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Management of benign disease of the breast
Breast
Management of benign disease of the breast
remenopausal women and persist after the menopause if the p woman uses hormone replacement therapy. Cysts usually present as smooth, discrete lumps; they can be painful and are sometimes visible. The patient undergoes triple assessment at first presentation. Cysts have a characteristic appearance mammographically and are readily diagnosed by ultrasound. The diagnosis can be confirmed by aspiration provided there is complete resolution of the lump and the fluid is not bloodstained. After aspiration, the breast should be re-examined to ensure complete resolution. A residual mass requires triple assessment.
Rhodri Codd Christopher A Gateley
Nodularity Focal nodularity is the commonest cause of a breast lump and is seen in women of all ages, but is more common in premenopausal women. The spectrum of normal histological features ranges from a predominance of ducts, lobules and stroma to features of fibrous change, sclerosis and cyst formation. This was formerly called ‘fibrocystic disease of the breast’, but the term ‘benign breast change’ is now preferred. Areas of discrete nodularity require triple assessment and reassurance if abnormality is absent.
Abstract Benign disease of the breast is common. Breast lumps, nipple discharge, breast pain, breast infection and gynaecomastia are reviewed.
Keywords benign breast disease; fibroadenoma; breast cyst; duct ectasia; intraduct papilloma; epithelial hyperplasia; mastalgia; chest wall pain; breast infection; gynaecomastia
Benign disease of the breast describes non-malignant disorders of the breast; >90% of new cases referred to Breast Clinics in the UK are non-malignant disorders. It is important to recognize symptoms and signs, to exclude malignancy and manage appropriately.
Other lumps Lipomas are common in the breast. They are soft, lobulated and radiolucent lesions that must be distinguished from pseudolipomas (a soft mass sometimes felt around a breast cancer). Haematomas of the breast commonly follow trauma (e.g. from a seatbelt in a road traffic accident) but can also occur after diagnostic and therapeutic intervention (e.g. fine-needle aspiration cytology, core biopsy). Rarely, a carcinoma presents as a spontaneous haematoma.
Breast lump About 60% of referrals to a Breast Clinic are due to a breast lump. The cause is benign in >90% of cases. Investigation of a breast lump is by the triple assessment: clinical examination, imaging and needle biopsy (Figure 1).
Fat necrosis follows trauma and may present as a breast lump; there is no history of trauma in about 60% of patients.
Fibroadenoma Fibroadenomas are aberrations of the normal development of breast tissue. They occur due to an exaggerated response of the lobules and stroma of the breast to normal hormonal stimuli. They are common between adolescence and the mid-twenties, affecting 7–13% of women in this age group. Fibroadenomas usually present as firm, rubbery, mobile lumps. Diagnosis is by clinical examination, imaging and needle biopsy. The patient can be reassured and surgical excision avoided if fibroadenoma is confirmed by triple assessment. Small fibroadenomas are excised at the patient’s request. Larger lesions (>4 cm) are usually excised if histology suggests a phyllodes tumour or if it is obvious after breast examination.
Nipple discharge About 7% of referrals to a Breast Clinic are because of nipple discharge. This symptom is often distressing, but only 5% of these patients have serious underlying disease. Breast cancer is more likely in older patients and in those who present with persistent single-duct discharge containing gross or occult blood. The management of nipple discharge is described in Figure 2. Coloured discharge Physiological discharge: two-thirds of premenopausal women can produce nipple secretions by manual expression or suction. It often presents with intermittent staining of the undergarments or bed linen. The discharge is multiductal and may be white, yellow, green or black. Investigation is not required and treatment is by reassurance.
Cysts Cysts are distended, involuted lobules, and represent 15% of discrete breast masses. They have a higher prevalence in
Duct ectasia is due to ductal involution, where the major sub areolar ducts shorten and dilate (become ectatic). It is commonest in the 30–50 age group and >40% have substantial duct dilation by the age of 70 years. The dilation leads to a slit-like nipple retraction (often bilateral). The discharge: • can be from single or multiple ducts • is coloured
Rhodri Codd MRCS is a Specialist Registrar in General Surgery at Royal Gwent Hospital, Newport, UK. Conflicts of interest: none declared. Christopher A Gateley FRCS FRCS(Gen) is a Consultant Breast and General Surgeon at Royal Gwent Hospital, Newport, UK. Conflicts of interest: none declared.
