Những Nguyên Tắc Thiết Yếu Trong Phẫu Thuật Tuyến Vú (Essentials of Breast Surgery)

3
The Breast Mass, Breast
Biopsies, and Benign Lesions
of the Breast
EVALUATION
History
Physical Examination
Directed Breast Imaging
Breast Biopsies of Palpable
Lesions
Breast Biopsies of Nonpalpable
Lesions
MANAGEMENT OF BENIGN
BREAST MASSES
Fibroadenoma
Cysts
Lipoma
Hamartoma
Trauma/Hematoma/Fat
Necrosis
Diabetic Mastopathy
Sclerosing Adenosis and Radial
Scar
Papilloma and Papillomatosis
The Breast Mass, Breast Biopsies, and Benign Lesions
of the Breast: Key Points
Describe a complete history and physical for the woman with a
breast complaint.
Know when imaging is indicated and what imaging tests are most helpful.
Describe the technique for performing a fine needle aspiration biopsy and core
needle biopsy, and know the relative pros and cons of each technique.
Explain the principles of the surgical breast biopsy.
Recognize the classic features of cysts and fibroadenomas and describe the
management options.
Understand when and why excisional biopsy of benign lesions such as radial
scars or papillomas is necessary.
41

One of the most common problems in pri-
mary care and specifically for the breast sur-
geon is the evaluation of a newly discovered
breast mass. Complaints of a breast lump are
extremely common. In one study, 16% of
women between the ages of 40 and 70 saw a
physician for a breast problem, and 40% of
these were breast lumps. The overwhelming
majority of these will be benign, even in refer-
ral practices, the most common causes being a
cyst or fibroadenoma.
When evaluating a patient who presents
with a breast mass, the clinician needs to care-
fully balance the risk of missing a cancer
with performing too many biopsies. In addi-
tion to the time and expense, breast biopsies
are
not
without
morbidities.
These
may
include bruising or hematoma, infection, or a
misdiagnosis. More than 500,000 breast biop-
sies are performed in the United States each
year; 75% to 80% are benign. The reason for
this high use of biopsies in the United States
is not surprising when one realizes that the fail-
ure to diagnose breast cancer has led malprac-
tice claim lists in the United States for several
years.
Evaluation
History
The first question to ask a patient presenting
with a breast mass (or derive from the chart)
is her age. Breast masses are different entities
in women younger than 30, between 31 and
50, or older than 50 years old. As the incidence
of breast cancer increases with age, so too will
the aggressiveness of the evaluation. On a sta-
tistical basis, 9 of 10 new masses in premeno-
pausal women are benign.
A careful history of the lump should include
the precise location of the mass and how it
was first noted (Box 3–1). Was this felt by the
patient and if so was it incidental or during a
monthly self-breast examination? If it was felt
by a doctor on a routine physical, did the
patient know about it and can she now locate
it? The physician should inquire about how
often the patient does self breast examina-
tions. If she does not do self-examinations,
the mass may have been present for longer.
How long has it been present and has it
changed in any way since she first noted it?
This includes not only getting larger since first
noticing it, but does it get larger or smaller at
particular times in the menstrual cycle. Are
there any associated symptoms such as nipple
discharge (and if so, the nature of that dis-
charge) or breast pain? Has she ever had any
breast masses or symptoms before, and if so,
how were they managed?
The physician should then gather informa-
tion to assess the risk of breast cancer in this
patient. Has she had breast cancer in the past?
How many previous biopsies has the patient
had, and does she know the pathology? This
is particularly important if a previous biopsy
demonstrated atypical hyperplasia or lobular
carcinoma in situ (LCIS) (Chapter 8). Some-
times it is useful to obtain the histologic slides.
The age of menarche, number of pregnancies,
age at first pregnancy, age of menopause, and
use of hormonal replacement therapy should
be documented. If hormone replacement is
used, what type (estrogen only or estrogen
plus progestin)? If the patient has had a hys-
terectomy,
what
was
the
reason
for
the
BOX 3–1 ESSENTIAL COMPONENTS
OF THE HISTORY IN THE
EVALUATION OF THE BREAST MASS


Patient age


Method of detection (self-examination,
incidental, physician’s examination)


Does the patient do monthly self-
examinations?


Length of time it has been present


Any change in size (particularly with
menstrual cycle)


Associated symptoms (pain, skin
changes, nipple discharge)


History of other breast masses or
fibrocystic disease


History of previous breast biopsies and
pathology


Menstrual history (age of menarche, age
at first pregnancy, number of
pregnancies, age at menopause)


Personal history of cancer and how was it
treated


Hodgkin’s disease and chest wall
radiation


Use of hormone replacement therapy


How long, what kind (estrogen only
or estrogen and progestin)?


