Not all breast problems are breast cancer, benign breast disorders may arise as a result of the cyclical hormonal fluctuations that occur in every woman before menopause or during the menstrual cycle. These disorders are in fact part of a spectrum that extends from a normal state, to overt benign disease. In between the two poles are disorders that should preferably be referred to as aberrations, rather than actual disease. Most of the conditions that result from the normal cyclical hormonal changes found in every woman, are just aberrations or slight deviations from normal. True disease is not that common in this setting. Symptoms of breast problems such as pain, nipple discharge or a mass should however prompt you to see your doctor.
Breast problems present in three different ways
  • Breast Pain

    What do I need to know about breast pain?
    Many women have breast tenderness and pain, also called mastalgia. It may come and go with monthly periods (cyclic) or may not follow any pattern (noncyclic).
    Cyclic pain is the most common type of breast pain. It may be caused by the normal monthly changes in hormones. This pain usually occurs in both breasts. It is generally described as a heaviness or soreness that radiates to the armpit and arm. The pain is usually most severe before a menstrual period and is often relieved when a period ends. Cyclic breast pain occurs more often in younger women. Most cyclic pain goes away without treatment and usually disappears at menopause.
    Noncyclic pain is most common in women 30 to 50 years of age. It may occur in only one breast. It is often described as a sharp, burning pain that occurs in one area of a breast. Occasionally, noncyclic pain may be caused by a fibroadenoma or a cyst. If the cause of noncyclic pain can be found, treating the cause may relieve the pain.
    Breast pain can get worse with changes in your hormone levels or changes in the medicines you are taking. Stress can also affect breast pain. You are more likely to have breast pain before menopause than after menopause.
    Does breast pain indicate breast cancer?
    Breast pain is not a common symptom of breast cancer. But in some cases painful lumps are caused by breast cancer.
    If breast pain becomes severe or lasts longer than 3 weeks, call your doctor to discuss your symptoms.
  • A Breast mass/lump

    There are many different types of breast lumps. An ultrasound is used to tell what a lump is. Most lumps are not breast cancer.
    • Developmental abnormalities in breast embryology
      • The nipple may fail to evert, giving rise to an inverted nipple, which is thus congenital (present from birth). If a woman suddenly develops an inverted nipple in adulthood, this should be checked by a doctor as it may be the first sign of breast cancer. Management of congenital nipple inversion can both be undertaken by manual techniques or surgery.
      • Supernumerary or additional breasts or nipples may develop along the milk line or milk streak. During pregnancy and lactation this supernumary breast tissue and nipples may enlarge and even produce milk. If it is of concern surgical removal of the tissue can be undertaken.
      • Breast absence or amazia. If something goes wrong with the embryological development, such as a genetic abnormality or if the pregnant mother is exposed to some poison (toxin, such as a toxic drug, or a virus), the breast may fail to develop. This can be managed by reconstructive surgery.
    • Prepubertal breast development
      This is a type of premature breast development which often occurs on one side only. The breast will develop without any problems. Occasionally this is seen in young toddlers or pre-teenagers.
      Management:
      • Investigations like an ultrasound may be done to ensure no other secondary sexual development is occurring
    • Solid Masses
      • Fibroadenoma
        Fibroadenomas are highly mobile (breast mouse), round, smooth, firm masses in the young woman’s breast, usually present in the teenager and the early twenties. Fibroadenomas arise from lobules and show hormonal dependence similar to the lobules from which they develop. Most fibroadenomas are 1 – 2 cm in size and growth beyond 5 cm is unusual. They may be multiple. These lumps are quite innocent and can be left well alone. They may disappear spontaneously.
        Most patients with these masses should have a triple assessment of a clinical examination, an ultrasound and a needle biopsy. Six month follow-up is necessary to see if the fibroadenoma is growing.
        When these tumours reach giant proportions (giant intracanalicular fibroadenoma), it is generally advisable to remove them, as they cause a lot of distress, and distort the breast simply due to their unwieldy size.
        During pregnancy and lactation the size of fibroadenomas may also vary. Fibroadenomas in pregnancy will be managed by sonar and needle biopsy. They do not interfere with breastfeeding.
        Calcified fibroadenomas are sometimes found in the elderly as hard discrete mobile masses that are readily identified on mammography. Surgical excision may be done through cosmetic incisions with attention to moving around local breast tissue so as not to leave an unsightly dent in the breast.
        • Cystosarcoma Phyllodes (Phyllodes tumour)
          There is a rare growth that may be confused with a fibroadenoma. This is the phyllodes tumour, which is more aggressive than fibroadenomas. They can be more difficult to diagnose, therefore a rapidly growing breast mass (one that has increased by over a 1 cm in six months) should be excised. Because they have the capacity to recur after removal by lumpectomy, and also because around 10% – 20% show features of malignancy (rarely they can spread, more commonly they reoccur locally and more aggressively), a procedure involving wide local removal with at least a 1 cm – 2cm margin is essential. This will always require some form of breast reconstruction when operating on the patients.
      • Solid Cystic Masse
        • Breast Hamartomas (Fibroadenolipoma)
          Hamartomas of the breast usually present as painless palpable masses. They are larger and softer than fibroadenomas. A core biopsy is recommended for diagnosis. Hamartomas have a distinct picture on mammogram showing a circumscribed density separated from normal breast tissue by a thin radiolucent zone. If clinical examination and investigations cannot be correlated, surgical excision is recommended.
        • Galactocele – presents as a breast lump
          This is simply a milk retention cyst, where no bacterial infection occurs. It can be treated by needle aspiration (the removal of a sample of fluid and cells through a needle) and milk suppression. Surgical excision can also be performed with the use of reconstructive techniques.
        • Fat necrosis
          Severe breast trauma (a motor vehicle accident or being punched in the breast) may cause fat necrosis, which can mimic breast cancer. A core biopsy will usually resolve the issue, if the doctor is worried about an underlying cancer.
      • Breast Abscesses
        • Lactating breast abscess
          Unsatisfactory breastfeeding may cause milk retention and stasis (the stoppage or diminution of flow). Infection soon results. This can be adequately treated with antibiotics early on (during the cellulitis or mastitis phase).
          During this phase the frequent expression of milk will help prevent stasis and progressive infection. Cabbage leaves kept cold in the fridge also provide relief from the discomfort.
          Note that the baby must continue to feed on the contralateral breast to prevent a breast abscess developing there. Also, milk must be expressed from the ipsilateral breast (the one with the abscess) that is involved in the inflammatory process.
          The current recommended treatment is high dose antibiotics as well as repeated ultrasound guided aspiration. If the mother or doctor wants to stop breastfeeding, lactation can be suppressed with fluid restriction and bromocriptine (antiprolactin).
        • Non-lactating Breast Abscesses
          Breast abscesses can occur in circumstances other than lactation. They can commonly be a complication of duct esctasia, or less frequently caused by underlying malignancies, TB or HIV/AIDS. Superficial skin lesions (boils, sebaceous cysts and recurrent skin abscesses can also occur).
          Management
          Antibiotics and ultrasound-guided drainage are the initial treatment modalities. This is followed in certain complicated cases by surgical drainage with biopsy of the abscess wall.
      • Cysts
        • Breast Cyst
          Breast cysts usually occur in the premenopausal period (35 to 50 years of age). They may be single or multiple. About 5% of women develop a breast cyst. They normally contain around 20ml of fluid. They are easily diagnosed using sonar (ultrasound). Treatment is by follow-up or aspiration. The fluid is usually yellow or greenish. Ultrasound is crucial to see it. The cyst is simple or complex. Complex cysts require aspiration and occasionally excursion.
        • Fibroadenosis (and cyclical breast pain)
          Breasts alter cyclically with the different stages of the menstrual cycle. In the week prior to menstruation, the breast normally increases in size and sometimes becomes nodular, with pain. All breasts have a certain amount of fibrosis and adenosis and disease should be attributed to a woman with breast symptoms. If concerned, a breast ultrasound can aid the doctor in determining whether this is a mass or just nodularity.
  • Nipple discharge