SURGERY 25:6
264
© 2007 Elsevier Ltd. All rights reserved.
Breast
Investigation of a breast lump Clinical examination reveals a discrete lump
<35 years of age Ultrasound
>35 years of age Mammogram ± ultrasound
Abnormal
Normal
Cyst
Solid
Aspirate
Ultrasound-guided needle biopsy
Clinical needle biopsy
Benign
Uncertain
Malignant
Reassure
Excision biopsy
Treat
Figure 1
Management of nipple discharge Nipple discharge History and examination
Lump
No lump
Investigate as Figure 1
Abnormal: investigate
Serous or bloodstained
Coloured discharge
Persistent
Resolves
Mammogram
Reassure
Reassure
Milk
Exclude drug-induced or endocrine cause
Normal
Microdochectomy or total excision of duct if symptoms are problematic
Figure 2
SURGERY 25:6
265
© 2007 Elsevier Ltd. All rights reserved.
Breast
• may be cheesy in appearance • may be bloodstained. Surgery is done only rarely for problematic large-volume discharge, or for the exclusion of malignancy if discharge is bloodstained.
behind the areola. Complications include loss of nipple sensation and partial or complete necrosis of the nipple (rare).
Mastalgia Twenty-five percent of referrals to Breast Clinics are due to mastalgia (breast pain). Pain can arise from the breast or may be referred from the chest wall; this must be differentiated because management differs.
Bloodstained discharge Bloody discharge causes a high degree of anxiety but is usually benign. It is usually caused by duct ectasia, intraductal papilloma or epithelial hyperplasia. Breast cancer accounts for about 10% of cases referred with bloodstained discharge.
True mastalgia Types: mastalgia is cyclical in two-thirds of cases and noncyclical in one-third. Cyclical pain worsens during the late luteal phase of the menstrual cycle and improves at the onset of menses. It is due to an exaggerated response to the normal hormonal changes that occur during the menstrual cycle and is associated with swelling and an increased nodularity of the breasts. Non-cyclical pain is unrelated to the menstrual cycle and tends to be less responsive to drug therapy than cyclical mastalgia.
Investigation of bloody discharge is initially by physical examination and mammography; a normal assessment does not exclude malignancy. Other diagnostic tests (e.g. nipple discharge cytology, galactography, mammary ductoscopy) have been proposed but have a high false-negative rate and do not affect management. In general, duct excision is required if malignancy cannot be excluded clinically and radiologicaly, and is therapeutic in benign cases. Intraductal papilloma is an aberration of normal development rather than a true benign neoplasm of the duct epithelium. They can be single or multiple and are associated with a 1.5–2-fold increase in the relative risk of developing breast cancer. They usually present with serous nipple discharge which arises from a single duct and may be bloodstained. A lump may be palpable beneath the nipple. Mammography may reveal a dilated duct and an intraductal lesion may be visible on ultrasound. Microdochectomy is diagnostic and curative.
Treatment Reassurance is often the only form of management necessary after significant disease has been excluded (breast cancer rarely presents with mastalgia alone). Gammalinoleic acid was withdrawn by the UK Medicines Control Agency in 2002 because they concluded there was no good evidence to support its use in the treatment of mastalgia. Danazol inhibits pituitary gonadotrophins; it combines androgenic activity with antioestrogenic and antiprogestogenic activity. Double-blind randomized controlled trials have shown significant improvement in breast pain when compared with placebo. Restricting use to the luteal phase reduces associated side effects. Bromocriptine is a dopamine agonist that effectively treats breast pain but side effects are common; it is rarely used. Tamoxifen is not licensed for breast pain in the UK. Long-term use is associated with increased risk of deep vein thrombosis and endometrial cancer. Randomized controlled trials have shown tamoxifen to be effective in improving breast pain; one trial compared tamoxifen to danazol and concluded that tamoxifen was superior because it was associated with fewer side effects. Other treatments include goserelin, progestogens, phytooestrogens, soya-milk, Agnus catus (fruit extract) and selective serotonin reuptake inhibitors.