Family history of all cancers, mother’s
and father’s side


Age of onset, bilateral disease?
42
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

operation and were the ovaries removed? A
social history, including both alcohol and
tobacco use, is also important. A full family
history should be obtained. This should not
be limited to breast cancer, nor to the maternal
side of the family. Rather it should include all
cancers and document the age of the family
members who had cancer. If a family member
did have breast cancer, was it bilateral?
Physical Examination
The breast examination includes inspection of
the breast and palpation of both the breast
and the regional lymph nodes (axillary, supra-
clavicular, and cervical) (Box 3–2). Although
there are several approaches to the examina-
tion, the breast surgeon should develop his or
her own systematic approach. Always keep in
mind that this is an awkward examination for
most women, and every attempt should be
made to keep the patient comfortable and
relaxed, maintain her privacy, and perform the
examination in a professional manner.
The examination should begin with the
patient in the sitting position. For premenopau-
sal women, you should document where the
woman is her menstrual cycle. The optimum
examination is 1 week after the onset of the
last period. At this time point, swelling and
tenderness of the breasts are at a minimum.
With the patient in the seated position, ask
her to point out the problem area. Some women
will tell you the abnormality is best felt while
sitting up; others need to lie back or on their
side. With the woman sitting straight, note
whether the breasts are symmetric. It is normal
for one breast to be larger than the other. Are
the nipples both everted (or both inverted)
and do they point in the same direction? Is the
color of the skin and venous pattern the same
on both sides? Is there any dimpling, retraction,
or redness? Are there any previous scars? Is a dis-
tortion obvious? The woman should then raise
her hands above her head and touch them
together. She should also put them on her hips
and press inward (Fig. 3–1). Both of these man-
euvers will exaggerate any retraction of the skin
or deviation of the breast.
With the patient still sitting up, the next
step is palpation of the axillary nodes. This
should begin with the cervical lymph nodes
along the anterior border of the sternocleido-
mastoid muscle. As you palpate downward,
you should examine the supraclavicular fossa.
There
may
be
some
infraclavicular
nodes
within the deltopectoral groove. To examine
the axillary nodes, you should face the patient
or stand slightly to her side. You should use
the nonpalpating hand to either steady the
patient’s shoulder, or support her arm, asking
her to let it go loose. This will relax the pector-
alis major and axillary fascia, allowing for a
better examination of the axilla (Fig. 3–2).
Begin high in the axilla with your examina-
tion. In this way, the axillary nodes are trapped
lower rather than initially pushed upward.
BOX 3–2 KEY COMPONENTS OF
THE BREAST EXAMINATION


Patient sitting up, facing the
examiner, arms to the side


Inspection for symmetry, contour,
scars, skin lesions, erythema, nipple
inversion


Palpation of the cervical and
supraclavicular basins


Palpation of the mass in the upright
position


Patient sitting up, arms above head,
touching


Inspection for dimpling, retraction,
protruding mass


Patient sitting up, arms on hips, pressing
inward


Inspection for dimpling, retraction,
protruding mass


Patient sitting up, physician supporting
weight of the arm


Palpation of bilateral axilla


Patient in the supine position, arm raised
over the head


Inspection for contour, scars, skin
lesions, protruding masses, dimpling,
or retraction


Examination of the nipple including
gentle attempt to express discharge


Palpation of the mass in the supine
position. Note size, consistency,
borders, fixation, and location
(including clock position and distance
from areola)


Palpation of the entire breast
parenchyma including inframammary
fold, axillary tail


Note locations of any additional
masses including size and location


Examine the opposite breast in same
way, noting symmetry between any
areas of concern
43
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

Gently palpate back and forth to feel whether
any nodes are apparent. Several passes should
be made from top to bottom, both anteriorly
and posteriorly in the axilla. If any lymph nodes
are detected, their size, consistency, and fixa-
tion should be noted. Several points should
be highlighted. In thin women, it is not un-
usual to palpate axillary nodes. These should
be soft, mobile, and less than 1 cm in size. It is
also not unusual to run your fingers over the lat-
eral edge of the pectoralis minor muscle, or
tonguelike extensions of breast tissue within
the axilla. These should not be mistaken for
lymph nodes.
Once the right and left axillary examina-
tions are completed, the patient should be
placed in the supine position. The patient’s
arm is brought over her head and her hand
placed behind her back. Some patients will
have difficulty with this maneuver because of
shoulder problems. The breast often falls later-
ally. This can be corrected for by placing a
small pillow under the back, or more com-
monly by displacing the breast medially with
the opposite hand during palpation. Some sur-
geons prefer to stand on the same side of the
breast being examined; some prefer the oppo-
site side. The examiner should map out an
approach to the breast so that the entire area
is examined; some use concentric circles or
spirals, some use a pattern like the spokes of
a wheel, others use up-and-down columns
(Fig. 3–3). The best method for palpating the
breast is a rotating or kneading motion with
A
B
C
Figure 3–1. Inspection of the breast in the upright position with the patient’s arms to the side (A), in the air
(B), and hands on hips (C). (From Bland KI, Copeland EM III. The breast, 3rd ed. Philadelphia: WB Saunders,
2004.)
44
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

