127 Breast Disorders

• There are very few true breast emergencies, and immediately life-threatening causes such as traumatic breast rupture or necrotizing fasciitis are exceedingly rare.

• Breast pain, particularly if cyclic, is common, and benign causes predominate.

• Breast cancer is a possible diagnosis in any patient with a chief complaint related to the breast, including breast pain or a mass, nipple discharge, or skin lesions.

• Most patients in whom breast cancer is diagnosed have no risk factors except age older than 50 years and female sex, and eight of nine patients have no family history of breast cancer.

• The emergency physician can play a role in reduction of the risk for lymphedema by early and aggressive treatment of even very minor infections and burns.

• Most medications are safe for use while breastfeeding, and the benefits of continuing breastfeeding generally outweigh the potential for harm.

• Few maternal infections, other than human immunodeficiency virus, present a significant risk to the breastfeeding infant.

Acknowledgment and thanks to Dr. Karen Jubanyik for her contribution to the first edition.

Epidemiology

Approximately one half of visits to physicians for breast complaints are for pain. New, palpable masses represent another common breast-related complaint. Although a benign condition will be diagnosed in 9 of 10 premenopausal women with a palpable breast mass, a new mass in a 75-year-old woman is malignant up to 70% of the time. Breast cancer is the most common cause of cancer-related mortality in women worldwide and second only to lung cancer in women in the United States. In 2006, it accounted for one third of all cancer diagnoses in women in the United States.¹

Although there are few true breast-related emergencies, perioperative issues represent a second significant group of emergency department (ED) visits. Breast surgery is relatively common in the United States. In addition to the 90,000 mastectomies performed annually, approximately 100,000 cosmetic augmentations and 100,000 reduction mammoplasties take place each year.² Many patients undergoing breast augmentation, either for reconstruction or cosmesis, experience significant complications and require additional surgery.

Pathophysiology

The unique anatomic structure of the breast contributes to the wide variety of pathologic conditions that may occur. Each breast contains approximately 20 glandular units (lobes) composed of glands and adipose tissue (Fig. 127.1). Each lobe drains into a lactiferous duct, which fuses with other ducts to form lactiferous sinuses just below the skin. The lactiferous sinuses store milk during lactation. Disruption (obstruction, infection, inflammation) of the glandular system may occur at any time during a female’s lifetime but predominates between menarche and menopause. The breast’s diffuse vascular network predisposes it to hematogenous spread of malignancy, as well as infection.

Fig. 127.1 The breast contains approximately 20 glandular units (lobes), each composed of a tubuloalveolar gland and adipose tissue.

(From Iglehart JD, Kaelin CM. Diseases of the breast. In: Townsend CM, Beauchamp RD, Evers BM, et al, editors. Sabiston’s textbook of surgery. 17th ed. Philadelphia: Saunders; 2004.)

Virtually all breast conditions that occur in women are seen in men as well, including benign conditions such as fat necrosis, allergic and irritant dermatitis, mastitis and abscess, and mammary tuberculosis. Malignant entities such as adenocarcinoma of the breast, Paget disease of the nipple, and lymphoma occur less frequently in men than in women. Breast cancer in men accounts for less than 1% of the total number of breast malignancies diagnosed in the United States. However, in other areas in the world (e.g., central Africa), male breast cancer is significantly more common. Men are at higher risk for the development of malignant melanoma and basal cell carcinoma of the breast. One condition, gynecomastia, occurs exclusively in men.

Presenting Signs and Symptoms

Differential Diagnosis and Medical Decision Making

See Box 127.1 for an overview of causes of breast-related complaints.

Box 127.1 Differential Diagnosis of Breast-Related Complaints

Mastalgia

Cyclic mastalgia

Noncyclic mastalgia

Extramammary pain

Dermatologic Conditions

Masses and Malignancy

Trauma

Partner violence

Blunt trauma

Penetrating trauma

Posttraumatic complications

Perioperative Conditions

Lactation-Related Complaints

Mastitis

Abscess

Special conditions

Mastalgia

Breast pain, especially as an isolated symptom, can be thought of as originating from one of three broad categories: cyclic mastalgia, noncyclic mastalgia, or extramammary.

Cyclic mastalgia occurs in premenopausal women, is associated with worsening symptoms in the late luteal phase of the menstrual cycle, and accounts for two thirds of patients with mastalgia. The typical pain of cyclic mastalgia is “achy” or “heavy” and bilateral. Resolution with the onset of menses is very reassuring.

Findings on physical examination may be normal, or tender nodularities may be detected. Fibrocystic breast conditions (the term fibrocystic breast disease has been replaced by the term fibrocystic breast condition to emphasize that it represents a spectrum of histologic entities) are not associated with axillary lymphadenopathy, skin thickening, edema or discoloration, or nipple abnormalities such as retraction or discharge. The presence of any of these findings raises the probability that the patient has another condition instead of or in addition to cyclic mastalgia.

Noncyclic mastalgia may be caused by a variety of conditions ³ (Box 127.2). It may be constant or intermittent, but it is not associated with the menstrual cycle. Noncyclic mastalgia tends to be unilateral and localized to a discrete area. Women with noncyclic breast pain are generally older than 40 years, and the cause is likely to be related to an anatomic lesion in the breast. It is rare for breast cancer to have pain as the sole initial symptom.⁴

Box 127.2 Causes of Noncyclic Mastalgia and Extramammary Pain

Breast-Related Mastalgia

Medication side effects

Extramammary Pain

Costochondritis

Chest wall trauma

Acute coronary syndrome or angina

Phantom pain (after mastectomy)

Extramammary breast pain can arise from the chest wall or from other sources. Although most of the conditions that cause isolated breast pain are not immediately life-threatening, some emergency conditions, including acute coronary syndrome and pulmonary embolism, can be accompanied by pain that appears to be originating from the breast.

Mondor disease (Fig. 127.2) is a superficial phlebitis of the lateral thoracic, thoracoepigastric, or superior epigastric vein. It typically occurs in middle-aged women. The condition can be unilateral or bilateral. It is often idiopathic but may be associated with other conditions.⁵ The classic Mondor cord is 2 to 3 mm in diameter and typically red and tender, tracks from the lateral margin of the breast across the costal margin, and extends from 2 to 30 cm. Any tenderness should resolve within weeks, but the cord may remain palpable for up to 6 months. There is no risk for systemic embolization.