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Chapter 93: Breast disorders

INTRODUCTION

Neither the cause of breast cancer, one of the most feared and emotion-engendering diseases, nor the means of preventing it are absolutely known.

ANONYMOUS LECTURER ON BREAST CANCER

Breast symptoms are common and their discovery provokes considerable anxiety and emotion because, to many women, a change in their breast means cancer.

Many breast lumps are actually areas of thickening of normal breast tissue. Many others are due to fibrocystic disease with either fibrosis or cyst formation or a combination of the two producing a dominant (discrete) lump.

Breast pain (mastalgia) can vary from localised breast pain due to an infection or a breast cyst to diffuse bilateral pain. For both breast presentations, the possibility of cancer must always be considered.

BREAST PAIN (MASTALGIA)

Mastalgia usually presents as a heaviness or discomfort in the breast or as a pricking or stabbing sensation. The pain may radiate down the inner arm when the patient is carrying heavy objects or when the arm is in constant use, as in scrubbing floors.

Key facts and checkpoints

  • The typical age span for mastalgia is 30–50 years.

  • The peak incidence is 35–45 years.

  • There are four common clinical presentations:

    • diffuse, bilateral cyclical mastalgia

    • diffuse, bilateral non-cyclical mastalgia

    • unilateral diffuse non-cyclical mastalgia

    • localised breast pain

  • The specific type of mastalgia should be identified.

  • The commonest type is cyclical mastalgia.

  • Premenstrual mastalgia (part of type 1) is common.

  • An underlying malignancy should be excluded.

  • Less than 10% of breast cancers present with localised pain.

  • Only about 1 in 200 women with mastalgia are found to have breast cancer.

  • The problems, especially types 2 and 3, are difficult to alleviate.

A DIAGNOSTIC APPROACH

A summary of the diagnostic strategy model for mastalgia is presented in TABLE 93.1.

Table 93.1Mastalgia: diagnostic strategy model
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Table 93.1 Mastalgia: diagnostic strategy model

Probability diagnosis

Pregnancy

Cracked or inflamed nipple Cyclical mastalgia:

• benign mammary dysplasia

Serious disorders not to be missed

Vascular:

  • acute coronary insufficiency

  • thrombophlebitis (Mondor disease)

Infection:

  • mastitis

  • breast abscess

Cancer:

  • breast (uncommon presentation)

  • mastitis carcinomatosa

Pitfalls (often missed)

Pregnancy

Chest wall pain (e.g. costochondritis)

Pectoralis muscle spasm

Referred pain, esp. thoracic spine

Bornholm disease (epidemic pleurodynia)

Herpes zoster

Mechanical:

  • bra problems

  • pendulous breasts stretching Cooper ligaments

  • weight change

  • trauma

Rarities:

  • hyperprolactinaemia

  • nerve entrapment

  • mammary duct ectasia

  • sclerosing adenosis

  • ankylosing spondylitis

Seven masquerades checklist

Depression

Drugs (e.g. OCP, HRT, marijuana)

Spinal dysfunction

Is the patient trying to tell me something?

Yes. Fear of malignancy. Consider psychogenic causes.

Probability diagnosis

In the non-pregnant patient, generalised pain, which may be cyclical or non-cyclical, is commonest. Typical patterns are illustrated in FIGURE 93.1

FIGURE 93.1

Pain patterns for ...

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