Management

Treatment can often be with a support bra worn at night. If conservative treatment fails, medicine would be instituted. Medication must be continued for at least two months before being considered a treatment failure. The drug with the least side effects and an average success rate at decreasing pain is gamolenic acid or evening primrose oil. Other medications with efficacy include danazole, a synthetic testosterone (inhibits the gonadotropin surge and enzymes of steroid synthesis) and bromocriptine (a dopamine antagonist).

Breast Lump

Identification of a breast lump is the most common reason patients seek medical attention. Breast lumps in women less than 40 are often benign but should be assessed in a methodical fashion.

Diagnosis

Often now referred to as the triple test, physical exam, mammogram and biopsy are the initial diagnostic methods. Sometimes ultrasound can be used to evaluate a questionable mass. MRI and PET scans are being considered as tools; however, now they are cost prohibitive and have questionable sensitivity and specificity. If the mass is still questionable, then core needle or excisional biopsy can be preformed.

Fibroadenoma

Masses in women less than 40 are most often a fibroadenoma, which develops from abnormal lobule development. Fibroadenomas are composed of stromal and epithelial elements. On a physical exam, these are discrete masses that are freely movable and soft.

Diagnosis

On an ultrasound, they are solid masses that have well circumscribed margins with a heterogeneous echo pattern. On a mammogram, a mass with circumscribed borders is seen. Four types of fibroadenomas exist:

1. Common

2. Giant

3. Juvenile

4. Phyllodes tumor

Giant fibroadenomas are ones that measure greater than 5 cm. Juvenile fibroadenomas are also large and occur in adolescent girls. Phyllodes tumors are seen in premenopausal women. Treatment of phyllodes tumors are with excision; however, they tend to recur. Fibroadenoma will increase in size in 10% of cases while 33% will regress.

Fibroadenomas are a long term risk factor for cancer only if proliferative disease is present or the fibroadenoma is complex.3 A complex fibroadenoma is one that contains cysts, sclerosing adenosis, epithelial calcifications, or apocrine changes.

A biopsy should be done if:

1. increases in size on ultrasound

3. atypia on x-ray or previous biopsy

Fibrocystic Disease

Fibrocystic disease is more common in women around age 40. This disease was first described in 1829 by Astley Cooper, of Cooper's ligament fame. These cysts form secondary to involution of the breast lobules.

Diagnosis

One to three per cent of cysts have been associated with breast cancer displayed by internal shadows as seen on ultrasound. Abnormal borders are sometimes seen on mammogram. These abnormal cysts should be aspirated and, if bloody, sent for cytology. Cysts should be excised for the following reasons:

1. aspirate is bloody

2. residual mass exists after aspiration

3. persistent refilling after aspiration

Cysts that carry an increased risk of cancer are ones that are palpable or ones that develop in women at a young age.4 Cysts that have atypical hyperplasia also have an increased risk of cancer.3

Other Benign Masses

There are other less common benign masses in women. These include lipomas, found in women of all ages. They are soft, fleshy and mobile and are usually diagnosed by excision. Fat necrosis is another benign mass, resulting from trauma. Fat undergoes involution to become a hard palpable mass. Because this mass is hard,

distinguishing it from a malignant tumor is difficult. Diagnosis is often made by excision. Lymph nodes in the breast are sometimes palpable, but a mammogram can usually determine this to be a benign lesion.

Breast Abscess

Breast infection sometimes is present as a palpable indurated mass. These are seen in nonlactating and lactating women but are far more common in the latter. Early treatment with antibiotics can prevent abscess formation. Treatment of breast abscess involves drainage of the collection. This can be done with incision and drainage or repeated aspiration and antibiotics, usually nafcillin or amoxicillin, to cover S. aureus.5 More extensive and loculated collections may be aspirated with ultrasound guidance.6

If an underlying lesion is present after treatment, then biopsy must be performed to rule out carcinoma. If the lesion is solid at the first aspiration, biopsy must be performed to rule out inflammatory carcinoma.

Treatment of a lactating abscess also includes the continued drainage of milk of the affected segment. Antibiotics that cannot be used in breast feeding mothers include floxins, which causes abnormal cartilage formation; sulfas, an increase in free bilirubin by displacing it from albumin and resulting in secondary kernicterus; or tetracyclines creating abnormal teeth development.

Nonlactating abscesses can occur periareolar or peripherally. Periareolar abscess occur more often in young women that smoke.1 This, pathologically, is seen as inflammation around nondilated subareolar ducts and can progress to a mammary duct fistula creating a communication between the skin and a subareolar duct. This fistula is usually seen after incision and drainage of an abscess. Treatment is by excision of the fistula and duct and administrating antibiotics. Peripheral nonlactating abscesses are associated with immune compromise. They are seen in diabetics or women with chronic steroid use. Incision and drainage is only done if the overlying skin is compromised.

Nipple Discharge

Another benign complaint is nipple discharge. If the discharge is bilateral, a non-breast source is often the cause. This may indicate an increased prolactin level. This suggests a pituitary tumor or a medication side effect (e.g., an anti-psychotic drug [dopamine blocker] can also stimulate this). Nipple discharge is only worrisome if it is bloody or spontaneously drains from one duct. This can be a sign of an intraductal papilloma or an invasive cancer. The most common cause of bloody nipple discharge is a benign intraductal papilloma. Investigation usually requires a ductogram to isolate the involved duct that, then, undergoes excision.

1. True or false: Breast abscesses are treated primarily with incision and drain age.

A: False. They can usually be treated with aspiration and IV antibiotics. If a residual mass is present is should be biopsied.

2. Periareolar abscesses are seen in which patients?

A: Smokers

References

1. Dixon JD, Morrow M. Breast disease a problem based approach, 1st ed. London: W.B. Saunders, 1999:1-205.

2. Mansel RE. Breast pain. BMJ 1994; 309:866-868.

3. Dupont WD, Page DL, Parl FF et al. Long-term risk of breast cancer in women with fibroadenoma. NEJM 1994; 331(1):10-15.

4. Dixon JM, McDonald C, Elton RA et al. Risk of breast cancer in women with palpable cysts: A prospective study. Lancet 1999; 353:1742-1745.

5. Dixon JM. Breast infection. BMJ 1994; 309:946-949.

6. Schwarz RJ, Shrestha RS. Needle aspiration of breast abscesses. Am J Surg 2001; 182:117-119.

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