Multiple peripheral papilloma syndrome occurs in 10% of cases, with lesions developing in the smaller peripheral breast ducts. Presentation is usually with a lump or mammographic abnormality. Nipple discharge is less likely. The risk of breast cancer is greater than with single papillomas. Epithelial hyperplasia is an increase in the number of cells lining the terminal duct lobular unit. The nipple discharge is serous or bloodstained. Hyperplasia is graded as mild, moderate or florid depending on the degree of hyperplasia (this does not correspond to the volume of discharge). The condition is called ‘atypical hyperplasia’ if the hyperplastic cells also show atypia. Atypical hyperplasia imparts a five-fold increase in the relative risk of developing breast cancer. Gestational nipple discharge usually occurs during the second trimester. It can cause a bloodstained discharge from multiple ducts, but this discharge is usually thin and from a single duct. Reassurance after a normal clinical examination is adequate, with follow-up after pregnancy and lactation.
Pain in the chest wall Most patients referred with non-cyclical breast pain have pain that originates from the chest wall. The suggestive features include unilateral pain that may be burning or stabbing. The pain may be associated with strenuous activity and may be reproduced by applying pressure on a specific area of the chest wall. It is commonly sited medially over the costochondral junctions (Tietze’s syndrome) or more laterally at the anterior axillary line (lateral chest wall pain). It is possible to isolate the breast by asking the patient to roll onto her side, allowing the breast to fall away from the chest wall i.e. the breast and the chest wall can be palpated separately for tenderness.
Surgical management of nipple discharge Microdochectomy is the excision of a single discharging duct after cannulation with a lacrimal probe. The diseased duct is isolated from the unaffected subareolar ducts and removed intact. Total duct excision is indicated for suspicious or persistent troublesome discharge from multiple ducts. A cone of retroareolar tissue is removed, encompassing all ducts to a depth of 2 cm
SURGERY 25:6
266
© 2007 Elsevier Ltd. All rights reserved.
Breast
Peripheral infection is less common than periareolar infection. It is nearly always associated with an underlying condition (e.g. diabetes, rheumatoid arthritis, minor trauma, hidradenitis, granulomatous lobular mastitis) or immunosuppressive drugs. The latter often presents with multiple peripheral abscesses and is likely to persist or recur after surgery. Treatment involves appropriate antibiotics and abscesses should be aspirated or drained.
In most cases, women are satisfied with reassurance alone, but treatment with NSAIDs is usually effective if the pain is severe or persistent.
Breast infection The incidence of established infection of the breast has fallen in the UK since the introduction of antibiotics and improved hygiene. It is occasionally seen in neonates, but is commonest in women aged 18–50 years. It can be divided into lactational and non-lactational infection in adults.
Unusual infections Tuberculosis of the breast is rare in the UK. It presents as an abscess due to infection of a tuberculous cavity, commonly with Staphylococcus aureus. Breast or axillary sinuses are present in up to 50% of cases. Diagnosis is often via open biopsy. Treatment involves surgical drainage and anti-tuberculous chemotherapy. Other – viral infections (e.g. herpes, molluscum contagiosum), fungal infections (e.g. Candida albicans), syphilis and actinomycosis can affect the breast but are rare.
Neonatal infection (mastitis neonatorum) is commonest in the first few weeks of life when the breast bud is enlarged. The cause is usually Staphylococcus aureus but Escherichia coli can occasionally lead to infection. Prompt antibiotic therapy is advised to avoid abscess development; if an abscess forms, it should be incised as peripherally as possible to avoid damaging the breast bud. Lactational infection is usually seen within the first six weeks of breastfeeding. The infection route is usually via a skin defect (e.g. cracked nipple). The causative organisms are usually skin commensals. The commonest organisms are Staphylococcus aureus and Staphylococcus epidermidis; Streptococci sp. are occasionally isolated. Presentation is with erythema, swelling, pain and tenderness. Women should be encouraged to continue breastfeeding or to manually express milk because this improves drainage of the affected area. Early administration of antibiotic (flucloxacillin 500 mg q.d.s.) is advised. Ultrasonography provides confirmation and allows guided aspiration if an abscess is suspected. This may need to be repeated every 2–3 days until pus is no longer aspirated. Persistent inflammation should be treated with a high index of suspicion because inflammatory breast carcinoma can present in a similar way.