A
B
C
Figure 3–2. Examination of the cervical (A), supraclavicular (B), and axillary nodes (C). (From Bland KI, Cope-
land EM III. The breast, 3rd ed. Philadelphia: WB Saunders, 2004.)
Figure 3–3. Methods of clinical breast examination. To ensure that the entire breast is examined, physicians
use a number of patterns, including concentric circles, back and forth, spikes of a wheel, or up and down.
(From Roses D. Breast Cancer. Philadelphia: Elsevier, 2005.)
45
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

the fingers that causes the breast tissue to
move back and forth beneath the skin. The
surgeon should note the overall consistency
of the breast tissue (e.g., soft, firm, dense.). In
general, younger women have denser fibro-
glandular tissue, but one should not be sur-
prised to find dense parenchyma in women
in their 60s.
The distribution of the fibroglandular tissue is
not always even throughout the breast, and this
often causes confusion during the breast exami-
nation. Often the tissue is concentrated in the
upper outer quadrant, causing some inexperi-
enced clinicians to think they have discovered
a large breast mass when in reality they are just
feeling the normal parenchyma. Breast tissue
may extend up into the axilla, and should not
be confused for an axillary mass or lymph node.
Always compare these asymmetries to the con-
tralateral breast. There may also be a vacancy of
tissue beneath the areola, with the normal tissue
being configured as a “doughnut.” This often
leaves a ridge of normal parenchyma, which
can be confused for a mass. The same can be said
for defects under scars from sites of previous
excisions.
Other
areas
that
are
sometimes
confused for masses include the ribs and a firm
inframammary ridge.
The nipple should be inspected for retrac-
tion, overlying skin changes, or discharge. It
is not always abnormal for the nipple to be
inverted. If this is the case, determine whether
it can be everted. There may be some cutane-
ous debris that is not necessarily a nipple dis-
charge. Beginning at the border of the areola
and sliding toward the tip, the nipple should
be gently squeezed to determine if there is a dis-
charge, as well as to feel any mass underneath
the nipple-areolar complex.
During the breast examination, the exam-
iner might identify a mass or nodule, or sev-
eral. Breast tissue in normal women is often
“lumpy.” The key is to identify masses that
are different from the remainder of the exami-
nation. If a mass is noted, the examiner should
take note of whether the mass has a complete
periphery that is distinct from the surrounding
tissue. Is the mass mobile? If not, why not? Is
it fixed to the skin or to the underlying muscle?
Is there tenderness associated with it? What is
the consistency; is it soft or hard? What are the
borders like; smooth or irregular?
For each mass found, the examiner should
accurately document the location and size. In
this manner, if it is to be managed by obser-
vation, the surgeon knows exactly what to
expect when the patient returns 4 to 6 months
later for a repeat examination. The location
should be documented as not only the position
on a clock, but also the number of centimeters
from the areolar border.
Directed Breast Imaging
The next step in the evaluation of the patient
with a breast mass is that of diagnostic breast
imaging. Mammography is indicated in any
patient age 35 years or older with a breast mass.
This is not only important for characterizing
the mass in question, but also looking for clini-
cally occult lesions or other findings that may
guide surgical therapy in case this mass proves
to be cancer. For women younger than age 35,
mammography should be obtained more selec-
tively. This should be based on the level of
suspicion associated with the mass and the den-
sity of the breast. The breast tissue in younger
women is often too dense to allow for accurate
imaging and interpretation.
The results of the mammogram must be
interpreted carefully. When evaluating a breast
mass, the mammogram results are only one
piece of information, and the decision to
biopsy should not be based on these films
alone. If the mass is clinically suspicious,
either because of the patient’s history or the
physical examination, then biopsy is indicated
whether or not the mammogram shows any-
thing. Cancers may be mammographically
occult. This is especially true in younger
women or with invasive lobular carcinoma.
The lump may be visible but indeterminate.
Even though the mammogram adds little to
the diagnosis or the decision to biopsy, it is
still necessary to screen the remainder of the
breast and the contralateral side.
On the other hand, the mammogram may
demonstrate a classic benign appearance for a
mass that otherwise feels suspicious, such as
fat necrosis, a benign calcifying fibroadenoma,
or a hamartoma. In other cases, a lump that
otherwise does not feel suspicious on exami-
nation, may have very worrisome findings on
mammography, prompting a biopsy. Although
both of these scenarios are less common, they
do support the strong role of diagnostic mam-
mography in evaluating breast masses.
Ultrasound can be a useful tool to deter-
mine whether a breast mass is a solid mass, a
simple cyst, or a complex cyst. It is particu-
larly useful in the evaluation of a breast mass
in a woman younger than age 35 years. It may
also be used in conjunction with mammogra-
phy in women older than 35. Increasingly,
breast surgeons are becoming certified in
breast ultrasound so they can easily perform
46
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

