.
a b
Figure 17.10 • Abscess of the left breast with thinned overlying skin: (a) before incision; (b) after incision and drainage
through a small stab incision.
in up to one-third of patients after incision and circumareolar incision produces the best cosmetic
drainage of a periareolar abscess.76 Fistulas require outcome. Complete excision of the granulation tis-
definitive surgical management. Options include sue lined tract (plus the affected ducts under the
fistulotomy, cutting down on a probe into the fis- nipple) and primary closure requires antibiotic
tula and allowing healing by secondary intention, cover (Fig. 17.11). There is a high risk of recurrence
which is painful after surgery and produces an in the presence of postoperative wound infection.77
ugly scar, and fistula excision and primary closure. An important aspect of the management of puer-
Excising a fistula is easier through a radial scar, but peral breast infections is the continued expression of
281
Chapter 17
Figure 17.11 • Diagrammatic illustration of the steps involved in excision of a mammary duct fistula performed through
a circumareolar incision with primary wound closure under antibiotic cover.
milk, with the most efficient breast pump being the The most common species isolated was the newly de-
baby's mouth. Emptying the breast increases the rate scribed Corynebacterium kroppenstedtii, followed by
of a good outcome in infective mastitis78 and although Corynebacterium amycolatum and Corynebacterium
bacteria and the antibiotic are present in the milk, this tuberculostearicum. These organisms are, however,
does not appear to harm the child.79 It is rarely neces- sensitive to penicillin and tetracycline, and treatment
sary to suppress lactation but in severe unremitting or with these antibiotics does not produce resolution
repeated infections, the prolactin antagonist cabergo- of granulomatous lobular mastitis so it is unlikely
line is effective at stopping milk flow. that these organisms have a major role. In patients
It is essential to remember that inflammatory car- diagnosed as having granulomatous lobular masti-
cinoma can be difficult to differentiate from breast tis on core biopsy, excision of the mass should be
infection. If the inflammatory mass does not settle avoided, as it is often followed by persistent wound
on appropriate management, then core biopsy of discharge and failure of the wound to heal. Steroids
any abnormal area should be considered. and other immunosuppressive agents have been used
with varying reports of their efficacy.82 There is no
convincing evidence that steroids alter the course
Other infections of this condition. They do improve symptoms dur-
ing administration of high doses but the condition
Granulomatous mastitis then worsens when the dose is reduced. Reports of
This is a rare condition, characterised by non- the benefit of injecting depot steroid are emerging.
caseating granulomas and microabcesses confined to a We no longer use steroids in this condition. It re-
breast lobule.80 Patients present with a firm irregular solves spontaneously over a period of 6–18 months.
mass (which is often indistinguishable from a carci- Treatment is supportive and is aimed at treating as-
noma) or multiple or recurrent abscesses (Fig. 17.12). sociated infection and abscesses.
The mass can be extremely tender. Young parous
women are most frequently affected and there is Hidradenitis suppurativa
no association with smoking. The role of organ- Hidradenitis is a condition affecting the apocrine
isms in the aetiology of this condition is unclear but glands of the skin, including the axillae, perineum and/
one study did isolate corynebacteria from nine of or breast areas. It is much commoner in smokers and
12 women with granulomatous lobular mastitis.81 the organisms responsible are similar to those present
282
Figure 17.12 • Granulomatous lobular mastitis in its various presentations with skin changes, a mass and abscesses.
in periareolar sepsis. Treatment in the acute phase com- can feel similar on palpation and appear similar on
prises management of any infection/abscesses by ap- imaging to a breast carcinoma or a cystic oily collec-
propriate antibiotics and aspiration or drainage of any tion. Patients usually give a history of direct trauma
abscess. Excision of the affected area with skin graft- (or surgery) to the affected breast and examination
ing has been reported to be effective in approximately may reveal bruising. It is important to assess such
50% of patients and may be the only long-term option patients with imaging and not dismiss dimpling and
for some patients. Smoking cessation is also beneficial. bruising as fat necrosis. Histologically, fat necrosis
is characterised by anucleate fat cells, surrounded
by histiocytic giant cells and foamy macrophages.
Miscellaneous benign lesions Severe fat necrosis can follow seat-belt damage and
such patients often have a significant defect in the
Montgomery's gland problems breast with significant distortion at the site where
Throughout the areola are blind-ending glands that the seat-belt has disrupted a significant area of
produce fluid to lubricate the areola during breast- breast fat.
feeding. These glands can become blocked, form-
ing hard nodules on the periphery of the areola.
Occasionally these can become infected. Unless
Lipomas
symptomatic, the management of these prominent
Due to the fatty nature of the breast it is not surpris-
Montgomery's glands is reassurance.