Gynaecomastia Gynaecomastia is a generalized enlargement of the male breast and is the commonest benign condition of the breast in males. It is a tender, symmetrical discoid enlargement of the male breast, which is in contrast to breast carcinoma, which tends to be unilateral, non-tender, eccentric and hard. Most cases of gynaeco mastia reflect an increased ratio of oestrogens to androgens due to age, disease, drugs or idiopathic factors. Only rarely is a functioning endocrine tumour the cause. Management involves thorough history-taking and clinical examination. Examination of the testes should be included because 5–10% of testicular tumours present with gynaecomastia. Ultrasound of the breast is the first-line imaging investigation although mammography may also be done. Needle biopsy is reserved for the investigation of suspected malignant lesions. The investigation of an endocrine cause of gynaecomastia is rarely productive and should be done selectively. Treating the cause may improve symptoms if a secondary cause is identified. Reassurance is often the only treatment necessary for patients with idiopathic gynaecomastia. Treatment options are hormonal or surgical. Tamoxifen and danazol have been used in the treatment of gynaecomastia, but danazol is the only agent licensed for its treatment in the UK. Surgery should be reserved for those who fail to respond to hormones and in those with severe cosmetic deformities. ◆
Non-lactational infection can be divided into those that occur in the periareolar region (periductal mastitis) and those that affect the peripheral breast tissue. Periductal mastitis usually affects young women; 90% of cases are smokers. Histologically, there is active inflammation around non-dilated subareolar breast ducts. It should not be confused with duct ectasia, which usually occurs in older women and is associated with involution and dilation of ducts. Causative organisms may be aerobic or anaerobic. Presentation is with breast pain, nipple retraction, nipple discharge, periareolar inflammation or an established abscess. Management involves early treatment with appropriate antibiotics, including co-amoxiclav, or a cephalosporin + metronidazole. An abscess can be managed by repeated aspiration or incision and drainage. Incision and drainage may lead to a mammary duct fistula, which will require surgical excision along with the diseased ducts. Recurrent periductal mastitis is treated by excision of the diseased ducts; repeated surgery is commonly required. Persistent inflammation or a solid mass on ultrasound should be investigated to exclude underlying cancer.
SURGERY 25:6
Further reading Dixon M. ABC of breast diseases, 3rd edn. Oxford: Blackwell, 2006. Holland PA, Gateley CA. Drug therapy of mastalgia. What are the options? Drugs 1994; 48: 709–16. Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast, 2nd edn. London: Baillière Tindall, 2000. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005; 353: 275–85.
267
© 2007 Elsevier Ltd. All rights reserved.
Management of benign disease of the breast
remenopausal women and persist after the menopause if the p woman uses hormone replacement therapy. Cysts usually present as smooth, discrete lumps; they can be painful and are sometimes visible. The patient undergoes triple assessment at first presentation. Cysts have a characteristic appearance mammographically and are readily diagnosed by ultrasound. The diagnosis can be confirmed by aspiration provided there is complete resolution of the lump and the fluid is not bloodstained. After aspiration, the breast should be re-examined to ensure complete resolution. A residual mass requires triple assessment.
Rhodri Codd Christopher A Gateley
Nodularity Focal nodularity is the commonest cause of a breast lump and is seen in women of all ages, but is more common in premenopausal women. The spectrum of normal histological features ranges from a predominance of ducts, lobules and stroma to features of fibrous change, sclerosis and cyst formation. This was formerly called ‘fibrocystic disease of the breast’, but the term ‘benign breast change’ is now preferred. Areas of discrete nodularity require triple assessment and reassurance if abnormality is absent.
Abstract Benign disease of the breast is common. Breast lumps, nipple discharge, breast pain, breast infection and gynaecomastia are reviewed.
Keywords benign breast disease; fibroadenoma; breast cyst; duct ectasia; intraduct papilloma; epithelial hyperplasia; mastalgia; chest wall pain; breast infection; gynaecomastia
Benign disease of the breast describes non-malignant disorders of the breast; >90% of new cases referred to Breast Clinics in the UK are non-malignant disorders. It is important to recognize symptoms and signs, to exclude malignancy and manage appropriately.
Other lumps Lipomas are common in the breast. They are soft, lobulated and radiolucent lesions that must be distinguished from pseudolipomas (a soft mass sometimes felt around a breast cancer). Haematomas of the breast commonly follow trauma (e.g. from a seatbelt in a road traffic accident) but can also occur after diagnostic and therapeutic intervention (e.g. fine-needle aspiration cytology, core biopsy). Rarely, a carcinoma presents as a spontaneous haematoma.
Breast lump About 60% of referrals to a Breast Clinic are due to a breast lump. The cause is benign in >90% of cases. Investigation of a breast lump is by the triple assessment: clinical examination, imaging and needle biopsy (Figure 1).
