Congenital abnormalities
Amazia
Congenital absence of the breast may occur on
one (Fig. 46.13) or both sides. It is sometimes associated with absence of the
sternal portion of the pectoralis major (Poland’s syndrome). It is more common
in males.
Polymazia
Accessory breasts (Fig.
46.14) have been
recorded in the axilla (the most frequent site), groin, buttock and thigh. They
have been known to function during lactation.
Mastitis of
infants
Mastitis of infants is at least as common in
the male as in the female. On the 3rd or 4th day of life, if the breast of an
infant is pressed lightly, a drop of colourless fluid can be expressed; a few
days later there is often a slight milky secretion, which disappears during the
3rd week. This is popularly known as ‘witch’s milk’. It is due to
stimulation of the foetal breast by maternal prolactin, thus is essentially
physiological.
Diffuse
hypertrophy
Diffuse hypertrophy of the breasts occurs
sporadically in otherwise healthy girls at puberty and, much less often, during
the first pregnancy.
The breasts attain enormous dimensions (Fig.
46.15) and may reach the knees when the patient is sitting. The condition is
rarely unilateral. This tremendous overgrowth is apparently due to an alteration
in the normal sensitivity of the breast to oestrogenic hormones, and some
success in treating it with antioestrogens has been reported. Treatment is
otherwise by reduction mammoplasty.
Injuries of the
breast
Haematoma
Haematoma, particularly a resolving haematoma,
gives rise to a lump which, in the absence of overlying bruising, is difficult
to diagnose correctly unless it is aspirated or incised.
Traumatic fat
necrosis
Traumatic fat necrosis may be acute or
chronic, and usually occurs in stout, middle-aged women. Following a blow, or
even indirect
violence (e.g. contraction of the pectoralis major), a lump, often painless,
appears. This may mimic a carcinoma, even displaying skin tethering and nipple
retraction, and biopsy is required for diagnosis. A history of trauma is not
diagnostic as this may merely have drawn the patient’s attention to a
pre-existing lump.
Acute and
subacute inflammations of the breast
Bacterial
mastitis
Bacterial
mastitis is the commonest variety of mastitis and nearly always commences
acutely. Although associated with lactation in the majority of cases, it is not
necessarily so. Of 100 consecutive cases of breast abscess, 32 occurred in women
who were not lactating (De Jode). Some of these will be associated with an
infected haematoma or with periductal mastitis and this will be discussed later.
‘Cleansing
the baby’s mouth’ with a swab is also an aetiological factor. The delicate
buccal mucosa is excoriated by the process; it becomes infected, and organisms
in the infant’s saliva are inoculated on to the mother’s nipple.
Whilst
ascending infection from a sore and cracked nipple may initiate the mastitis, in
many cases the lactiferous ducts will first become blocked by epithelial debris
leading to stasis — this theory is supported by the relatively high incidence
of mastitis in women
Clinical
features. The affected breast, or more usually a segment of it, presents the
classical signs of acute inflammation. Early on this is a generalised cellulitis,
but later an abscess will form.
Treatment.
During the cellulitic stage the patient should be treated with an appropriate
antibiotic, e.g. flucloxacillin, and the breast rested, with feeding on the
opposite side only. The infected breast should be emptied of milk using a breast
pump. Support of the breast, local heat and analgesia will help to relieve pain.
If
an antibiotic is used in the presence of undrained pus, an ‘antibioma’ may
form. This is a large, sterile brawny oedematous swelling which takes many weeks
to resolve.
The
breast should be incised and drained if the infection does not resolve within 48
hours, or if, after being emptied of milk, there is an area of tense induration
or other evidence of an underlying abscess.
The
presence of pus can be confirmed with a needle aspiration, and the pus analysed
for the infection and for cytology. This has the advantage of allowing diagnosis
on the smear of a rare inflammatory carcinoma (Fig.
46.16). In contrast to the
majority of localised infections, fluctuation is a late sign and incision must
not be delayed until it appears. Usually the area of induration is
sector-shaped, and in early cases about one-quarter of the breast is involved (Fig.
46.17); in many late cases the area is more extensive (Fig.
46.18). When
in doubt an ultrasound scan may clearly define an area ‘ripe’ for drainage.
Drainage of an intramammary abscess. The usual incision is sited in a radial
direction over the affected segment, although if a circumareolar incision will
allow adequate access to the affected area this should be preferred because of a
better cosmetic result. The incision passes through the skin and the superficial
fascia. A long haemostat is then inserted into
Finally,
the haemostat having been withdrawn, a finger is introduced and any remaining
septa are disrupted. The wound may then be lightly packed with ribbon gauze or a
drain inserted to allow dependent drainage.