ultrasonography in the office. This allows for
not only a rapid assessment of breast masses
but also for image guidance for aspiration or
core needle biopsy.
The benefits of magnetic resonance imaging
(MRI) in the diagnosis and staging of breast
cancer have been touted recently. MRI has
emerged as an imaging modality for the breast
with a wide array of purported uses (see Chap-
ter 2). In the clinical assessment of a benign
mass, however, there is limited data to suggest
that a suspicious lesion found on clinical
examination or mammography but seen as
benign on MRI is unlikely enough to represent
cancer that a biopsy can be avoided. MRI, with
its high sensitivity and lower specificity, may
also lead to the detection of other lesions that
require biopsy. Not all institutions that perform
breast MRI have the ability to perform MRI-
guided biopsies. Even though MRI may have
benefits in defining the extent of a known
breast cancer, or screening the remainder of
the breast and contralateral breast in patients
with breast cancer, its use in the evaluation of
a palpable breast mass is limited. MRI is indi-
cated in the evaluation of a breast mass in a
woman with silicone breast implants, as well
as in women with documented axillary metas-
tases but no primary lesion identified on breast
imaging studies (the “occult breast cancer”).
Triple Diagnosis
One of the greatest fears among breast surgeons
is that of misdiagnosing a breast cancer pre-
senting as a palpable mass, leading to a delay
in diagnosis. Unfortunately, this fear (both on
the part of the patient and the doctor) has
probably led to a large number of unnecessary
excisional breast biopsies.
When can a breast mass be safely observed?
The term “triple diagnosis” refers to the combi-
nation of physical examination,mammography,
and fine-needle aspiration biopsy (FNAB) for
diagnosing palpable breast masses (Table 3–1).
If all three tests are suggestive of benign disease,
the likelihood of missing a cancer is extremely
low (0% to 0.6%). This approach is clearly more
cost-effective than subjecting these women to
an excisional biopsy.
If all three tests suggest benign disease, the
patient should return in 4 to 6 months for a
repeat clinical examination to assure stability
or regression. The patient should then be
seen again at 1 year. If either the mammogram
or the FNAB is suggestive of malignancy,
then a more definitive tissue biopsy is strongly
indicated. If the physical examination is con-
cerning, but the mammogram and FNAB are
both benign, then a detailed discussion should
be held with the patient regarding the risks
and benefits of biopsy versus observation.
Breast Biopsies of Palpable Lesions
In some cases, the history, physical examination
and directed breast imaging will suggest that
observation without a biopsy may be a reason-
able approach. In these cases, the patient should
return for a follow-up clinical appointment in 4
to 6 months to assure stability. The patient
should also be instructed to perform monthly
self-examinations and
return earlier if she
notices any change in symptoms or size. In these
situations, it is not prudent to simply reassure
the patient this is likely benign and give her an
TABLE 3–1
Percent Probability of a Cancer after Triple Diagnosis (Physical
Examination, Mammogram, Fine-Needle Aspiration)
Benign Physical Examination
Mammogram
Findings
FNA
Benign
FNA
Suspicious
FNA
Positive
Benign
0.6%
16.0%
100%
Suspicious
4.1%
32.4%
100%
Positive
5.7%
55.7%
100%
Suspicious Physical Examination
Mammogram
Findings
FNA
Benign
FNA
Suspicious
FNA
Positive
Benign
7.1%
43.8%
94.7%
Suspicious
6.9%
62.5%
99.6%
Positive
35.7%
91.4%
99.4%
From Donegan WL. N Engl J Med 1992;327:937-942. Need permission
47
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