Fat necrosis follows trauma and may present as a breast lump; there is no history of trauma in about 60% of patients.
Fibroadenoma Fibroadenomas are aberrations of the normal development of breast tissue. They occur due to an exaggerated response of the lobules and stroma of the breast to normal hormonal stimuli. They are common between adolescence and the mid-twenties, affecting 7–13% of women in this age group. Fibroadenomas usually present as firm, rubbery, mobile lumps. Diagnosis is by clinical examination, imaging and needle biopsy. The patient can be reassured and surgical excision avoided if fibroadenoma is confirmed by triple assessment. Small fibroadenomas are excised at the patient’s request. Larger lesions (>4 cm) are usually excised if histology suggests a phyllodes tumour or if it is obvious after breast examination.
Nipple discharge About 7% of referrals to a Breast Clinic are because of nipple discharge. This symptom is often distressing, but only 5% of these patients have serious underlying disease. Breast cancer is more likely in older patients and in those who present with persistent single-duct discharge containing gross or occult blood. The management of nipple discharge is described in Figure 2. Coloured discharge Physiological discharge: two-thirds of premenopausal women can produce nipple secretions by manual expression or suction. It often presents with intermittent staining of the undergarments or bed linen. The discharge is multiductal and may be white, yellow, green or black. Investigation is not required and treatment is by reassurance.
Cysts Cysts are distended, involuted lobules, and represent 15% of discrete breast masses. They have a higher prevalence in
Duct ectasia is due to ductal involution, where the major sub areolar ducts shorten and dilate (become ectatic). It is commonest in the 30–50 age group and >40% have substantial duct dilation by the age of 70 years. The dilation leads to a slit-like nipple retraction (often bilateral). The discharge: • can be from single or multiple ducts • is coloured
Rhodri Codd MRCS is a Specialist Registrar in General Surgery at Royal Gwent Hospital, Newport, UK. Conflicts of interest: none declared. Christopher A Gateley FRCS FRCS(Gen) is a Consultant Breast and General Surgeon at Royal Gwent Hospital, Newport, UK. Conflicts of interest: none declared.
SURGERY 25:6
264
© 2007 Elsevier Ltd. All rights reserved.
Breast
Investigation of a breast lump Clinical examination reveals a discrete lump
<35 years of age Ultrasound
>35 years of age Mammogram ± ultrasound
Abnormal
Normal
Cyst
Solid
Aspirate
Ultrasound-guided needle biopsy
Clinical needle biopsy
Benign
Uncertain
Malignant
Reassure
Excision biopsy
Treat
Figure 1
Management of nipple discharge Nipple discharge History and examination
Lump
No lump
Investigate as Figure 1
Abnormal: investigate
Serous or bloodstained
Coloured discharge
Persistent
Resolves
Mammogram
Reassure
Reassure
Milk
Exclude drug-induced or endocrine cause
Normal
Microdochectomy or total excision of duct if symptoms are problematic
Figure 2
SURGERY 25:6
265
© 2007 Elsevier Ltd. All rights reserved.
Breast
• may be cheesy in appearance • may be bloodstained. Surgery is done only rarely for problematic large-volume discharge, or for the exclusion of malignancy if discharge is bloodstained.
behind the areola. Complications include loss of nipple sensation and partial or complete necrosis of the nipple (rare).
Mastalgia Twenty-five percent of referrals to Breast Clinics are due to mastalgia (breast pain). Pain can arise from the breast or may be referred from the chest wall; this must be differentiated because management differs.
Bloodstained discharge Bloody discharge causes a high degree of anxiety but is usually benign. It is usually caused by duct ectasia, intraductal papilloma or epithelial hyperplasia. Breast cancer accounts for about 10% of cases referred with bloodstained discharge.
True mastalgia Types: mastalgia is cyclical in two-thirds of cases and noncyclical in one-third. Cyclical pain worsens during the late luteal phase of the menstrual cycle and improves at the onset of menses. It is due to an exaggerated response to the normal hormonal changes that occur during the menstrual cycle and is associated with swelling and an increased nodularity of the breasts. Non-cyclical pain is unrelated to the menstrual cycle and tends to be less responsive to drug therapy than cyclical mastalgia.
