COMMON BREAST CONDITIONS

What is a breast cyst?

Breast cysts are spaces filled with fluid that occur in the breast. They are most common in women in their forties and fifties, approaching the menopause.

How are breast cysts diagnosed?

The following tests may be performed:

• Clinical breast exam
• Mammogram
• Ultrasound
• Fine needle aspiration

What is the treatment for breast cysts?

Breast cysts may require treatment if they are large or causing pain. Treatment consists of a fine needle aspiration of the cyst.

Duct ectasia is a benign (not cancer) breast condition. It’s caused by normal breast changes that happen with age, and it’s nothing to worry about.

Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), which are surrounded by glandular, fibrous and fatty tissue. As women get nearer to the menopause and the breasts age (from 35 years onwards) the ducts behind the nipple shorten and widen. This is called duct ectasia. Sometimes a secretion is produced and can collect in the widened ducts. This can irritate the lining of the ducts. Some people also experience pain, although this is not common. There can also be a discharge of these secretions through the nipple, which is usually thick but can also be watery. It can vary in colour, and can occasionally be bloodstained.

Sometimes a lump can also be felt behind the nipple. This can be because the tissue behind the nipple has become infected or scarred. The nipple may become inverted (pulled inwards) as the ducts shorten.

How is it diagnosed?

After your GP has examined your breasts you’re likely to be referred to a breast clinic. At the breast clinic you’ll have a breast examination and probably a mammogram (breast x-ray) and/or ultrasound scan (which creates a picture of the breast using high-frequency sound waves).

If you have nipple discharge that’s bloodstained, this may be tested to help confirm the diagnosis.

Treatment

Most cases of duct ectasia don’t need any treatment as it’s a normal part of ageing and any symptoms will usually clear up by themselves.

Try not to squeeze the nipple as this may encourage further discharge. In the meantime, if you have any pain you may want to take pain relief such as paracetamol.

If you continue to have discharge from the nipple (without squeezing) which doesn’t settle, you may be offered an operation to remove the affected duct or ducts. You may be offered removal of just the affected duct or ducts (a microdochectomy) or removal of all the major ducts (a total duct excision). The operation is usually done under a general anaesthetic, and you’ll be in hospital for the day, but sometimes you might have to stay overnight. You’ll have a small wound near the areola (darker area of skin around the nipple) with a stitch or stitches in it, and your doctors will tell you how to care for it afterwards.

You’ll be advised about which pain relief to take after the operation as your breast may be sore and bruised. The operation will leave a small scar but this will fade in time.

After the operation your nipple may be less sensitive than before, and for a few people it may become inverted.

The operation should solve the problem but, as finding all the ducts can sometimes be difficult, your symptoms may return and you may need further surgery to remove more ducts. It’s important to go back to your GP if you have any new symptoms.

What this means for you

Having duct ectasia doesn’t increase your risk of developing breast cancer in the future.

However, it’s still important to be breast aware and go back to your GP if you notice any other changes in your breasts, regardless of how soon these occur after your diagnosis of duct ectasia.

Fibroadenomas are solid benign (noncancerous) breast lumps that are common in young women. They can increase in size during pregnancy and breastfeeding.

How are fibroadenomas diagnosed?

If you find a lump in your breast, you should consult with a doctor. The following tests may be performed:

• Clinical breast exam
• Mammogram (in women over 40 years old)
• Ultrasound
• Fine needle aspiration or Core needle biopsy

Michelle and her team of specialists are incredibly sensitive to the anxiety a breast lump creates for her patients. Therefore, we follow strict guidelines for evaluation, biopsies and pathology reports. On the day of your breast biopsy, you will be given an idea of the most likely diagnosis and the biopsy report will follow within a few days.

What is the treatment for fibroadenomas?

If fibroadenomas are large or are causing the patient concern, they may require surgical removal (excisional biopsy), but this is rare. Many fibroadenomas stop growing or shrink over time.

An intraductal papilloma is a benign (not cancer) breast condition. Intraductal papillomas are most common in women over 40 and usually develop naturally as the breast ages and changes.

Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), which are surrounded by glandular, fibrous and fatty tissue. Sometimes a wart-like lump develops in one or more of the ducts. It’s usually close to the nipple, but can sometimes be found elsewhere in the breast.

You may feel a small lump or notice a discharge of clear or bloodstained fluid from the nipple. Generally intraductal papillomas aren’t painful but some women can have discomfort or pain around the area.

Intraductal papillomas can occur in both breasts at the same time. Intraductal papillomas generally don’t increase the risk of developing breast cancer. However, when an intraductal papilloma contains atypical cells (cells which are abnormal but not cancer), this has been shown to slightly increase the risk of developing breast cancer in the future. Some people who have multiple intraductal papillomas may also have a slightly higher risk of developing breast cancer.

How are they found and treated?

Intraductal papillomas can be found by chance following routine breast screening (a mammogram or breast x-ray), after breast surgery or if you go to your GP (local doctor) with symptoms. You will then be referred to a breast clinic where you’ll be seen by specialist doctors or nurses.

