Breast Disorders

Breast Disorders

*Breast pain
*Fibrocystic change
*Nipple discharge
*Breast infection
*Phyllodes Tumor
*Paget's Disease

Breast Tests --Breast MRI, Breast Ultrasound, Breast Mommogram and Ductogram ---extensive information on what diagnostics help with these and many other types of breast concerns.

Breast Pain- Breast Disorder

Breast pain is a common complaint or breast disorder and a source of great distress for many women. The medical term for breast pain is mastodynia. Breast pain can occur in a cyclic fashion corresponding with the onset of your periods, or it can be non-cyclic. Non-cyclic breast pain does not have easily identifiable triggers.

The key to the evaluation of breast pain is to make sure there is no underlying problem that is the source of the pain. This includes a complete breast examination as well as a mammogram and/or ultrasound depending on the woman’s age. If there is no underlying abnormality as the cause of the pain, it is generally due to hormonal stimulus.

Post-menopausal women on estrogen supplements may find a relief in their breast discomfort by lowering the dose of the supplemental estrogen or by discontinuing it entirely. For women not on supplemental estrogen, a variety of tools can be utilized to manage the pain. This may include anti-inflammatory medications such as Motrin or Aleve or or in some cases hormonal manipulation.

For women who have cyclic breast pain, controlling the breast pain may require use of oral contraceptives to modulate the hormonal changes during the menstrual cycle. In addition, the drug, Danazol, most commonly used for management of endometriosis, can be very effective in reducing breast pain. For mild cases evening primrose oil, a fatty acid supplement, can provide relief of symptoms if taken regularly over a period of several weeks.

Fortunately, most breast pain is not constant or severe and is often a self-limiting breast disorder.

Fibrocystic Change -Breast Disorder

Fibrocystic changes are commonly present in an otherwise normal breast–this is not a breast disease that requires treatment per se. The term fibrocystic mastopathy is used to describe dense “lumpy” breasts. Excessive caffeine consumption can cause the development of fibrocystic changes.

Women with fibrocystic changes may notice a palpable lump during their self-examination or a mammogram may show that a particular area of the breast is unusually dense. Finding a lump such as this can create significant anxiety so it's important to have a complete evaluation to acess the lump and determine if there is an actual mass or cyst. This evaluation includes a breast examination by your physician as well as additional breast imaging, including additional mammographic views or an ultrasound. When physical examination and breast imaging cannot completely resolve the underlying cause of the lump or density, a biopsy may be recommended. In most cases, the biopsy will be done using a fine needle aspiration, which entails placing a small needle into the palpable thickening and extracting a sample of cells for examination. If there is concern that a fine needle aspiration will not make the diagnosis, than a core needle biopsy which obtains a slightly larger sample of breast tissue may be performed.

If you have fibrocystic breasts it does not mean that you are at greater risk of developing breast cancer. It is true however, that women with fibrocystic breasts may have more difficult to interpret mammograms. If this is the case, then breast ultrasound is often utilized along with screening mammography to further evaluate areas on the mammogram that may be too dense for accurate assessment.

Fibrocystic breast changes do not necessarily require any treatment. Women with symptomatic fibrocystic changes particularly women with breast pain may be counseled to limit their caffeine intake or to undergo drainage of large cysts if they are present.

Nipple Discharge- Breast Disorder

Nipple discharge is a common breast symptom or breast disorder and one that can be particularly alarming when first discovered. There are many underlying causes of nipple discharge. The breast specialist’s job is to differentiate the serious underlying causes of nipple discharge from those that do not require any further evaluation. Benign conditions such as fibrocystic change, duct ectasia, and periductal mastitis can all create nipple discharge that emanates from both breasts and is generally present from more than one duct. The discharge is usually cloudy and may be green, dark or gray. This type of discharge generally is present with manipulation of the nipple and occasionally can be stimulated by taking a shower.

Generally, a complete breast exam of this breast disorder and a close examination of the nipple discharge will be done to determine what may be causing the discharge. A mammogram and an ultrasound, that would evaluate the main milk ducts behind the nipple, may be used.

If the discharge is not concerning and the mammogram and ultrasound show no suspicious findings, then you can be assured that there is no problem.

Women who develop a discharge that is spontaneous, that is, does not require manipulation to identify, and comes from a single breast and usually a single duct will need more extensive evaluation. This discharge is generally clear yellow, also called serous, or bloody. Although this type of discharge does not mean there is an underlying breast cancer, it is very important to have an extensive evaluation so it can be excluded.

