Breast Lump / Nipple Discharge /

Mastalgia
(Case Scenarios)

Dr. Reda Abd Eltawab

Professor of General and Breast Surgery

Dr. Karim Fahmy

Lecturer of General and Breast Surgery

Faculty of Medicine, Ain Shams University

Case 1

50-year-old female presents with a nipple discharge from Lt

breast of 2 weeks duration. She has an unremarkable medical
history and denies a history of previous breast biopsies or breast
conditions. She reports a family history significant for breast
cancer in a maternal grandmother and aunt. Her breast exam is
unremarkable with symmetric, moderate-sized breast, without
skin changes and with no erythema, dimpling, or nipple
inversion. On palpation, there is no dominant mass and nipple
discharge from Lt breast.

1.What is your differential diagnosis?

2.What is diagnostic work up?
© Breast diseases 2007 2
History
&examination

 Color of discharge
– Yellow: Abscess/Periductal mastitis
– Blood-stained: Duct papilloma/carcinoma
– Clear: physiological/carcinoma
– Milky: Lactating breast /drugs /prolactinoma
– Green: Duct ectasia
 Color of discharge
 Single or multiple ducts
 Unilateral or bilateral
 Spontaneous or induced
 Most dangerous discharge is single,
bloody, spontaneous discharge in
female pt > 50
Distressing discharge is Persistent discharge > twice weekly
Causes of nipple discharge
Mammogram shows clustered
microcalcifications ??!!

What
. is your
plan?

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Image-guided core biopsy and has a pathology report
that reveals ductal carcinoma in situ (DCIS), nuclear
grade 3 with associated comedo necrosis, estrogen
receptor (ER) positive by immunohistochemistry.

What is next?

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MANAGEMENT OF
DCIS

© Breast diseases 2007 8

 Case:2 • US /FNA

• 18 years young female

presented to the breast
clinic with a firm rubbery 1
cm mass of the right breast.
• The mass moves freely
inside the breast.
What is your diagnosis?

Confirm diagnosis?
 Fibro adenoma

• Surgical removal only at the option of the patient.

 Case:3

• 35 years old female presenting with pain and

tenderness of both breasts of 10 years duration,
related to the menstrual cycle, with multiple
nodular masses that come and go in relation to
menses.
• Now she has a rounded,firm (tense cystic) 2 cm
mass in her right breast of 6 weeks duration.
• Diagnosis: Fibrocystic disease +
• Probably a cyst but it could be carcinoma!!
• What should we do?
• Mammography

• Ultrasonography
• Aspiration
• If still suspicious we do
formal biopsy
 Case:4
• 52 years old female
presented with the picture
of blood discharge from
the right nipple, that
comes out spontaneously
from a single orifice for
several months, not
responding to any type of
treatment.
• On examination no
palpable mass inside the
breast.
Investigations
 Duct papilloma

• Diagnosis:
But it could be carcinoma.
• Investigations:
Surgical exploration
 Case:5
• A 26 years lactating
mother had cracks in
the nipple,
presenting with a
fluctuating red hot
tender mass in her
left breast with
leucocytosis and
hectic fever.
 Abscess
• Rule: Only lactating • No mammography!!
females are entitled to • Ruling out carcinoma :
get an intramammary After doing incision and
abscess. In nonlactating drainage you have to
ladies think in infected take tissue biopsy from
carcinoma. the wall of the abscess
for pathological
examination.
 Case:6
• A 69 years old female has
an ill-defined firm mass
under the left nipple,
movable on chest wall
but not movable inside
the breast, with
retraction of the nipple 3
months ago.
Diagnosis: Cancer
Management:
 Case:7
• A 60 years old lady doing
routine screening
mammogram.
• The radiologist reported an
irregular area of increased
density with fine
microcalcifications. It wasn’t
there two years ago.
• On examination NAD(no mass
felt)
 We need tissue diagnosis.

• How to obtain biopsy

from something that we
don’t feel!!
• What we don’t The
Radiologist does.
• Radiological guided core biopsy.
• Wire localization.
• Mammotome.
Mastalgia
Case scenario

34 years old white female, presented for treatment of severe

breast pain, known as mastalgia, of five years duration. The pain
was menstrual related , however, she had some tenderness
throughout the entire month. Colleen described multiple lumps
in each breast, and about two years prior had a large lump
drained. Examination revealed no skin discoloration, breast
contour changes. Supraclavicular, axillary, and supratrochlear
lymph nodes were non-palpable and non-tender. Multiple,
discreet nodules were present in each breast with especially
diffuse, dense tissue in the upper and outer breast quadrants.
The breasts were tender to palpation and there was no nipple
discharge
1.What is your differential diagnosis?
2.What is diagnostic work up?© Breast diseases 2007 26
Mastalgia
 FIBROCYSTADENOSIS (FIBROCYSTIC
DISEASE OF THE Breast)

 It is due to aberration of normal development and involution

(ANDI ) of breast .
 When diffuse small, multiple cysts are the main component,
 It is the most common breast disease.
 It is common in upper and outer quadrant.
 It is an exaggerated response of breast stroma and epithelium.
 Rare in nulliparous/ovulating/OCP taking women
Classification

Nonproliferative: moderate hyperplasia of ductal luminal

cells—no life time risk for cancer.
 Proliferative without atypia: (severe hyperplasia).
 Proliferative with atypia: (Atypical ductal/lobular
hyperplasia) risk factor for breast cancer—often mimics in
situ carcinoma. RR is 4.5.

© Breast diseases 2007 29

 Clinical Features

 bilateral, painful, diffuse, granular,

tender, swelling Common in upper
outer quadrant.
 Pain and tenderness are more just
prior to menstruation (cyclical
mastalgia).
 It subsides during pregnancy,
lactation and after menopause.
 Discharge from the nipple when
present will be serous or
occasionally greenish.
 Occasionally shotty enlargement
of axillary lymph nodes can occur
(20%)..

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Thank you & Good Luck