as-needed follow-up appointment, because it is
this scenario that often leads to litigation in the
rare case that a benign-appearing mass turns
out to be a cancer.
In many cases, however, some type of
biopsy may be indicated. There are several
choices for performing a biopsy of a breast
mass, each with relative advantages and disad-
vantages (Table 3–2). The choice of biopsy
depends on the level of suspicion of the mass,
the size and location of the mass, the resources
available (e.g., an experienced cytopathologist),
and the desires of the patient.
Fine-Needle Aspiration
Fine-needle aspiration (FNA) is a quick and
technically simple method of diagnosing both
breast masses and axillary lymph nodes. How-
ever, the procedure does have its limitations.
FNA is useful in differentiating between a solid
mass and a cystic mass. Aspiration of a cyst is
not only diagnostic, but also therapeutic. FNA
of a solid mass allows for cytology (Tables 3–3
and 3–4). The reliability of the cytology, how-
ever, is dependent upon the experience of the
cytopathologist. Reports of sensitivity, specific-
ity, and accuracy vary among reports, with diag-
nostic accuracy ranging from 77% to 99%.
However, in the hands of an experienced cyto-
pathologist, sensitivity can approach 96% and
specificity 99%. Thus an individual surgeon’s
choice of FNA versus core-needle biopsy will
depend in part on the level of expertise of the
cytopathologist. It is therefore incumbent upon
the surgeon to know this information.
It is important to remember that FNA has
both false-negative and false-positive results.
If the mass is suspicious on physical exam or
mammography, but the FNA is negative, a
more definitive tissue biopsy should be consid-
ered. Likewise, a positive FNA should be con-
sidered highly suggestive of cancer, but not
absolute. It is not unreasonable to proceed
with a lumpectomy and sentinel lymph node
biopsy in the face of a highly suspicious lesion
and a positive FNA; even in the unlikely cir-
cumstance that the FNA results turn out to be
falsely positive, the morbidity associated with
this procedure is not significantly greater than
for an excisional breast biopsy. The most dra-
matic mistake that can be made is to proceed
with a mastectomy on the basis of an FNA. If
a patient with a positive FNA desires mastec-
tomy, then either a core biopsy should be per-
formed before proceeding, or an excisional
biopsy and frozen section should be obtained
in the operating room before mastectomy.
Nor can FNA differentiate between in situ
and invasive carcinoma. Again, if this informa-
tion alters your management, a core biopsy or
excisional biopsy should be obtained.
What about a negative FNA on a nonsuspi-
cious lesion? Given the false-negative rate asso-
ciated with FNA, the conventional teaching was
that FNA could not be used to rule out cancer.
However, when combined with mammography
and physical examination, FNA can be quite
reliable. The triple diagnosis is more sensitive
and specific than each test alone. When the
results of all three tests indicate a benign mass,
TABLE 3–2
Comparison of Breast Biopsy Techniques
FNA
Core Biopsy
Excisional Biopsy
Technical ease
Simple
Moderate
Complex
Cost
Inexpensive
More expensive
Most expensive
False-positives
Yes
No
No
False-negatives
Yes
Rare
Very Rare
Complications
Few
Some
Increased
Interpretation
Needs cytopathologist
Routine pathology
Routine pathology
Immunohistochemistry
Difficult
Easy
Easy
TABLE 3–3
Fine-Needle Aspiration
Biopsy Diagnoses
1. Benign
No evidence of malignancy
2. Atypical/
indeterminate
Nondiagnostic cellular findings
3. Suspicious
Significant atypia or
architectural distortion
suggestive, but not
diagnostic, of malignancy
4. Malignant
Cellular findings are diagnostic
of malignancy
5. Unsatisfactory
Scant cellularity or artifact
precluding diagnosis
48
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

the incidence of cancer is 0% to 0.6%. When
the results of all three tests suggest malig-
nancy, the incidence of cancer is 99% to
100%. If the three tests lack concurrence,
then the possibility of malignancy is higher
and a more definitive tissue diagnosis should
be considered. This is particularly true in
younger women, in whom mammography
may be less sensitive.
Procedure
FNA is typically performed with a 10- or 20-mL
syringe and a 21- to 27-gauge needle. Although
some physicians prefer it, no local anesthesia is
necessary because the injection of lidocaine
may be more uncomfortable than the FNA
itself. Furthermore, the anesthetic or a hema-
toma can obscure the mass. The patient should
be resting comfortably in the supine position.
The arm can be over the head or by the side,
whichever is most comfortable for the patient
and allows for the best delineation of the mass.
The skin should be prepped with alcohol and
sterile technique should be used. One hand is
used to secure the mass while the other directs
the needle. Care must taken so that the needle
is not directed toward the chest wall, because
pneumothorax is a possible complication. It is
better to direct the needle tangentially.
Even though a syringe and needle is all that
is necessary, it is technically easier to perform
the procedure with a syringe holder that allows
for
suction to be
applied to
the syringe
(Fig. 3–4). Withdraw the plunger to introduce
air into the syringe. Advance the needle into
the mass and then place full suction on the
syringe. Immediately you may obtain fluid, sig-
naling the presence of a cyst. Continue aspirat-
ing until no more fluid can be obtained and the
mass has completely disappeared. If the aspirate
is bloody or if the mass does not completely
disappear, the fluid should be sent for cytology.
Otherwise, the routine cytologic analysis of cyst
fluid is not necessary.
If no fluid is obtained, then the mass is solid.
Keeping negative pressure on the syringe, the
needle should be passed back and forth within
the mass. Usually doing this within a single nee-
dle tract will give a satisfactory yield, but if no
material is seen in the hub of the needle, the
needle can be introduced at different angles.
While doing this, the wrist should be rotated
slightly so that the needle is twisting. Although
some advocate keeping negative pressure on
the syringe while withdrawing the needle from
the mass, this is not necessary and may pull the
specimen into the syringe, making it difficult to
expel the cells. It is better to return the plunger
to the 5-mL mark and withdraw the needle.
The specimen can than be blown out onto a
glass slide. The needle should touch the surface
of the slide. A small drop (no greater than 5 mm
in diameter) is expressed onto the slide. The
slides are then smeared with a second glass
slide. One slide is quickly sprayed with a fixa-
tive; the other is allowed to air-dry. A simpler
option is to empty the contents of the syringe
into CytoLyt solution or tissue culture medium.
Tissue medium is preferred if fresh, unfixed cells
may be necessary (e.g., for flow cytometry in
the case of a potential lymphoma). In the cyto-
pathology laboratory, cells are then collected
from the medium with Nuclepore filtration or
centrifugation, or they are prepared for a cell
block for paraffin embedding. Complications
of FNA are rare but can include hematoma,
infection (mastitis), and pneumothorax.
Core-Needle Biopsy
Unlike FNA, which removes cells that require a
cytopathologist
to
interpret,
a
core-needle
TABLE 3–4
Benign versus Malignant Features on Fine-Needle Aspiration
Benign
Malignant
Cellularity
Hypocellular
Hypercellular
Architecture
Cohesive, orderly cells
Few single cells
Dyscohesive, disorderly
Several isolated cells
Cell population
Heterogeneous
Homogeneous
Nuclear size
Uniform
Variable and enlarged
Nuclear
membranes
Smooth, fine, and evenly distributed
chromatin
Irregular, coarse, and clumped
chromatin
Nucleoli
Absent
Present
Necrosis
Absent
Present
Myoepithelial cells
Present
Absent
49
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