    Nipple discharge is any fluid that comes out of the nipple area in your breast.
    Sometimes discharge from your nipples is okay and will get better on its own. You are more likely to have nipple discharge as you get older and if you have been pregnant at least once. Nipple discharge is usually not a symptom of breast cancer.
    Here are some reasons for nipple discharge:
    • Pregnancy
    • Stopping breastfeeding
    • Rubbing on the area from a bra or t-shirt
    • Infection
    • Inflammation and clogging of the breast ducts (mammary duct ectasia)
    • Injury to the breast
    • Non-cancerous brain tumors
    • Small growth in the breast that is usually not cancer (intraductal papilloma)
    • Severe hypothyroidism (underactive thyroid gland)
    • Fibrocystic breast (normal lumpiness in the breast)
    • Use of certain medicines, such as birth control pills, cimetidine, methyldopa, metoclopramide, phenothiazines, reserpine, tricyclicantidepressants, or verapamil
    • Use of certain herbs such as anise and fennel
    • Widening of the milk ducts
    Cancers that can cause nipple discharge are:
    • Breast cancer
    • Paget’s disease of the breast (a rare form of breast cancer)
    Nipple discharge that is NOT normal is:
    • Bloody
    • Comes from only one nipple
    • Comes out on its own without you squeezing or touching your nipple
    Nipple discharge is more likely to be normal if:
    • It comes out of both nipples
    • Happens when you squeeze your nipples
    The color of the discharge does not tell you whether it is normal or not. The discharge can look milky, clear, yellow, green, or brown.
    Exams and Tests
    Tests that may be done may include:
    • Prolactin blood test
    • Thyroid blood tests
    • Head CT scan or MRI to look for pituitary tumor
    • Mammography
    • Ultrasound of the breast
    • Breast biopsy
    • Ductography or ductogram, an x-ray with contrast dye injected into the affected milk duct
    • Skin biopsy, if Paget’s disease is a concern
    In most cases, nipple problems are not breast cancer. These problems will either go away with the right treatment, or they can be watched closely over time. If unsure, make an appointment with your doctor to verify.

Profile

Dr Lim Siew Kuan is a consultant general surgeon with more than 10 years of surgical experience. Her sub-specialty interest is in breast surgery, and the management of both malignant and benign breast conditions. She did her advanced training in Breast Oncoplastics and Reconstructive Surgery at the National Cancer Center, South Korea. This allows her to provide her patients with better treatment and cosmetic outcomes. Dr Lim is one of the few breast surgeons in Singapore who is trained in oncoplastic and reconstructive breast surgery.

Address

38 Irrawaddy Road #06-53
Mount Elizabeth Novena Specialist Centre
Singapore 329563
Farrer Park Hospital (By Appointment Only)
1 Farrer Park Station Road #11-01 Connexion
Singapore 217562
Fax: +65 6705 2619

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