Mastitis from
milk engorgement
Mastitis from milk engorgement is liable to
occur around weaning time, and sometimes in the early days of lactation when one
of the lactiferous ducts becomes blocked with epithelial debris. In the latter
instance only a sector of the breast becomes indurated and tender.
Chronic
intramammary abscess
Chronic intramammary abscess which follows
inadequate drainage or injudicious antibiotic treatment is often a very
difficult condition to diagnose: when encapsulated within a thick wall of
fibrous tissue, the condition cannot be distinguished from a carcinoma without
the histological evidence from a biopsy.
Tuberculosis of
the breast
Tuberculosis of the breast, which is
comparatively rare, is usually associated with active pulmonary tuberculosis or
tuberculous cervical adenitis.
Tuberculosis
of the breast (Fig. 46.19) occurs more often in parous women and usually
presents with multiple chronic abscesses and sinuses and a typical bluish
attenuated appearance of the surrounding skin. The diagnosis rests on
bacteriological and histological examination. Treatment is with antituberculous
chemotherapy. Healing is usual although often delayed, and mastectomy should be
restricted to patients with persistent residual infection.
Actinomycosis
Actinomycosis of the breast is rarer still.
The lesions present the essential characteristics of faciocervical actinomycosis.
Syphilis of the
breast
A primary chancre of the nipple has been
referred to (above). Secondary lesions of syphilis include diffuse syphilitic
mastitis.
Mondor’s
disease
Mondor’s disease is thrombophlebitis of the
superficial veins of the breast and anterior chest wall (Fig.
46.20) although it
has also been encountered in the arm.
In
the absence of injury or infection, the cause of thrombophlebitis —like that
of spontaneous thrombophlebitis in other sites — is obscure. The pathognomonic
feature is a thrombosed subcutaneous cord, usually attached to skin. When the
skin over the breast is stretched by raising the arm, a narrow, shallow
subcutaneous groove alongside the cord becomes apparent. The differential
diagnosis is lymphatic permeation from an occult carcinoma of the breast. The
only treatment required is restricted arm movements, and in any case the
condition subsides within a few months without recurrence, complications or
deformity.
Duct ectasia/periductal
mastitis
Pathology
This is a dilatation of the breast ducts
associated with periductal inflammation, the pathogenesis of which is obscure
and almost certainly not uniform in all cases, although the disease is much more
common in smokers.
The
classical description of the pathogenesis of duct ectasia asserts that the first
stage in the disorder is a dilatation in one or more of the larger lactiferous
ducts which fill with a stagnant brown or green secretion. This may discharge.
These fluids then set up an irritant reaction in surrounding tissue leading to
periductal mastitis or even abscess and fistula formation (Figs 46.21 and
46.22). In some cases a chronic indurated mass forms beneath the areola which
mimics a carcinoma.
Fibrosis
eventually develops which may cause slit-like nipple retraction.
An
alternative theory suggests that periductal inflammation is the primary
condition and anaerobic bacterial infection is found in some cases.
An
association between recurrent periductal inflammation and smoking has been
demonstrated which may suggest that arteriopathy is a contributing factor in its
aetiology.
Clinical
features
Nipple discharge (of any colour), a subareolar
mass, abscess, mammary duct fistula and/or nipple retraction are the commonest
symptoms (Fig. 46.23).
Treatment
In the case of a mass or nipple retraction, a
carcinoma must be excluded by obtaining a mammogram and negative cytology or
histology. If any suspicion remains the mass should be excised.
Antibiotic
therapy may be tried, the most appropriate agents being flucloxacillin and
metronidazole.
Aberrations of
normal development and involution (ANDI)
Nomenclature
The nomenclature of benign breast disease is
very confusing. This is because over the last century a variety of clinicians
and pathologists has chosen to describe a mixture of physiological changes and
disease processes according to a variety of clinical, pathological and
aetiological terminology. As well as leading to confusion, patients were often
unduly alarmed or overtreated by ascribing a pathological name to a variant of
physiological development. To sort out this confusion, a new system has been
developed and described by the Cardiff Breast Clinic2 — ANDI. (Many
alternative terms have been applied to this condition including fibrocystic
disease, fibroadenosis, chronic mastitis and mastopathy.)
A etiology
The breast is a dynamic structure which
undergoes changes throughout a woman’s reproductive life, and superimposed
upon this, cyclical changes throughout the menstrual cycle. This is illustrated
in Fig. 46.24. The pathogenesis of ANDI involves disturbances in the breast
physiology extending from an extreme of normality to well-defined disease
processes. There is often little correlation between the histological appearance
of the breast tissue and the symptoms.
Risk of
malignancy developing in association with benign breast pathology
These relative risks according to different
histological features found at biopsy are illustrated in Table
46.1.
Pathology
The disease consists essentially of four
features which may vary in extent and degree in any one breast.
