Breast Lumps
Problems
Problems benign | pain | discharge | lumps | male problems

 

Breast Lumps

 

There are many different types of breast lumps. An ultrasound is used to tell what a lump is. Most lumps are not breast cancer.

 

Developmental abnormalities in breast embryology

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The nipple may fail to evert, giving rise to an inverted nipple, which is thus congenital (present from birth).  If a woman suddenly develops an inverted nipple in adulthood, this should be checked by a doctor as it may be the first sign of breast cancer. Management of congenital nipple inversion can both be undertaken by manual techniques or surgery.

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Supernumerary or additional breasts or nipples may develop along the milk line or milk streak, a reminder of the embryology of the breast in more primitive animals. During pregnancy and lactation this supernumary breast tissue and nipples may enlarge and even produce milk.  If it is of concern to the patient surgical removal of the tissue can be undertaken.

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Breast absence or amazia.  If something goes wrong with the embryological development, such as a genetic abnormality or if the pregnant mother is exposed to some poison (toxin, such as a toxic drug, or a virus), the breast may fail to develop. This can be managed by reconstructive surgery. The most important step is to ultrasound the normal breast and to ensure that there are no masses. No surgical removal of the normal breast must be done.

 

Breast enlargement in the baby

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Occasionally, female sex hormone (oestrogens) crosses the placenta in increased quantities prior to birth. This results in a breast bud in the young infant.

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It is essential that these small breast buds are not squeezed or biopsied, as this can affect normal development of the breast.
No treatment is required and the problem disappears within a few months after the birth.

 

Prepubertal breast development

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This is a type of premature breast development which often occurs on one side only.  The breast will develop without any problems. Occasionally this is seen in young toddlers or pre-teenagers.

 

Management

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No treatment is required except for firm reassurance that all is fine.

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Investigations may be done to ensure no other secondary sexual development is occurring. These breasts should NOT be biopsied without a specialist opinion. Only a breast ultrasound should be done.

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Open surgical biopsies will interfere with breast development.


Breast masses can be divided into inflammatory masses and non-inflammatory masses, solid and cystic masses.  It is most important to determine that the mass is not a cancer.  A triple assessment of a clinical examination, either sonar and /or a mammogram should be obtained (depending on the age of the women) as well as a core needle biopsy.

 

Solid Masses

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Fibroadenoma
Fibroadenomas are highly mobile (breast mouse), round, smooth, firm masses in the young woman’s breast, usually present in the teenager and the early twenties. Fibroadenomas arise from lobules and show hormonal dependence similar to the lobules from which they develop. Most fibroadenomas are 1 - 2 cm in size and growth beyond 5 cm is unusual. They may be multiple. These lumps are quite innocent and can be left well alone.  They may disappear spontaneously.  The clinical diagnosis of fibroadenomas may be incorrect in up to 50% of patients and it is for this reason that all patients with these masses should have a triple assessment of a clinical examination, an ultrasound and a needle biopsy.

Six month follow-up is mandatory to see if the fibroadenoma is growing.

If the patient is worried about the lump, a core biopsy will reassure her in most cases.  If still worried (when there is a strong family history of breast cancer), the lump should be removed to allay her fears.  Indications for surgery are:

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Pain or other symptoms.

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Size greater than 3 cm.

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Cosmesis.

When these tumours reach giant proportions (giant intracanalicular fibroadenoma), it is generally advisable to remove them, as they cause a lot of distress, and distort the breast simply due to their unwieldy size.

Fibroadenomas may increase in size (20%), decrease in size (30%) or remain the same size (50%).

During pregnancy and lactation the size of fibroadenomas may also vary. Fibroadenomas in pregnancy should also be managed by sonar and needle biopsy. They do not interfere with breastfeeding.

Calcified fibroadenomas are sometimes found in the elderly as hard discrete mobile masses that are readily identified on mammography.

Surgical excision should always be done through cosmetic incisions with attention to moving around local breast tissue so as not to leave an unsightly dent in the breast.

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Cystosarcoma Phyllodes (Phyllodes tumour)
There is a rare growth that may be confused with a fibroadenoma. This is the phyllodes tumour, which is more aggressive than fibroadenomas. They can be more difficult to diagnose, therefore a rapidly growing breast mass (one that has increased by over a 1 cm in six months) should be excised. Needle biopsy can be inaccurate with phyllodes tumours but are nevertheless the best place to start. Because they have the capacity to recur after removal by lumpectomy, and also because around 10% – 20% show features of malignancy (rarely they can spread, more commonly they reoccur locally and more aggressively), a procedure involving wide local removal with at least a 1 cm - 2cm margin is essential.This will always require some form of breast reconstruction when operating on the patients.