ing that lipomas are common. They tend to present
in the fifth decade14 and have to be distinguished
Fat necrosis from any sinister cause. Imaging shows a radiolu-
cent lobulated mass. Fine-needle aspiration is often
Following trauma to the breast, fat necrosis can reported as inadequate (C1) due to fat only being
occur. Fat necrosis can produce either a mass that aspirated and is not recommended. A pseudolipoma
283
Chapter 17
is a mass that clinically appears to be a simple li- with a spontaneous haematoma. Breast h aematoma
poma but is actually caused by a small cancer that can also occur spontaneously in patients on antico-
produces compressed fat lobules as the suspensory agulant therapy.
ligaments of the breast shorten. Liposarcomas occur
only very rarely in the breast.83 Larger or symptom-
atic lipomas can be excised. Some of the larger lipo- Para areola cysts
mas develop deep in the fascia overlying the chest
wall muscles. These cysts are rare and occur in pubertal and post-
pubertal teenagers (11–16 years), presenting as dis-
crete superficial cystic masses at the areola margin;
Granular cell tumours occasionally they become infected. They can be
interpreted as solid on ultrasonography because
This is an uncommon, usually benign neoplasm that of numerous internal echoes. Diagnosis and treat-
originates from Schwann cells of peripheral nerves ment can be by aspiration, although if they cause
in the breast. About 6% of all granular cell tumours no symptoms and ultrasonography shows a cystic
involve the breast. The mean age at diagnosis is lesion, no intervention is required as they disappear
40 years. Clinically and on imaging they are dif- with time.
ficult to differentiate from a breast carcinoma due
to their fibrous consistency, fixation to the pectoral
fascia and skin retraction. Granular cell tumours Mondor's disease
are usually benign but there have been reports of
malignant cases. Treatment is by local excision, en- Mondor's disease is spontaneous superficial throm-
suring a narrow clear margin to prevent recurrence. bophlebitis of a breast vein. It is often initially painful
and often there may be a history of trauma or sur-
gery to the breast. Clinically, there may be a thick-
Diabetic mastopathy ened palpable cord with associated erythema. Its
aetiology in the absence of surgery, trauma or infec-
This is a form of sclerosis occurring in premeno- tion is unknown. It is a self-limiting condition that
pausal women, and occasionally men, with long- normally resolves within a couple of weeks but can
standing type I diabetes, often associated with other be very painful. Non-steroidal anti-inflammatory
diabetic complications, particularly retinopathy. agents massaged over the area of tenderness im-
It can result clinically in one or more hard masses prove the pain. Mondor's disease most commonly
within the breast that have features making it in- involves one or more of three venous channels:
distinguishable clinically from malignancy, but on the thoracoepigastric vein, the lateral thoracic
histology the findings are of sclerosing lymphocytic vein and the superior epigastric vein. The upper,
lobulitis or ‘diabetic mastopathy’. The disease prob- inner portion of the breast is never involved.
ably represents an immune reaction to the abnormal
accumulation of altered extracellular matrix in the
breast, which is a manifestation of the effects of hy- Gynaecomastia
perglycaemia on connective tissue. It does not seem
to predispose to breast carcinoma or lymphoma and True gynaecomastia is caused by hyperplasia of the
in patients without diabetes it is not clear why some stromal and ductal tissue of the male breast. It is
get it and others do not.84 responsible for considerable embarrassment and
worry and is the commonest condition affecting the
male breast (Fig. 17.13). Pseudogynaecomastia gives
Haematomas a similar appearance but is due to excess adipose
tissue with no increase in stromal or ductal tissue.
These most commonly follow trauma such as a road Both types can present together.85 Gynaecomastia
traffic incident, but can occur after core biopsy, fine- associated with Klinefelter syndrome is associated
needle aspiration or open biopsy. In extremely un- with actual lobule formation and a risk of breast
usual circumstances a breast carcinoma may present cancer approaching that of the female population.
284
Box 17.1 • Pathological causes of gynaecomastia
Decreased androgens
Reduced production
• Chromosomal abnormalities, e.g. Klinefelter's syndrome
• Bilateral cryptorchidism
• Hyperprolactinaemia
• Bilateral torsion
• Viral orchitis
• Renal failure
Androgen resistance
Figure 17.13 • Bilateral senescent gynaecomastia. • Testicular feminisation
Increased oestrogens
Gynaecomastia can occur from any age and pres-
Increased secretion
ents as a concentric painful swelling. It is a common
• Testicular tumours
condition, occurring in at least 35% of men at some • Carcinoma of the lung
time in their life. It is benign and usually reversible.
Increased peripheral aromatisation
An important differential diagnosis is a primary • Liver disease
breast cancer but breast cancers present with eccen- • Adrenal disease
tric masses that are usually painless. • Thyrotoxicosis
The aetiology of gynaecomastia is due to a relative
hyperoestrogenism.86 This is caused by decreased
androgen production, increased oestrogen produc-
tion or an increase in peripheral aromatisation. In
patients where no endocrine abnormality or drug usually elicit the underlying cause. Examination