Investigation of bloody discharge is initially by physical examination and mammography; a normal assessment does not exclude malignancy. Other diagnostic tests (e.g. nipple discharge cytology, galactography, mammary ductoscopy) have been proposed but have a high false-negative rate and do not affect management. In general, duct excision is required if malignancy cannot be excluded clinically and radiologicaly, and is therapeutic in benign cases. Intraductal papilloma is an aberration of normal development rather than a true benign neoplasm of the duct epithelium. They can be single or multiple and are associated with a 1.5–2-fold increase in the relative risk of developing breast cancer. They usually present with serous nipple discharge which arises from a single duct and may be bloodstained. A lump may be palpable beneath the nipple. Mammography may reveal a dilated duct and an intraductal lesion may be visible on ultrasound. Microdochectomy is diagnostic and curative.
Treatment Reassurance is often the only form of management necessary after significant disease has been excluded (breast cancer rarely presents with mastalgia alone). Gammalinoleic acid was withdrawn by the UK Medicines Control Agency in 2002 because they concluded there was no good evidence to support its use in the treatment of mastalgia. Danazol inhibits pituitary gonadotrophins; it combines androgenic activity with antioestrogenic and antiprogestogenic activity. Double-blind randomized controlled trials have shown significant improvement in breast pain when compared with placebo. Restricting use to the luteal phase reduces associated side effects. Bromocriptine is a dopamine agonist that effectively treats breast pain but side effects are common; it is rarely used. Tamoxifen is not licensed for breast pain in the UK. Long-term use is associated with increased risk of deep vein thrombosis and endometrial cancer. Randomized controlled trials have shown tamoxifen to be effective in improving breast pain; one trial compared tamoxifen to danazol and concluded that tamoxifen was superior because it was associated with fewer side effects. Other treatments include goserelin, progestogens, phytooestrogens, soya-milk, Agnus catus (fruit extract) and selective serotonin reuptake inhibitors.
Multiple peripheral papilloma syndrome occurs in 10% of cases, with lesions developing in the smaller peripheral breast ducts. Presentation is usually with a lump or mammographic abnormality. Nipple discharge is less likely. The risk of breast cancer is greater than with single papillomas. Epithelial hyperplasia is an increase in the number of cells lining the terminal duct lobular unit. The nipple discharge is serous or bloodstained. Hyperplasia is graded as mild, moderate or florid depending on the degree of hyperplasia (this does not correspond to the volume of discharge). The condition is called ‘atypical hyperplasia’ if the hyperplastic cells also show atypia. Atypical hyperplasia imparts a five-fold increase in the relative risk of developing breast cancer. Gestational nipple discharge usually occurs during the second trimester. It can cause a bloodstained discharge from multiple ducts, but this discharge is usually thin and from a single duct. Reassurance after a normal clinical examination is adequate, with follow-up after pregnancy and lactation.
Pain in the chest wall Most patients referred with non-cyclical breast pain have pain that originates from the chest wall. The suggestive features include unilateral pain that may be burning or stabbing. The pain may be associated with strenuous activity and may be reproduced by applying pressure on a specific area of the chest wall. It is commonly sited medially over the costochondral junctions (Tietze’s syndrome) or more laterally at the anterior axillary line (lateral chest wall pain). It is possible to isolate the breast by asking the patient to roll onto her side, allowing the breast to fall away from the chest wall i.e. the breast and the chest wall can be palpated separately for tenderness.
Surgical management of nipple discharge Microdochectomy is the excision of a single discharging duct after cannulation with a lacrimal probe. The diseased duct is isolated from the unaffected subareolar ducts and removed intact. Total duct excision is indicated for suspicious or persistent troublesome discharge from multiple ducts. A cone of retroareolar tissue is removed, encompassing all ducts to a depth of 2 cm
SURGERY 25:6
266
© 2007 Elsevier Ltd. All rights reserved.
Breast
Peripheral infection is less common than periareolar infection. It is nearly always associated with an underlying condition (e.g. diabetes, rheumatoid arthritis, minor trauma, hidradenitis, granulomatous lobular mastitis) or immunosuppressive drugs. The latter often presents with multiple peripheral abscesses and is likely to persist or recur after surgery. Treatment involves appropriate antibiotics and abscesses should be aspirated or drained.
In most cases, women are satisfied with reassurance alone, but treatment with NSAIDs is usually effective if the pain is severe or persistent.
Breast infection The incidence of established infection of the breast has fallen in the UK since the introduction of antibiotics and improved hygiene. It is occasionally seen in neonates, but is commonest in women aged 18–50 years. It can be divided into lactational and non-lactational infection in adults.