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Solid Cystic Masse

Breast Hamartomas (Fibroadenolipoma)
Hamartomas of the breast usually present as painless palpable masses. They are often underestimated by medical professionals and not well recognised. They are larger and softer than fibroadenomas and may account for some diagnostic confusion when biopsied, as the cells are difficult to differentiate from atypical cells on FNA (fine needle aspiration). A core biopsy is recommended for diagnosis.Hamartomas have a distinct picture on mammogram showing a circumscribed density separated from normal breast tissue by a thin radiolucent zone. If clinical examination and investigations cannot be correlated, surgical excision is recommended.

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Galactocele – presents as a breast lump
This is simply a milk retention cyst, where no bacterial infection occurs. It can be treated by needle aspiration (the removal of a sampleof flid and cells through a needle) and milk suppression. Surgical excision can also be performed with the use of reconstructive techniques.

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Fat necrosis
Severe breast trauma (a motor vehicle accident or being punched in the breast) may cause fat necrosis, which can mimic breast cancer. A core biopsy will usually resolve the issue, if the clinician is worried about an underlying cancer. In a young woman with a hitory of trauma, all that is required is reassurance aonce investigations confirm that this is fact necrosis (materly inactivity by the attending doctor).

 

Breast Abscesses

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Lactating breast abscess

Unsatisfactory breastfeeding may cause milk retention and stasis(the stoppage or diminution of flow).  Infection soon results. This can be adequately treated with antibiotics early on (during the cellulitis or mastitis phase). 

During this phase the frequent expression of milk will help prevent stasis and progressive infection. Cabbage leaves kept cold in the fridge also provide relief from the discomfort.

Note that the baby must continue to feed on the contralateral breast to prevent a breast abscess developing there. Also, milk must be expressed from the ipsilateral breast (the one with the abscess) that is involved in the inflammatory process.

Unsatisfactory breastfeeding may cause milk retention and stasis(the stoppage or diminution of flow).  Infection soon results. This can be adequately treated with antibiotics early on (during the cellulitis or mastitis phase). 

During this phase the frequent expression of milk will help prevent stasis and progressive infection. Cabbage leaves kept cold in the fridge also provide relief from the discomfort.

Note that the baby must continue to feed on the contralateral breast to prevent a breast abscess developing there. Also, milk must be expressed from the ipsilateral breast (the one with the abscess) that is involved in the inflammatory process.

The current recommended treatment is high dose antibiotics (Augmentin is the drug of choice and safe in breastfeeding mothers) as well as repeated ultrasound guided aspiration (we seldom have to resort to surgical incision and drainage procedures today).

If the mother or doctor wants to stop breastfeeding, lactation can be suppressed with fluid restriction and bromocriptine (antiprolactin).

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Non-lactating Breast Abscesses
Breast abscesses can occur in circumstances other than lactation. 

They can commonly be a complication of duct esctasia, or less frequently caused by underlying malignancies, TB or HIV/AIDS. Superficial skin lesions (boils, sebaceous cysts and recurrent skin abscesses can also occur).

Management
Antibiotics and ultrasound-guided drainage are the initial treatment modalities. This is followed in certain complicated cases by surgical drainage with biopsy of the abscess wall.

An antibiotic must be used in the mastitis and/or abscess phase.

Antibiotic of choice is Augmentin if no penicillin allergy is present. Other options if the patient is allergic to penicillin are bactrim or a quinolone.

 

Cysts

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Breast Cyst
Breast cysts usually occur in the premenopausal period (35 to 50 years of age). They may be single or multiple.  About 5% of women develop a breast cyst.  They normally contain around 20ml of fluid.  They are easily diagnosed using sonar (ultrasound).  Treatment is by follow-up or aspiration.  The fluid is usually yellow or greenish. Ultrasound is crucial to see it. The cyst is simple or complex. Complex cysts require aspiration and occasionaly excursion.

Provided there is no blood (red or black) in this fluid and that there is no residual lump remaining after the aspiration, no further treatment is necessary.  If there is blood or a residual lump, further evaluation is mandatory.  This takes the form of sending the aspirate for cytology (it is a good principle to send all aspirates for cytology) and then to biopsy the residual mass if present under radiological guidance or to excise it surgically.

 

Fibroadenosis (and cyclical breast pain)
Breasts alter cyclically with the different stages of the menstrual cycle. In the week prior to menstruation, the breast normally increases in size and sometimes becomes nodular, with pain. This can mimic a breast mass.  The term fibroadenosis is confusing and misleading and represents what is going on inside the breast at a tissue level. Breasts are uniquely different to palpation (examination with the hands), some are smooth, some are nodular and the term should not be used so as to imply a disease of the breast. All breasts have a certain amount of fibrosis and adenosis and disease should be attributed to a woman with breast symptoms. If concerned, a breast ultrasound can aid the clinician in determining whether this is a mass or just nodularity.

It should be noted that many healthcare practitioners prefer the name "benign breast disease" to fibroadenosis.