Triple assessment

At the breast clinic you’ll probably have three different tests, known as triple assessment, to help make a diagnosis. These are:

• a breast examination
• a mammogram (breast x-ray) and/or an ultrasound scan (which uses high-frequency sound waves to produce an image)
• a fine needle aspiration (FNA) or core biopsy

Occasionally you may be offered a vacuum assisted biopsy as an alternative to a core biopsy. After an injection of local anaesthetic, a small cut is made in the skin. A hollow probe connected to a vacuum device is placed through this. Using an ultrasound or mammogram as a guide, a larger volume of breast tissue is sucked through the probe by the vacuum into a collecting chamber. This means that several samples of breast tissue can be collected without removing the probe. The samples are sent to the laboratory where they are examined under a microscope. This can occasionally be therapeutic as well as diagnostic. This procedure can cause some bruising for a few days afterwards.

Excision biopsy

After a triple assessment, Michelle may want you to have an operation called an excision biopsy. This is surgery to remove more breast tissue, which will be examined under a microscope.

An excision biopsy can be carried out under a local or general anaesthetic. Your surgeon may use dissolvable stitches placed under the skin which won’t need to be removed. However, if non-dissolvable stitches are used, they’ll need to be taken out a few days after surgery. You’ll be given information about this and about looking after the wound before you leave the hospital. The operation will leave a scar but this will fade over time.

Follow-up

You will be seen to check the wound and get the results of your laboratory analysis about a week after surgery.

What this means for you

For most people, having an intraductal papilloma doesn’t increase their risk of breast cancer.

If your intraductal papilloma contains atypical cells, or if you have multiple intraductal papillomas, you may be worried or anxious that your risk of breast cancer is slightly increased. However, this doesn’t necessarily mean you’ll develop breast cancer in the future.

Even though your intraductal papilloma has been removed, it’s still important to be breast aware and go back to your GP if you notice any other changes in your breasts.

Nipple discharge may be common for premenopausal women—especially milky discharge. This is usually due to normal hormonal changes within a woman’s body. It often occurs in both breasts.

There are some specific types of nipple discharge that warrant closer evaluation:

• Bloody nipple discharge – If the discharge is bloody, a papilloma is suspected. This wart-like group inside the duct irritates the tissue, producing the reddish discharge. This can also be a symptom of breast cancer, so proper evaluation is recommended.

• Greenish nipple discharge – If the discharge is army green in color, it can be a sign that there is a breast cyst underneath the nipple and areola area that is spontaneously draining. This can be further evaluated with breast imaging studies, such as ultrasound.

• Clear nipple discharge – Clear discharge can be a sign of abnormal cells (including cancer cells) within the breast. The risk of cancer is lower when there is discharge from both breasts.

How do I know when to see a breast specialist?

It is always important to have nipple discharge evaluated, as it may signal other worrisome health problems. If you have discharge coming from one or both of your breasts, and if the discharge is new and has not been thoroughly investigated, we strongly recommend that you make an appointment with us as soon as possible.

How will I be evaluated for nipple discharge?

Michelle will give you a clinical breast exam, ask about your personal medical history, and probably order a mammogram and/or ultrasound to rule out any possible masses. Ultrasound is very useful at evaluating causes of nipple discharge. She may also order a ductogram, which is a dilation of the duct to search for the source of the discharge. In some cases, a biopsy will be performed.

Periductal mastitis occurs when the ducts under the nipple become inflamed and infected. It’s a benign condition (not cancer), which can affect women of all ages but is more common in younger women.

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
• a pulled-in (inverted) nipple.

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

People who smoke have an increased risk of being affected by periductal mastitis, because substances in cigarette smoke can damage the ducts behind the nipple. Nipple rings (piercings) can increase the chances of infection and make periductal mastitis more difficult to treat.

How is it diagnosed?

Your GP will refer you to Michelle who can make a definite diagnosis. To do this you will probably have a breast examination, mammogram and/or ultrasound scan.

If you have discharge from the nipple a sample may be looked at under a microscope, especially if it’s bloody, to help confirm the diagnosis.

Treatment

Some people may not need any treatment for periductal mastitis as it can clear up by itself. However go back to your GP if your symptoms return or if you have any new symptoms. Smoking can slow down the healing process, so if you smoke it’s a good idea to try to cut down or to stop.

If you need treatment, this will usually be with antibiotics. You may also want to take pain relief, such as paracetamol, if your breast is painful.

If you have developed an abscess and/or a fistula, your specialist will decide the best way to treat it. This may involve using a fine needle and syringe to draw off (aspirate) the pus, or sometimes an opening is made in the skin to allow the pus to be drained. This can be done under either local or general anaesthetic.

If periductal mastitis doesn’t get better after taking antibiotics or if it comes back, you may need to have an operation to remove the affected duct or ducts.

After the operation your nipple may be less sensitive than before.

The operation should solve the problem but, if it comes back, more ducts may need to be removed, as finding all the ducts can sometimes be difficult.

What this means for you

Having periductal mastitis does not increase your risk of breast cancer. However, it’s still important to be breast aware and go back to your GP if you notice any further changes in your breasts regardless how soon these occur after having periductal mastitis.