biopsy provides material that can be interpreted
by a pathologist. It uses a disposable, hand-held
instrument that provides a 1- to 2-cm long spec-
imen (14 to 18 gauge). Automated spring-
loaded devices are the most convenient and
have essentially replaced the hand-actuated
core biopsy needles. The spring-loaded devices
are not only simpler but also have a greater diag-
nostic accuracy. Core-needle biopsy is highly
accurate, with false-positive results being rare.
Treatment decisions, including mastectomy or
neoadjuvant chemotherapy, can thus be based
on a core-needle biopsy diagnosis. In addition,
core-needle biopsy allows for the immunohis-
tochemical staining of the specimen for hor-
mone receptors, Her-2/neu, or other markers
that may be important in clinical decision
making (immunohistochemical staining [IHC]
can be done on a cell block obtained from an
FNA, but this is less reliable and not performed
at all institutions). Core-needle biopsy can be
associated with a false-negative rate ranging
from 1% to 20%. Much of this is secondary to
missing the lesion with the device. This is less
common for larger lesions. Some very firm
lesions may be difficult to advance the needle
into, also leading to a false-negative finding. If
the mass is suspicious but the core-needle
biopsy shows normal breast parenchyma or
other discordant pathology, either an incisional
or excisional biopsy is needed to make the
diagnosis.
Procedure
Unlike FNA biopsy, core-needle biopsy is a
slightly more invasive procedure and requires
local anesthetic (Fig. 3–5). Before beginning,
it is useful to outline the lesion with a water-
soluble pen, then secure the mass with the
nondominant hand and mark the location
where the needle will be introduced. This site
should be chosen so that the needle is not
Figure 3–4. Fine needle aspiration of a breast mass. (From Bland KI, Karakousis CP, Copeland EM. Atlas of surgi-
cal oncology. Philadelphia: WB Saunders, 1995, Figure 8–3.)
50
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

heading down toward the chest wall, but tan-
gentially, to avoid pneumothorax. It should
also be placed in a location that will be easy to
excise if the mass proves to be a cancer. Once
this is completed, the breast is prepped with
iodine solution and sterilely draped. The skin
at the site of entry is anesthetized with 1% lido-
caine solution and an 11-blade is used to make a
small puncture wound in the skin.
The mass is stabilized with the nondominant
hand. The needle is then introduced into the
mass and fired. It is withdrawn, opened, and
the specimen retrieved and placed into fixative.
This is repeated 2 to 5 times until an adequate
specimen has been obtained. Hemostasis is
then achieved by holding direct pressure for 5
minutes. The skin is reapproximated with a ster-
ile adhesive dressing. The specimen container is
immediately labeled with the patient’s name,
medical record number, and the site of the
biopsy to avoid any chance of error. Complica-
tions include infection (mastitis), hematoma,
and rarely pneumothorax.
Excisional Biopsy
Often, an excisional biopsy is necessary to
diagnose a palpable mass. An excisional biopsy
refers to the surgical removal of the entire
mass, sometimes with a small rim of normal
tissue around it. In many cases, this is driven
by the patient, who wants the mass removed
even if it is benign. Excisional biopsy is also
indicated in patients for whom FNA biopsy
or core-needle biopsy was indeterminate or
was unable to be performed. If the mass is
small, or located in such a way that the sur-
geon cannot be confident that the biopsy
device will truly sample the abnormality, an
excisional biopsy might be a better option.
Likewise, if the results of the biopsy of a suspi-
cious mass are returned as “normal breast
parenchyma,”
then
this
might
indicate
a
missed biopsy and an excisional biopsy is
indicated.
Excisional breast biopsies can be performed
on an outpatient basis under local anesthesia
alone or with intravenous (IV) sedation. Gen-
eral anesthesia is rarely necessary. A mixture of
long-acting and short-acting local anesthetic is
recommended, which greatly reduces the need
for narcotics postoperatively. A combination
of 5 mL of 1% lidocaine, 4 mL of 0.5% Mar-
caine, and 1 mL of 8.5% sodium bicarbonate
provides excellent local anesthesia, extended
pain control, and minimal discomfort during
infiltration. Continued infiltration of the tis-
sues throughout the procedure, especially pos-
terior to the mass because this area does not
typically get anesthetized initially, keeps the
patient comfortable throughout the procedure.
It is imperative to remember that this mass
could be cancer. Incisions should be placed with
a subsequent reexcision lumpectomy or mas-
tectomy in mind (Fig. 3–6). Circumareolar inci-
sions are cosmetically pleasing and should be
used whenever feasible, but excessive tunneling
to get to the mass should be avoided. If the
lesion is a cancer, excessive tunneling would
make a reexcision lumpectomy difficult and
negatively impact the final cosmetic result.
Likewise, incisions placed at the very periphery
of the breast may hide the incision, but they
might be very difficult to incorporate in a stan-
dard mastectomy incision if that is ultimately
required. If a circumareolar incision is not
appropriate, a curvilinear incision along Langer
lines is the best choice. Many surgeons prefer a
radial incision when performing a lumpectomy
for a cancer in the inferior half of the breast, par-
ticularly in the 6-o’clock position (see Chapter
12). This may be associated with a better cos-
metic result after radiation therapy. If there is a
high suspicion of cancer for a mass located in
this position, it may be reasonable to use a radial
incision for the excisional biopsy.
If there is even a minimal suspicion of can-
cer, a ridge of normal tissue should be taken
with the mass. The specimen should be ori-
ented for the pathologist. Using a long stitch
to mark lateral, a short stitch to mark superior,
Figure 3–5. Core biopsy. (From Sabel M, Sondak V,
Sussman J. Essentials of Surgical Oncology. Philadel-
phia: Elsevier, 2006.)
51
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

