Breast Disfigurement and Support Problems

Background - importance and magnitude of problem
Diagnostic goals - for overall category

Congenital anomalies

• asymmetry
• polythelia/polymastia
• amastia/athelia
• nipple retraction
• hypoplasia
• tuberous
• congenital absence of pectoralis mucscle (Poland's syndrome)
• macromastia


• menarchal (virginal) hypertrophy
• macromastia drug induced
• breast atrophy
• breast ptosis
• pseudo ptosis post pregnancy

Background

Congenital birth defects and physiologic changes which alter breast appearance are fairly common. Breast hypertrophy at the time of the onset of a woman's menstrual periods and breast atrophy at cessation of a woman's menstrual periods during menopause, are the rule rather than the exception. The degree to which the breasts hypertrophy or atrophy, however, is what results in disfigurement. Those excessive changes may require therapy. While breast asymmetry is quite a common finding, asymmetry to the extent that it requires surgical therapy is unusual. Birth defects such as polythelia (accessory nipples) and inversion of the nipples are common. Most of the time, however, these are treated as minor disfigurements and do not require any therapy.

With the exception of drug induced macromastia, all of the disfigurement and support problems are possible candidates for surgical therapy (usually plastic surgery) only if they negatively affect a woman's self image. If a woman has increased stress or anxiety about these findings or her concern about them results in altering her daily physical, work or social activity, she may benefit from surgical therapy. Since any surgical treatment may result in chronic pain or disfigurement by scaring, consequences of surgical therapy must be weighed against the improvement in self image and its result on health that will come about.

Breast skin lesions

Flat lesions

• Paget's disease
• areolar excoriation
• allergic eczematous dermatitis
• scabies (sarcoptes scabiei)
• hemorrhagic necrosis of breast skin
• intertrigio

Raised lesions

• seborrheic keratosis
• Fox-Fordyce disease
• molluscum contagiosum
• metastatic cancer


• periareolar hair growth

Background

The skin of the breast is subject to any inflammatory or neoplastic process that any skin is subject to. Inflammation such as dermatitis or interigio are fairly common as are raised lesions of seborrheic keratoses. Most of the other flat (macular) or raised (papular) lesions are uncommon but their precise diagnosis is important in order to specifically direct therapy.

The primary goal of diagnosing a breast skin lesion is to rule out a malignant process such as metastatic carcinoma or Paget's disease of the breast, a non-invasive cancer but associated with deeper cancers. Except for seborrheic keratoses and papillomas of the skin in the creases underneath the breast which both have a characteristic appearance, any raised lesion should be biopsied. Inflammatory lesions may be treated initially with antibiotic or antifungal creams but if they do not respond completely to those regimens, they require biopsies to rule out Paget's disease. Most lesions that occur in the skin contact area of bra undergarments should be removed so they do not become ulcerated and chronic.

Breast pain - cyclic and bilateral

• premenstrual mastalgia
• cystic breast disease
• fibroadenosis
• exogenous estrogens
• marijuana/street drugs
• exercise related (running, weight lifting)

Background

Breast tenderness just prior to the menstrual period during the reproductive years is a common finding. The cyclicity and bilaterality usually parallel hormonal changes or the menstrual cycle. Both estrogen, which stimulates ductal growth of the breast and progesterone, which stimulates glandular growth of the breast can be associated with or cause breast pain. In the second half of the menstrual cycle both of these hormone levels are high.

Goals

Since any breast pain can worsen premenstrually due to hormonal changes, it is important to make sure that there is not pain that persists throughout all or most of the menstrual cycle. Those entities would fall in a different diagnostic group. Since this group contains mostly benign entities, determination of the pain's bilateral nature and lack of persistence throughout the month is very important. Cyclic but irregular manifestations of breast pain may be present with exercise related problems or marijuana abuse. Fibrocystic changes are determined by physical examination whereas physical findings in the other entities in this category are usually unremarkable.

Return to choices || Top of page

Breast pain - noncyclic or unilateral

acute mastitis

• staphloccal
• streptoccal (erysipelas)
• plasma cell


• trauma
• hemorrhage
• fat necrosis
• sclerosing adenosis
• thrombosis (Mondors syndrome)
• infarction of adenofibroma during pregnancy
• duct ectasia
• costochondral joint inflammation (Tietze's syndrome)

Background

Except for infectious conditions of the breast associated with nursing an infant, most breast infections are relatively uncommon. A sudden thrombosis or infarction is usually related to trauma or surgery but can occur spontaneously.

Goals

In general, malignant processes of the breast do not present with breast pain, therefore most of these conditions are treated medically rather than surgically. With an infectious condition of the breast, it is important to initiate early treatment so that generalized cellulitis does not turn into an abscess cavity that will require surgical drainage. Inflammatory carcinoma of the breast is a malignancy that can present like breast infection. If such a suspected infection does not quickly resolve with antibiotics, further diagnostic studies must be carried out.