Unusual infections Tuberculosis of the breast is rare in the UK. It presents as an abscess due to infection of a tuberculous cavity, commonly with Staphylococcus aureus. Breast or axillary sinuses are present in up to 50% of cases. Diagnosis is often via open biopsy. Treatment involves surgical drainage and anti-tuberculous chemotherapy. Other – viral infections (e.g. herpes, molluscum contagiosum), fungal infections (e.g. Candida albicans), syphilis and actinomycosis can affect the breast but are rare.
Neonatal infection (mastitis neonatorum) is commonest in the first few weeks of life when the breast bud is enlarged. The cause is usually Staphylococcus aureus but Escherichia coli can occasionally lead to infection. Prompt antibiotic therapy is advised to avoid abscess development; if an abscess forms, it should be incised as peripherally as possible to avoid damaging the breast bud. Lactational infection is usually seen within the first six weeks of breastfeeding. The infection route is usually via a skin defect (e.g. cracked nipple). The causative organisms are usually skin commensals. The commonest organisms are Staphylococcus aureus and Staphylococcus epidermidis; Streptococci sp. are occasionally isolated. Presentation is with erythema, swelling, pain and tenderness. Women should be encouraged to continue breastfeeding or to manually express milk because this improves drainage of the affected area. Early administration of antibiotic (flucloxacillin 500 mg q.d.s.) is advised. Ultrasonography provides confirmation and allows guided aspiration if an abscess is suspected. This may need to be repeated every 2–3 days until pus is no longer aspirated. Persistent inflammation should be treated with a high index of suspicion because inflammatory breast carcinoma can present in a similar way.
Gynaecomastia Gynaecomastia is a generalized enlargement of the male breast and is the commonest benign condition of the breast in males. It is a tender, symmetrical discoid enlargement of the male breast, which is in contrast to breast carcinoma, which tends to be unilateral, non-tender, eccentric and hard. Most cases of gynaeco mastia reflect an increased ratio of oestrogens to androgens due to age, disease, drugs or idiopathic factors. Only rarely is a functioning endocrine tumour the cause. Management involves thorough history-taking and clinical examination. Examination of the testes should be included because 5–10% of testicular tumours present with gynaecomastia. Ultrasound of the breast is the first-line imaging investigation although mammography may also be done. Needle biopsy is reserved for the investigation of suspected malignant lesions. The investigation of an endocrine cause of gynaecomastia is rarely productive and should be done selectively. Treating the cause may improve symptoms if a secondary cause is identified. Reassurance is often the only treatment necessary for patients with idiopathic gynaecomastia. Treatment options are hormonal or surgical. Tamoxifen and danazol have been used in the treatment of gynaecomastia, but danazol is the only agent licensed for its treatment in the UK. Surgery should be reserved for those who fail to respond to hormones and in those with severe cosmetic deformities. ◆
Non-lactational infection can be divided into those that occur in the periareolar region (periductal mastitis) and those that affect the peripheral breast tissue. Periductal mastitis usually affects young women; 90% of cases are smokers. Histologically, there is active inflammation around non-dilated subareolar breast ducts. It should not be confused with duct ectasia, which usually occurs in older women and is associated with involution and dilation of ducts. Causative organisms may be aerobic or anaerobic. Presentation is with breast pain, nipple retraction, nipple discharge, periareolar inflammation or an established abscess. Management involves early treatment with appropriate antibiotics, including co-amoxiclav, or a cephalosporin + metronidazole. An abscess can be managed by repeated aspiration or incision and drainage. Incision and drainage may lead to a mammary duct fistula, which will require surgical excision along with the diseased ducts. Recurrent periductal mastitis is treated by excision of the diseased ducts; repeated surgery is commonly required. Persistent inflammation or a solid mass on ultrasound should be investigated to exclude underlying cancer.
SURGERY 25:6
Further reading Dixon M. ABC of breast diseases, 3rd edn. Oxford: Blackwell, 2006. Holland PA, Gateley CA. Drug therapy of mastalgia. What are the options? Drugs 1994; 48: 709–16. Hughes LE, Mansel RE, Webster DJT. Benign disorders and diseases of the breast, 2nd edn. London: Baillière Tindall, 2000. Santen RJ, Mansel R. Benign breast disorders. N Engl J Med 2005; 353: 275–85.
267
© 2007 Elsevier Ltd. All rights reserved.