and a double stitch to mark deep will allow the
pathologist to use a six-color inking system so
that if it is cancer, the location of any close or
positive margin can be identified (Fig. 3–7).
After hemostasis is assured, the wound is
closed. No attempt to approximate the edges
of the cavity should be attempted, nor should
a drain be placed. Two layer closure with deep
dermal sutures followed by either a subcuticu-
lar stitch or tissue adhesive is recommended
for reapproximating the skin.
Incisional Biopsy
Incisional biopsy involves removing only a
small part of a breast mass. In essence, a core-
needle biopsy is a form of incisional biopsy,
and for this reason true operative incisional
biopsies have become much less common.
Today, the only indication for performing an
incisional
biopsy
are
when
a
core-needle
biopsy of a large breast mass fails to demon-
strate a suspected malignancy, or demonstrates
in situ disease for a suspected invasive cancer.
In these cases, excision of the mass is not
recommended as if it is invasive disease, and
the patient may benefit from neoadjuvant
chemotherapy and an attempt at breast con-
servation, whereas an excisional biopsy may
commit the patient to mastectomy if it is cancer
(see Chapter 18).
Figure 3–6. When marking out an incision for a breast biopsy, a subsequent reexcision lumpectomy or mas-
tectomy should be kept in mind. Excessive tunneling should be avoided. Radial incisions in the inferior hemi-
sphere of the breast may yield a better cosmetic outcome if cancer is highly suspected. (From Bland KI,
Karakousis CP, Copeland EM. Atlas of surgical oncology, Philadelphia: WB Saunders, 1995, Figure 8–4.)
Long stitch:
lateral
Short stitch:
superior
Double stitch:
deep (posterior)
Figure 3–7. Orientation of a left breast biopsy spec-
imen. The specimen should be oriented in three
planes so that the pathologist can use a multicolor
staining system to identify close or positive margins
in case in situ or invasive cancer is diagnosed.
52
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

The same principles of excisional biopsy are
applied to incisional biopsy. The site of the
incision should be placed in a curvilinear fash-
ion paralleling Langer lines in a way that it is
easily reexcised with a subsequent lumpec-
tomy or mastectomy. Hemostasis is crucial
because a hematoma may not only complicate
subsequent surgery, but also may spread malig-
nant cells. Despite the need for hemostasis, it
is better to perform the biopsy of the lesion
with a scalpel because excess electrocautery
artifact will distort the histology. Once the
lesion is removed, electrocautery is used to
obtain hemostasis, which may be difficult
because open tumor surfaces tend to bleed
quite a bit.
Breast Biopsies of Nonpalpable
Lesions
With increased screening and improved detec-
tion of small abnormalities, the need for
image-guided biopsies of nonpalpable lesions
is increasing rapidly. Several methods exist for
biopsy of nonpalpable lesions, and while these
have typically been the domain of radiologists,
breast surgeons are increasingly performing
their own image-guided biopsies.
Ultrasound-Guided Biopsy
Ultrasound can be used to guide the placement
of a biopsy needle into a sonographically evi-
dent mass. This is useful not only for nonpalp-
able ultrasound visible lesions, but also those
lesions that are only vaguely palpable on physi-
cal examination, or have indiscrete margins,
such that the surgeon is not confident that the
biopsy device is within the abnormality. Ultra-
sound-guided biopsies is advantageous in that
the patient does not need to lie on her stomach
or have her breast compressed, and there is no
associated radiation. Many radiologists feel
that it is faster and easier than stereotactic
biopsy. Today many surgeons, especially breast
surgeons, have incorporated ultrasound into
their practice. This allows for immediate, addi-
tional diagnostic information for the patient
with a breast mass, as well as guidance for biop-
sies. Use of ultrasound to guide a biopsy, by
allowing real-time visualization of the needle
within the lesion, assures adequate sampling
and improves accuracy.
A linear array transducer of at least 7.5 MHz
or 10 MHz is recommended. The linear shape
of the ultrasound beam allows for better
visualization of both the needle and the lesion
during the procedure. Before beginning the
procedure,
the
surgeon
should
image
the
lesion and plan the approach. It is useful to
mark the breast accordingly. The breast is
prepped and then anesthetized. This should
include both the site of the skin incision and
the track that the needle will travel toward
the mass. An 11-blade is used to make a small
incision in the skin and the core biopsy device
is introduced into the breast. With the lesion
visualized, the needle is identified in the longi-
tudinal plane and slowly advanced toward the
lesion (Fig. 3–8). As with palpable biopsies, the
needle should remain parallel to the chest wall
Figure 3–8. A, Image demonstrates predeployment
of core-needle biopsy device. B, Postdeployment
image demonstrates device in mass. C, Orthogonal
projection
documents
biopsy
device
in
mass.
(Images courtesy of Dr. Alexis Nees, Department of
Radiology, University of Michigan.)
53
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

