COMMON BREAST CONDITIONS

Breast pain is the commonest symptom for a patient being referred into clinic, and thankfully is rarely a sign of breast cancer. It is increasingly common in patients as they near the time of menopause although breast pain can occur at any age. Common causes include:

• Changes in hormone levels around the time of menopause
• Shoulder or neck injury
• Chest wall inflammation
• Medication – oral contraceptive pill / contraceptive implant / HRT
• Mastitis or breast infection / abscess
• Pregnancy

It is common to arrange a test such as a mammogram for patients who attend because of concerns about pain, or occasionally an ultrasound scan. Many patients can be reassured with breast pain, and we can discuss means of reducing and improving your symptoms after your assessment.

Breast cysts are small fluid filled spaces within breast tissue. They are most common in women from their forties onwards as they approach menopause, and often present with a lump in the breast. They are not pre-cancerous and do not increase your risk of developing breast cancer.

How are breast cysts diagnosed?

The following tests may be performed:

• Clinical breast exam
• Mammogram
• Ultrasound
• Fine needle aspiration of the cyst

What is the treatment for breast cysts?

Breast cysts often require no specific treatment, but do so if they are large or causing pain. Treatment consists of a fine needle aspiration of the cyst, where the fluid is removed using a syringe under ultrasound guidance.

Fibroadenomas are solid, benign breast lumps that are common in young women. They can increase in size during puberty, pregnancy, breastfeeding and as women head towards the menopause.

How are fibroadenomas diagnosed?

If you find a lump in your breast, you should be referred to the breast clinic. Following a discussion of your symptoms and breast examination the following tests may be performed:

• Mammogram (in women over 40 years old)
• Ultrasound
• Ultrasound guided breast biopsy if required ( frequently recommended in women over 30 years old with lumps suggestive of a fibroadenoma)

Following a biopsy, a further appointment will be arranged so we can discuss the outcome of the biopsy, normally within a week. All biopsies (including non-cancerous biopsies like fibroadenomas) are discussed at the MDT to ensure transparency of patient care and decision making.

What is the treatment for fibroadenomas?

Many fibroadenomas do not continue to enlarge and may shrink over time, but if fibroadenomas are large or are causing discomfort they may require surgical removal. This is normally done in the operating theatre under a general anaesthetic but often as a day case procedure.

Duct ectasia is a benign, non- cancerous condition caused as breast tissue ages. It may not cause any symptoms at all, but can occasionally cause the nipple to become pulled inwards (inverted) as the milk ducts become shorter and widened. It can also lead to nipple discharge which may vary in colour including cream, green, brown, watery and on occasion blood-stained.

How is duct ectasia diagnosed?

After referral to the breast clinic we will discuss your symptoms, and you will be offered a breast examination. It is common to recommend a mammogram (breast x-ray) and an ultrasound scan.

What is the treatment for duct ectasia?

Most cases of duct ectasia don’t need any specific treatment as it is not a condition which puts you at any health risks, and does not increase your risk of breast cancer. If you continue to have discharge from the nipple which doesn’t settle and has a significant impact on your quality of life, you may choose to undergo an operation to disconnect and remove the milk ducts below the nipple to treat these symptoms.

This operation is normally carried out under a general anaesthetic in the operating theatre and can often be done as a day case procedure. Some younger patients may choose to have only part of their milk ducts removed if they wish to consider breast feeding in the future, but many patients may choose to have all the ducts below their nipple removed. It leaves a scar around the edge of the lower half of the areola skin which will often fade in the fullness of time leaving a good aesthetic outcome.

As with any operation, there are advantages and disadvantages which are important to consider when deciding if it is the right thing for you to undertake.

Periductal mastitis occurs when the tissue containing the milk ducts under the nipple and areola skin become inflamed and infected. It’s a benign condition which can affect women of all ages but is more common in younger women and smokers.

Symptoms include:

• the breast becoming tender and hot to the touch
• the skin may appear reddened
• discharge from the nipple, which can be bloody or non-bloody
• Discharge from the area of skin change on the breast
• a pulled-in (inverted) nipple.

Occasionally, a collection of pus (abscess) or an abnormal opening between the duct and the skin may develop (fistula).

People who smoke have a significantly increased risk of being affected by periductal mastitis, because some chemicals in cigarette smoke can cause inflammation in the ducts behind the nipple. Nipple piercings can also increase the chances of infection and make periductal mastitis more difficult to treat.

How is periductal mastitis diagnosed?

The condition is normally relatively easy to identify on clinical examination, but it is common to arrange investigations such as a mammogram and ultrasound scan to confirm this.

If you have discharge from the nipple or breast, a sample may be sent to check for any evidence of active infection and to help guide the use of antibiotics.

What is the treatment for periductal mastitis?

Some people may not need any treatment for periductal mastitis as it can clear up by itself. Continuing to smoke can prevent the inflammation from clearing up, so if you smoke it’s a good idea to try to cut down or to stop.

You may also want to take pain relief as the breast is frequently painful with this condition, and antibiotics may be required.

If you have developed an abscess then it may need to be drained, but this may often be done using a fine needle and syringe to draw off any pus. It is uncommon to need an operation for this condition.

If periductal mastitis doesn’t get better after taking antibiotics or if it comes back repeatedly, you may need to consider having an operation to remove the affected duct or ducts. As with all surgery, there are risks as well as benefits to an operation, and it is important that any questions you have about surgery are answered before you commit to an operation.

An intraductal papilloma is a benign, non-cancerous breast condition. It is most common in women over 40 and may develop as their breast tissue changes with age.

A papilloma is a small wart-like lump which may develop in one of the milk ducts. It is usually close to the nipple, but can sometimes be found elsewhere in the breast. It may cause clear or bloodstained discharge from the nipple, or less commonly a lump. Generally speaking it is not painful.

Intraductal papillomas don’t change into breast cancer, but some types of papilloma (atypical or multiple papillomas) may be linked with an increased risk of developing breast cancer in the future.

How are papillomas found and treated?

Intraductal papillomas can be found by chance following breast screening or after investigations for nipple discharge, a breast lump or breast pain. They are often best seen on a breast ultrasound scan and if suspected you may be offered a local anaesthetic biopsy during this scan.

If the initial biopsy confirms a papilloma, you may be offered a vacuum assisted biopsy ( VAB) at a later date in order to remove the whole lesion. This allows the laboratory staff to examine the whole papilloma in detail down the microscope (to be sure there are no atypical features) and should also stop or reduce symptoms like nipple discharge.

Occasionally, if the papilloma is very close to the skin of the breast, or if there are any atypical features on the original biopsy, then a surgical excision biopsy may be recommended. This is normally carried out in the operating theatre under a general anaesthetic, but can usually be done as a day case procedure.

If a papilloma is found to have any atypical features, it is likely that screening mammograms will be offered more frequently than three yearly NHS Breast Screening Programme.