is found, the cause may be a reduction in andro- of breast, axilla, testes and abdomen should be
gen receptors and/or a local increase in aromatase performed.
activity.87 Causes can be divided into physiologi- Investigations of gynaecomastia are directed to ex-
cal, pathological, drug induced (medicinal and rec- cluding a primary breast carcinoma or a secondary
reational) and idiopathic. Excess intake of beer or pathological cause. Biochemical assessment (liver
lager can result in gynaecomastia as a consequence and renal function tests, γ-glutamyltransferase,
of the phyto-oestrogens present in these drinks. prolactin, α-fetoprotein, β-human chorionic
A combination of regular cannabis use and drinking gonadotrophin and total testosterone) is only re-
large volumes of lager is particularly potent at caus- quired in rapidly growing gynaecomastia. Imaging
ing gynaecomastia. (with mammography and/or ultrasound) plus
biopsy (fine-needle aspiration cytology and/or core
1. Physiological, or primary, gynaecomastia shows biopsy) can be performed if the cause of the gyn-
a trimodal pattern, with peaks in the neonatal aecomastia is indeterminate, or if surgery is being
period, puberty and senescence. It is often self- considered or cancer is suspected.
limiting but will occasionally require treatment.
2. Pathological causes are listed in Box 17.1. Treatment
3. Common drugs that produce gynaecomastia in-
Reassurance of the transient and benign nature
clude: spironolactone (antiandrogen); histamine
is often all that is required in the management of
H2 antagonists, antipsychotics and methyldopa
potential gynaecomastia. More than 80% resolve
(gonadotrophin disturbance); digoxin, cannabis
within 2 years without any treatment. In drug-
and griseofulvin (oestrogen receptor competi-
related gynaecomastia, withdrawal of the drug
tors); and anabolic steroids (Box 17.2). HIV
or change to an alternative should be considered.
treatment with highly active anti-retrovirals is
For pathological gynaecomastia, the underlying
also commonly associated.
cause needs to be addressed.
The degree of gynaecomastia is classified using For those cases requiring treatment there are two
appearance (Table 17.2). A thorough history will options: medical treatment and surgical excision.
285
Chapter 17
Medical management benefits from a high success Table 17.2 • Classification of gynaecomastia
rate and avoidance of an operation.
Grade Clinical appearance
The evidence for the three commonly prescribed I Small but visible breast
drugs (danazol,88 tamoxifen89 and clomifene90) is development with little
based on small non-randomised trials and does not redundant skin
include recurrence rates, optimum dose, length of IIa Moderate breast
treatment or associated long-term risks. Tamoxifen development with no
at a dose of 10 mg is the agent of choice.
redundant skin
IIb Moderate breast
In the UK, danazol is the only drug licensed for
development with redundant
the treatment of gynaecomastia. A short 6-week
skin
course is recommended, with 100 mg b.d. for the
III Marked breast development
with much redundant skin
From Simon BE, Hoffman S, Kahn S. Classification and
Box 17.2 • Drugs associated with gynaecomastia surgical correction of gynecomastia. Plast Reconstr Surg 1973;
51:48–52.105 With permission from Lippincott, Williams & Wilkins.
Hormones © American Society of Plastic Surgeons.
• Anabolic steroids (bodybuilders)
• Oestrogenic agonists
• Antiandrogens (treatment of prostate cancer),
first week followed by 100 mg t.d.s. for the sec-
e.g. cyproterone acetate, goserelin
ond to sixth weeks, response being assessed at the
Recreational drugs
eighth week. Imaging and clinical photography can
• Alcohol
be used to evaluate success of treatment. Repeat
• Cannabis
courses may be required. Tamoxifen at a daily dose
• Heroin
of 10 mg produces excellent response rates and is
Cardiovascular drugs
the drug we use in the limited number of patients
• Digoxin
we treate with medication.
• Spironolactone
• Captopril Due to the high risk of poor cosmesis associated
• Enalapril with gynaecomastia surgery and subsequent risk of
• Amiodarone litigation, operation should only be considered after
• Nefedipine medical failure or where the gynaecomastia is large
• Verapamil (class IIa/III). Marking the extent of the gynaeco-
Antiulcer drugs mastia prior to surgery is essential. Patients with
• Cimetidine limited gynaecomastia can have excision performed
• Ranitidine through a periareolar incision to reduce scarring.
• Omeprazole The use of lighted retractors and diathermy aids
Antibiotics surgery. A disc of breast tissue should be left be-
• Ketoconazole hind the nipple combined with an intact pectoral
• Metronidazole fascia and overlying fat to prevent retraction and
• Minocycline fixation to the muscle (saucer deformity). Skin
Psychoactive agents flaps are kept thick to prevent deformity and skin
• Tricylic antidepressants necrosis. Patients should be warned about nipple
• Diazepam necrosis, sensory changes and recurrence, as well
• Phenothiazines as cosmetic problems. In larger cases excess skin is
Others removed, requiring repositioning of the nipple and
• Domperidone even free nipple grafts.91 In young patients, excess
• Metoclopramide skin often corrects itself without need for excision.
• Penicillamine The use of liposuction alone or combined with lim-
• Phenytoin
ited surgery or mammotomy improves cosmetic
• Theophylline
outcomes. Ultrasound-assisted liposuction allows
286
Small to moderate Moderate to large