Return to choices || Top of page

Nipple - discharge milky

Physiologic hyperprolactinemia

• pregnancy
• lactation
• suckling and chronic nipple stimulation
• stress

Pharmacologic hyperprolactinemia

• amitriptyline (Elavil®)
• androgens (testosterone)
• anesthetics (usually post surgical)
• chlorpromazine (Thorazine®)
• cimetadine (Tagamet®)
• estrogens
• fluphenazine
• haloperidol (Haldol®)
• metoclopramide (Reglan®)
• monoamine oxidase inhibitors (Nardil®, Parmate®)
• opiates (codiene, pain pills, morphine)

Pituitary tumors and disorders

• prolactinoma
• acromegally
• Cushing's disease
• Nelson's syndrome
• empty sella syndrome
• pseudotumor cerebri


• hypothyroidism
• chronic renal failure
  

Chest wall trauma or tumor

• mastectomy
• thoracotomy
• chest burns
• breast prosthesis


• herpes zoster
• spinal cord lesions
• tabes
• syringomyelia
  

  Ectopic prolactin production

  • hypernephroma
  • bronchogenic cancer
  
  
• persistent postpartum amenorrhea-galactorrhea
• spontaneous amenorrhea-galactorrhea

Background

While milk from the breast represents normal physiology for a nursing mother, for a woman who is not pregnant, a milk-like discharge is abnormal. It is not an infrequent occurrence, since many medications can cause galactorrhea. It can also happen for unknown reasons or even excessive nipple stimulation. Tumors which may cause this problem are relatively unusual. Endocrine abnormalities which may be associated with milky discharge from the nipple are more common however.

Goals

For the most part breast cancers are not associated with a milky type of nipple discharge. For that reason it is important to establish that the nipple discharge is milky either by its characteristic color or by making a slide of a drop of the discharge and staining it with a dye such as iodine or methylene blue which confirms fat globules in the discharge. If there are fat globules in the discharge, this is a case of galactorrhea and there is a very low concern of malignancy. Once galactorrhea is established, a prolactin level is drawn to see if it is elevated. If the prolactin is normal and the fat globules were not checked for on direct smear, that must be confirmed. Thyroid abnormalities may cause galactorrhea so that a TSH (thyroid stimulating hormone) level is also usually drawn. Prolactin levels over 100 ng/ml should initiate a search for central nervous system tumors or lesions.

Return to choices || Top of page

Nipple discharge - serous, serosanguinous, bloody

• fibrocystic breast disease
• mammary duct ectasia
• intraductal papilloma
• epithelial hyperplasia
• epithelial hyperplasia of pregnancy
• cancer or benign breast tumors

Background

A serous or yellowish discharge is fairly common if patients have fibrocystic changes of the breast. Any blood-tinged (serosanguineous) or bloody discharge often indicates an intraductal papilloma or a malignancy of the breast. While very worrisome for malignancy, bloody nipple discharge is actually most likely to be due to a benign process.

Goals

After a thorough exam, a mammogram should be included to rule out underlying malignancy that is undetectable by physical exam. Any bloody nipple discharge needs surgical investigation even if the exam and the mammogram are negative.

Return to choices || Top of page

Breast masses

fibroadenoma

• adult
• juvenile


• cysts - fibrocystic breast disease
• duct ectasia
• juvenile papillomatosis
• fibromatosis
  

  papilloma

  • solitary
  • multiple
  
  
• apocrine metaplasia
• adenosis
• sclerosing adenosis
• epitheliosis
• fat necrosis
• galactocoele
• lipoma
• granular cell myoblastoma
• Wegener's granulomatosis
• neurofibroma
  
  carcinoma
  mammary duct
  infiltrating (80%)
  • papillary carcinoma
  • intraductal carcinoma
  • colloid carcinoma
  • medullary carcinoma
  
  

  noninfiltrating (5%)

  • papillary carcinoma
  • intraductal carcinoma
  • intracystic carcinoma
  
  

  mammary lobular

  • infiltrating
  • noninfiltrating

  sarcomas

  • cystoscarcoma phylloides
  • stromal sarcoma
  • liposcarcoma
  • angioscarcoma
  
  
• lymphoma
  

  rare cancers

  • sweat gland carcinoma
  • tubular carcinoma
  • adenoid cystic carcinoma
  • metaplastic lesions
  • inflammatory carcinoma (2%)
  • Paget's disease (1%)
  • metastatic cancers

Background

Because of the high frequency in the population of fibrocystic breast changes (40%), palpable breast masses are quite common. Breast cancer will involve one out of every 11 women at sometime during their life.

Goals

At physical examination, any breast mass should be differentiated as to whether it is a discrete mass or whether it is a diffuse, rubbery mass. Any discrete mass must have a biopsy performed even if mammogram imaging studies are negative. Diffuse, non-discrete masses are likely to be due to fibrocystic breast disease, but it must be remembered that the greater those changes are, the more difficult it is to palpate a discrete mass amongst the fibrocystic change. Patients with only diffuse fibrocystic changes palpable should be advised on discontinuance of caffeine related substances in foods and asked to return visit for further examination. If there is no change in the size of diffuse changes, or there is any suspicion of a discrete mass, further procedural evaluation (aspiration, fine needle biopsy, open biopsy) is reccomended. Once a biopsy is performed, treatment is based on the type of pathology present. Return to choices || Top of page