A complete breast examination as well as a mammogram and ultrasound may be performed. In many cases the discharge will not be associated with any underlying abnormality on mammogram or ultrasound. For a discharge from a single duct in one breast a ductogram is very helpful to evaluate the lining of the offending milk duct. This procedure involves placing a small catheter into the opening of the duct and injecting a contrast material which will outline the duct providing a roadmap picture. A mammogram is then taken to define the duct anatomy.

In the vast majority of cases the discharge is related to underlying growth in the duct called a papilloma. Papillomas are rarely malignant but generally will require a surgical procedure to remove the duct containing the papilloma to insure there is no underlying early form of breast cancer.

Breast Infection -Breast Disorder

Breast infections are classified as breast abscesses or as mastitis.

Abscesses

Abscesses are well defined collections of infected material or pus that generally require some form of drainage for management. With this breast disorder symptoms will typically include redness or warmth in the area of the abscess and breast pain. Infections including fever or chills may be present.

Breast abscesses that occur directly behind the nipple are often caused by a condition known as periductal mastitis or duct ectasia. These types of breast abscesses as a breast disorder are notorious for their ability to recur even after satisfactory drainage and antibiotic therapy. Multiple recurrences of abscesses behind the nipple may eventually lead to the recommendation to have the diseased ducts surgically removed.

Abscesses that occur further away from the nipple in other quadrants of the breast can be seen in the immediate post-partum period. These abscesses may respond to drainage using a needle-guided approach but occasionally will require surgical drainage in addition to antibiotic therapy.

Breast abscesses in post-menopausal women that occur outside of the nipple area require special consideration. Without an underlying cause such as lactation or periductal mastitis, it is uncommon for post-menopausal women to develop abscesses. It is important to perform a thorough imaging evaluation including mammogram and ultrasound to exclude an underlying breast cancer. Drainage of an abscess in this age group always requires close followup to make sure there is not an underlying breast tumor.

Mastitis

Mastitis refers to an infection in the soft tissue of the breast, but no well-defined collection that requires drainage. This is most commonly seen in women who are lactating and breastfeeding. Most cases of mastitis will respond to antibiotic therapy. Severe cases may require intervenous antibiotics and when symptoms begin to improve, oral antibiotics can be utilized. Women who are beyond childbearing age who develop symptoms of diffuse redness in one breast should be evaluated for inflammatory carcinoma.

Phyllodes Tumor

Phyllodes tumors are rare solid lumps that usually present as a mass found during a woman’s breast self-examination or on a routine physical examination. Smaller masses may be detected mammographically. Phyllodes tumors appear very similar to a benign lump known as a fibroadenoma breast disorder. These lumps are usually well circumscribed and painless. Imaging evaluation including a mammogram and ultrasound is usually performed and when a solid lump is identified a biopsy is important to obtain tissue for accurate diagnosis. A phyllodes tumor cannot be differentiated from a fibroadenoma by a needle biopsy. This means that your doctor may not be able to accurately tell you whether a solid lump is a benign fibroadenoma or a phyllodes tumor. Risk factors for phyllodes tumor are rapid growth and size greater than 2 cms at the time of the evaluation. In many cases your doctor may recommend complete surgical removal of this mass to ensure that it is not an underlying phyllodes tumor for this breast disorder.

Phyllodes tumors are not all cancerous. Many will be classified as benign and not require further evaluation. A skilled pathologist is needed to distinguish a benign phyllodes tumor from one with more aggressive malignant potential. In any event, women who undergo surgery for removal of a phyllodes tumor require close surveillance with followup mammogram and physical examination at regular intervals. Malignant phyllodes tumors are best managed with a wide excision of normal breast tissue around the tumor to obtain clean margins. In most cases, radiation therapy is not required. Very large malignant phyllodes tumors may require complete removal of the breast for management.

Paget's Disease- Breast Disorder

Paget’s Disease is the identification of breast cancer cells within the skin around the nipple. Women may notice the development of redness, itching or peeling of the skin on the nipple of their breast in this breast disorder. Nipple discharge may be absent. The diagnosis of Paget’s Disease can be made by performing a biopsy of the nipple skin. In the vast majority of cases Paget’s disease of the nipple is associated with an underlying breast cancer. Most often the underlying breast cancer is an intraductal carcinoma also known as ductal carcinoma in situ. Thorough evaluation includes a complete breast examination as well as a diagnostic mammogram of the effected side. If an underlying suspicious lesion can be identified by mammography, this should be biopsied to confirm the diagnosis. Women identified with Paget’s Disease and an underlying breast cancer are most often managed with a total mastectomy, however, there are exceptions to this rule. A skilled breast specialist can help a woman decide whether she would be a candidate for breast preservation under these circumstances.

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