breast breast
Firm subcutaneous Consider skin

nodule only excision
Liposuction Liposuction
Residual Residual
lump lump
Open excision Open excision
Redundant
skin
Skin reduction
Figure 17.14 • Algorithm for management of gynaecomastia.
treatment of more fibrous areas and increases the should also be recorded. Examination will show
number of patients suitable for this technique.92 An if any breast reductions or mastopexy (breast lift)
approach to management including liposuction is have been performed. In the patient who has under-
outlined in Fig. 17.14.93 In those for whom surgery gone a reduction mammaplasty it is useful to know
has produced an unsatisfactory cosmetic result, fur- the approximate volume reduction and whether
ther liposuction and lipofilling can be effective in there were wound healing problems.
achieving a satisfactory final result. Imaging of breasts post-cosmetic surgery can pose
technical challenges. Scarring and calcification from
fat necrosis is commonly seen after breast reduction
Common complications of and can make mammographic interpretation diffi-
cosmetic breast surgery cult. Assessment of the augmented breast should in-
clude mammography (using the Ekland technique)
Cosmetic surgical procedures to the breast are in- and ultrasound. Magnetic resonance imaging (MRI)
creasing in popularity. The frequency of patients is useful in assessing disease extent and is the tech-
presenting with symptoms either as a consequence nique of choice if implant rupture is suspected. Due
of previous operations or with an unrelated prob- to the obvious risk of implant damage, any needle
lem in a patient who has undergone cosmetic sur- biopsy of an augmented breast should be performed
gery means an understanding of such procedures under image guidance.
and their complications can allow rapid diagnosis
and that the treatment is appropriate. It is highly
recommended that if there are complications from
Breast augmentation
recent surgery the operating surgeon assesses their complications
own patient runs better. However, it is not uncom-
mon for these patients to be referred to a breast Capsular contraction
clinic. Any foreign tissue placed within a body will pro-
Assessment involves a detailed history of the origi- duce a reaction or scar. The scarring around an
nal procedure as well as standard triple assessment. implant produces a capsule, which contracts over
In the augmented patient it is useful to know the time. Due to the relative inertness of silicone and
type of implant used (particularly with the recent the textured surface of modern implants, capsular
knowledge that some implants have a high rate contracture causing symptoms or significant distor-
of leakage and rupture) as well as the size, shape, tion is less common than it used to be. It can be
composition and its position (subpectoral or sub- exacerbated by postoperative complications such
mammary). The time since surgery and any post- as haematoma or a subclinical infection. Capsular
operative surgical complications (e.g. haematoma) contraction tends to produce pain, change in shape
287
Chapter 17
and hardness of the breast. A grading for capsular (silicone granulomas). Silicone can also migrate to
contraction is shown in Box 17.3. Treatment de- axillary nodes, which can become quite large. They
pends on severity of symptoms and patient wishes. have a snowstorm appearance on ultrasound, which
Removal plus capsulotomy or capsulectomy for is quite typical. Care should be taken in removing
rupture is the standard treatment with or without such nodes. They are the sentinel nodes of the breast
re-augmentation. and aggressive removal of nodes containing silicone
can cause both breast and arm oedema. Therefore,
Rippling/palpable implant edge these nodes should only be removed if there is defi-
Due to the pressure effect of the implant on the nite evidence they are causing symptoms.
breast tissue, some degree of glandular atrophy can
occur. This can make the underlying implant more
palpable, especially in the thin woman. Round, non- Breast reduction problems
cohesive implants, due to their softness and fluid
nature, can have a palpable ‘rippling’. This is com- Fat necrosis
monly felt superiorly when placed submammary in Scarring and fat necrosis can result from devascu-
a slim patient or if there is marked ptosis. Rippling larisation of fatty breast tissue or following wound
and sometimes the implant edge can be felt on the healing problems. This may not be noticed until