1.
Cyst formation. Cysts are
almost inevitable and very variable in size.
2.
Fibrosis. Fat and elastic
tissue disappears and is replaced by dense white fibrous trabeculae. The
interstitial tissue is infiltrated with chronic inflammatory cells.
3.
Hyperplasia of epithelium in
the lining of the ducts and acini may occur with or without atypia.
4.
Papillomatosis. The epithelial hyperplasia
may be so extensive that it results in papillomatous overgrowth
within the ducts.
Clinical
features
The symptoms of ANDI include an area of
lumpiness (seldom discrete) and/or breast pain (mastalgia).
A
benign discrete lump in the breast is commonly a cyst or fibroadenoma. True
lipomas occur rarely.
Lumpiness
may be bilateral, commonly in the upper outer quadrant, or less commonly
confined to one quadrant of one breast. The changes may be cyclical, with an
increase in both lumpiness and often tenderness before a menstrual period.
Noncyclical
mastalgia is commoner in perimenopausal and postmenopausal women. It may be
associated with ANDI or with periductal mastitis, or referred from, for example,
a musculoskeletal disorder. About 10 per cent of breast cancers exhibit pain at
presentation. Common breast symptoms are illustrated in Table
46.2.
Treatment of
lumpy breasts
If the clinician is confident that he or she
is not dealing with a discrete abnormality (and clinical confidence may be
buttressed by mammography or ultrasound scanning if appropriate), then initially
the woman can be offered firm reassurance. It is perhaps worthwhile reviewing
the patient at a different point in the menstrual cycle, say 6 weeks after the
initial visit, and often the clinical signs will have resolved by that time.
There is a tendency for women with lumpy breasts to be rendered unnecessarily
anxious and to be submitted to multiple random biopsies because the clinician
lacks the courage of his or her convictions.
Treatment of
mastalgia
For
noncyclical mastalgia it is important to exclude extramammary causes such as
chest wall pain, and it may be necessary to carry out a biopsy on a very
localised tender area which might be harbouring a subclinical cancer. Treatment
may be with nonsteroidal analgesics or by injection with local anaesthetic of a
‘trigger spot’.
Breast cysts
These occur most commonly in the last decade
of reproductive life due to a nonintegrated involution of stroma and epithelium.
They are often multiple, may be bilateral and can mimic malignancy. Diagnosis
can be confirmed by aspiration and/or ultrasound.
Treatment
A solitary cyst or small collection of cysts
can be aspirated. If they resolve completely, and if the fluid is not
bloodstained, no further treatment is required. However, 30 per cent will recur
and require reaspiration. Cytological examination of cyst fluid is no longer
practised routinely. If there is a residual lump or if the fluid is
bloodstained, a local excision for histological diagnosis is advisable, as is
also the case if the cyst repeatedly reforms.
Galactocele
Galactocele, which is rare, usually presents
as a solitary, subareolar cyst, and always dates from lactation. It contains
milk and in longstanding cases its walls tend to calcify. It can become
enormous (Fig. 46.25).
These usually arise in the fully developed
breast during the 15—25-year period, although occasionally they occur in much
older women. They arise from hyperplasia of a single lobule, and usually grow up
to 2—3 cm in size. They are surrounded by a well-marked capsule and can thus
be enucleated through a cosmetically appropriate incision. However, in a patient
under 30 years these do not require excision unless associated with suspicious
cytology, or if they become very large, or if the patient expressly desires the
lump to be removed.
Phyllodes
tumour
These benign tumours, previously sometimes
known as serocystic disease of Brodie or cystosarcoma phyllodes, usually occur
in women over the age of 40 but can appear in younger women (Fig.
46.26). They
present as a large, sometimes massive tumour, with an unevenly bosselated
surface. Occasionally ulceration of overlying skin occurs owing to pressure
necrosis. In spite of their size they remain mobile on the chest wall.
Histologically there is a resemblance to a fibroadenoma, but despite the name of
cystosarcoma phyllodes they are rarely cystic and only very rarely develop
features of a sarcomatous tumour. These may metastasise via the bloodstream.
Treatment for the benign type is enucleation
in very young women or wide local excision. Massive tumours, recurrent tumours
and those of the malignant type will require mastectomy.
There will always be cases where the clinician
cannot be sure whether a particular lump in the breast is an area of mammary
dysplasia, a benign tumour or an early carcinoma.
If
there is doubt on either clinical, cytological or radiological examination it
is essential to obtain a tissue diagnosis. This is often possible by needle
biopsy. In the advent of a negative result, open biopsy of the mass is
necessary. Because of the possibility of reporting errors, the authors suggest
that frozen section reporting should rarely be used and certainly should not
form the basis for a decision to undertake a