Evaluation of Breast Masses and Nipple Discharges
Annekathryn Goodman
A solitary or dominant breast mass or an abnormal nipple discharge may be a harbinger of breast cancer, the most common malignancy among women. Because such a finding, whether discovered by the patient or by her physician, will raise legitimate fears, the primary physician must be able to proceed with deliberate speed in reaching a diagnosis that excludes carcinoma. Women who present with breast pain also often harbor concerns about breast cancer. In most cases, assurance can be provided along with symptomatic management when necessary.
Breast Mass
Pathophysiology
A breast mass may represent proliferative changes in epithelial or mesenchymal tissue or fluid-filled cysts. The breast is a complex organ composed of epithelium, which forms acini and ducts; fibrous tissue, which provides support; and fat. It is exquisitely sensitive to its hormonal milieu. Estradiol stimulates the proliferation of epithelial cells and accompanying increases in periductal vascularity. Progesterone induces the development of acini and opposes the mesenchymal actions of estrogens.
Benign Changes.
With each menstrual cycle, the breast exhibits its own cycle of proliferation and desquamation of duct lining. However, the response of epithelium, fibrous tissue, and fat to the same hormonal stimulation is variable. Certain areas of the breast may overshoot in the monthly preparation for pregnancy, causing thickening of the breasts and lumpiness.
The overgrowth may involve proliferation of fibrous tissue alone or also involve epithelial cells of the ducts and glands, leading to fibroadenomas or ductal dysplasia. Lumps can also be caused by the collection of fluids—essentially colostrum or dissolved cellular debris—which form microcysts or macrocysts. Simple cysts explain 20% to 25% of palpable masses. They are especially common in premenopausal women of age 40 to 49 years.
These physiologic events may combine to produce a breast that is fibrocystic in quality (hence the advice by experts to drop the term fibrocystic disease). Fibrocystic changes can be found clinically in approximately 50% of women during their reproductive years and histologically in 90%. Most investigators believe that benign breast disease, including neoplasms such as fibroadenomas and intraductal papillomas and fibrocystic change, represents a spectrum of responses to normal hormonal stimulation rather than distinct diseases.
Although the variable response of breast tissue to physiologic proliferative and involutional hormonal stimuli is responsible for most benign masses, there are other causes. Infection, usually associated with duct obstruction, can result in an inflammatory mass. Redness, warmth, and tenderness are prominent features. Mammary duct ectasia can result in infection and yet may simulate cancer because it can produce nipple discharge, nipple inversion, and a mass. Periareolar infection may ensue. Blunt trauma can lead to hematoma formation.
The multiple causes of benign breast lesions can be classified according to their histology and where they confer a risk of breast cancer being diagnosed at some time in the future (Table 113-1).
Cancerous Changes.
Breast cancers derive from ductal or epithelial cells. They may invade immediately or grow in situ. Breast cancer in younger women tends to be lobular in pathologic appearance and multicentric but not calcifying or rapidly invading. Ductal carcinomas are prominent in older women. They are typically unicentric, readily calcified (producing the characteristic microcalcifications helpful in radiologic detection), and much more rapidly invasive than lobular lesions.
Growth is often associated with increasingly malignant behavior, characterized by the loss of estrogen and progesterone receptors, metastasis, and more aggressive local invasion. Although metastasis can occur early, it is not an invariably early event and usually does not occur in lesions less than 1 cm in diameter (unless lymphatics have been invaded). Local growth may extend to the skin or chest wall. Axillary nodes are typically the first clinical site of spread beyond the breast.
Clinical Presentation
The proportion of solitary or dominant breast masses that prove to be cancers varies from 5% to 20%, depending on the age of patients and at what point in the clinical process the case series is assembled. Masses noted by either patients or primary care clinicians are often not confirmed on a surgical examination. A surgically identified mass has a higher probability of cancer compared to clinically palpable masses that are not present surgically. The effect of age on the prevalence of breast cancer among women presenting with a lump is striking. Prevalence increases from 1% for women 40 years old or younger to 9% from women ages 41 to 54 and to 37% for women age 55 or older.
Cancers.
Cancer in the breast typically presents as a painless, discrete mass. Pain is a presenting symptom in fewer than 7% of cases and is almost always accompanied by a mass. Early on, the mass may be movable; later, it can become fixed. Nipple retraction or inversion of new onset may also herald an underlying cancer. Signs of more advanced disease include skin retraction, change in breast contour, thickening or dimpling of the skin, and fixation of the mass to the chest wall. A ductal carcinoma may present as an isolated serosanguineous nipple discharge (see Nipple Discharge).
Benign Lesions.
Benign lesions may be present in a manner clinically indistinguishable from that of cancers, but a few patterns are characteristic. In fibrocystic change, the breasts are diffusely lumpy and fibrous in quality. One breast may be more involved than the other. As isolated cyst may also be a presentation of benign disease, but those that yield blood on aspiration or recur after aspiration may be related to a malignant process.
Breast Pain and Nipple Discharge
Cyclic breast pain, occurring in the late luteal phase of the menstrual cycle, is a common problem. In one survey among American women, 58% described mild cyclic pain, and 11% described moderate or severe pain. Pain was reported to interfere with normal sexual activity in nearly one half of those who experienced it and with physical activity in more than one third. Noncyclic pain, unrelated to the menstrual cycle, may be due to a cyst or mastitis. Pain arising in the chest wall can be mistaken for breast pain.
TABLE 113-1 Classification of Benign Breast Lesions on Histologic Examination, According to the Relative Risk of Breast Cancer | |||||||||||||||
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