medial or lateral edges if there is a large implant or some time has passed postsurgery. Triple assess-
paucity of glandular cover. Treatment is reassurance ment will rule out any malignancy and allow for
and explanation, lipofilling the area above the rip- reassurance. Large areas that are symptomatic can
pling or revisional surgery to place the implant in be treated by a combination of liposuction and
the submuscular plane. lipofilling.
Implant rupture Inclusion cyst
Rupture is most commonly due to implant failure over
An inclusion cyst occurs due to implantation of ke-
time but may be caused by trauma or iatrogenic injury.
ratinising squamous epithelium within the dermis if
Modern silicone breast implants tend to contain cohe-
an area of incomplete de-epithelialised skin (usually
sive gel, which tends not to have the same frequency of
the pedicle for the nipple) has been buried during a
rupture seen with liquid silicone implants.
breast reduction operation. A discrete lump may be
Women with rupture present with pain, change
palpable or an impalpable lesion may be discovered
in breast shape or a lump. Once identified, treat-
on subsequent mammographic screening.
ment is removal of implant plus capsule. Residual
silicone can leak into the breast and chest wall
and cause a reaction producing hard lumps Assessment of patients with
benign breast disease
Box 17.3 • Classification of capsular contraction
The current issues include:
Grade I (absent) • Is a one-stop clinic the best method of
The breast is soft with no palpable capsule and looks diagnosing breast disease?
natural. • Fine-needle aspiration cytology, core biopsy or
Grade II (minimal) both?
• Should benign breast disease become the remit
The breast is slightly firm, with a palpable capsule but looks
of nurse specialists?
normal.
Grade III (moderate)
The breast is firm with an easily palpable capsule and looks One-stop clinics
abnormal.
Grade IV (severe) The aim of the one-stop clinic is to provide the pa-
tient with all the relevant investigations and to es-
The breast is hard, cold, painful and distorted.
tablish a diagnosis at the initial visit. This requires
288
the availability of a breast radiologist to provide There is little if any benefit from combining fine-
immediate interpretation of the examination and needle aspiration (FNA) and core biopsy as FNA
investigations. Even with all these available, a de- disrupts the cancer, makes it more difficult to visu-
finitive diagnosis is not always possible.94 There alise and this may adversely affect subsequent core
are benefits in reducing anxiety in such a service biopsy accuracy. The only continuing role of FNA
(especially in the majority with normal breasts or in patients with breast cancer is in assessment of
benign disease) but this benefit is only in the short suspicious lymph nodes. If recurrence is suspected
term.95 Patients like these clinics and they reduce core biopsy should be performed of the recurrence
the number of clinic visits and letters, improving because knowledge of the current ER and HER-2
administration efficiency. Although there have been status of the cancer is essential and these can differ
concerns that immediate reporting may affect ac- from the initial primary tumour.
curacy and that there may be a possible detrimental There is increasing evidence that symptomatic
psychological aspect for those with cancer,96 these lumps should be biopsied under ultrasound guid-
are more than offset by the benefits. It is well rec- ance.101 This ensures that the abnormality is visu-
ognised that at the time when a patient is given alised with the biopsy needle within it, improving
bad news, little other information provided in the sensitivity. Suitably trained surgeons or breast phy-
consultation is remembered. By concentrating on sicians, as well as radiologists, can undertake these
establishing and delivering a diagnosis at the first biopsies safely.102
visit, it is then possible to have a more useful and
constructive second visit to consider management Future management of
of any cancer detected.
benign breast disease
Fine-needle aspiration cytology, The last few years have seen the expansion of
breast physicians, nurse specialists and the for-
core biopsy or both? mation of nurse consultants. Their roles have ex-
panded to help with the increasing breast workload
Fine-needle aspiration cytology was the mainstay
and the lack of breast specialists. There is evidence
of diagnosis of symptomatic breast lumps for more
that such professionals can play an important
than 30 years. Its introduction allowed preopera-
part in symptomatic clinics, perform follow-
tive diagnosis and avoided a large number of open
up clinics and run symptom-specific clinics (e.g.
excision biopsies. It has the benefit of being easy
mastalgia clinics) as long as there is specialist
to perform, but can cause patient discomfort and
back-up.103,104 The future roles of these individu-
has a high sensitivity and specificity (in experienced
als are likely to expand. One note of caution: in
hands97). The result can be interpreted quickly, al-
a clinic of 30 symptomatic patients run by three
lowing rapid diagnosis. Its major disadvantage is
or four individuals, there will be an average three
that it does not provide architectural information on
cancers – that is, one per individual in the clinic. If
the area examined and therefore cannot differenti-
a nurse specialist does one new patient clinic once
ate in situ and invasive disease. It has been reported
a week, they may only see 40–45 cases of breast
that it is possible to grade tumours on cytology98
cancer per year. Some breast abnormalities and
and although it can provide oestrogen receptor sta-
cancer types are rare. What is not clear is what is
tus,99 full profiling is not possible from cytology.
adequate training for such individuals. If any indi-
vidual is to give a ‘consultant’ opinion in such clin-
Core biopsy has taken over as the preoperative ics, then ideally they should have seen hundreds
technique of choice for diagnosing palpable breast
of breast cancers and the whole range of common
lumps and areas of nodularity.100 The improved
sensitivity and specificity and greater information and rare presentations before they make final deci-
available (architecture, oestrogen receptor and sions on whether patients can be discharged. This
human epidermal growth factor receptor 2 (HER-2) is also true for trainees who cover for consultant
status, grade, presence of vascular invasion or surgeons in such clinics. The breast surgeons of the
calcification) with core biopsy is the reason for this
future may be less involved in diagnosis and more
change.
active surgically.
289
Chapter 17
Key points
• The majority of patients seen in a breast clinic have normal breasts or benign disease.
• Many conditions occur so commonly against the background of breast development, cyclical
activity and involution that they are best considered aberrations of this process.
• Following a diagnosis of benign disease, reassurance alone is insufficient. An explanation of the
cause, possible risks and treatment options is required.
• Spontaneous, single-duct persistent (>2 per week) or bloodstained nipple discharge requires a
definitive diagnosis that may only be obtained by duct excision.
• Breast pain is common and the majority originates in the underlying chest wall, not the breast itself.
• For true cyclical breast pain, tamoxifen is effective.
• Breast cysts diagnosed on ultrasound require aspiration only if symptomatic or complex on scan.
• Breast infection requires early antibiotic therapy and rapid referral to hospital if it does not settle
rapidly on antibiotics.
• Breast abscesses should be assessed by ultrasound and treated by repeated aspiration or
mini-incision and drainage.
• Gynaecomastia is an increasing problem. The cause should be ascertained and surgery only
performed after other options have been exhausted.
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17

Benign breast disease

Introduction Supernumerary nipples and

Congenital abnormalities Breast hypoplasia

breasts. A pedicled or free myocutaneous flap,

Figure 17.2 • Hypoplasia pre- and post-surgery with expansion followed by implant.

Aberrations of normal breast

Microdochectomy Consider ductoscopy Total duct

*See indications section in total duct excision Localised duct

Treatment is by complete excision. Patients with this Nipple adenoma

Figure 17.7 • Nipple adenomas.

Sclerotic/fibrotic lesions explains the cause of any localised mass is unwise.

Non-ANDI conditions been shown to inhibit growth of Gram-positive bac-

Box 17.1 • Pathological causes of gynaecomastia

Small to moderate Moderate to large

Firm subcutaneous Consider skin

Open excision Open excision

Figure 17.14 • Algorithm for management of gynaecomastia.

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