to avoid pneumothorax. Once the needle is
within the mass, its three-dimensional posi-
tion in the mass can be assessed by turning
the transducer 90 degrees to the trajectory.
Once assured that it is in good position, the
device is fired and withdrawn, and the speci-
men is retrieved. As with palpable masses,
two to five specimens are taken, all through
the single skin incision.
Stereotactic Core-Needle Biopsy
Stereotactic core-needle biopsy is indicated for
any mammographically detected lesion that is
not easily seen on ultrasound. Stereotactic
mammography was introduced in Sweden in
the 1970s and introduced in the United States
in Chicago by Dr. Kambiz Dowlatshahi in
1980. At that time, stereotactic mammography
was used to guide FNA biopsies and was accu-
rate but limited by inadequate specimens. In
the late 1980s, stereotactic biopsies using
biopsy guns and large-gauge needles greatly
increased the success rate, and this approach
rapidly became accepted as an alternative to
surgical excision. The use of stereotactic mam-
mography to guide core-needle biopsies has
greatly reduced the need for surgical biopsies
of benign lesions and has minimized the num-
ber of operations needed for cancer patients.
The ease and low morbidity of stereotactic
biopsy has also increased the number of biop-
sies for BI-RADS 3 lesions, decreasing the
chance of missed cancers. Overall, the proce-
dure can be done in 30 minutes with a false-neg-
ative rate of less than 2%. Not all patients are
candidates for stereotactic core-needle biopsy
and may be better served by wire localization
biopsy (Box 3–3).
The procedure may be performed with the
patient upright or prone, but prone is preferred
for keeping the patient stable during the proce-
dure. The patient lies down on the table and the
breast to be biopsied is placed through an open-
ing (Fig. 3–9). Stereotactic localization is based
on the principle of parallax. Two angled radio-
graphic views acquired 15 degrees on either side
of the center are used to determine the location
of the lesion based on the “shift” between the
two acquired views (Fig. 3–10). The breast is
compressed between a compression paddle
and a charge-coupled (CCD) plate. A scout
image is taken to confirm the lesion is within
the working window. The two angled views are
taken and the computer then generates the
three-dimensional coordinates of the target
chosen by the radiologist. Small motors in the
table align the vertical and horizontal positions
of the biopsy sled. The depth is set by the radiol-
ogist using information from the computer.
Once the target is set, the skin and the pro-
jected path of the needle are anesthetized.
A small incision in the skin is made and the nee-
dle is inserted to the determined depth. Two
more offset images are taken to confirm place-
ment and the device is fired. There are a number
of biopsy instruments available for stereotactic
biopsy, including spring-loaded and vacuum-
assisted devices and axial coring devices. Several
specimens are obtained. Some radiologists have
recommended that for spring-loaded devices, at
least five 14-gauge cores should be taken for
accurate sampling, more for microcalcifications
or if a smaller gauge needle is used. The vacuum-
assisted devices are typically larger; most opera-
tors use an 11-gauge needle, although the same
minimal number of cores should be taken.
When the target of the biopsy is the microcalci-
fications, these are radiographed to confirm
their removal. Once assured that an adequate
biopsy has been performed, a tissue marking
clip should be placed at the site of the biopsy
so that the area can be easily targeted in the
future in case the lesion requires reexcision.
Postprocedural
mammograms
(craniocaudal
and mediolateral oblique) confirm that the
correct site was sampled and the clip is in the
correct spot. Complications include infections,
hematoma, and bleeding,
BOX 3–3 CONTRAINDICATIONS TO
STEREOTACTIC CORE BIOPSY


Patients who cannot lie prone for
up to 45 minutes (patients with
back, neck, or shoulder problems)


Patients who cannot keep still for up to
45 minutes (anxiety, chronic cough,
neurologic or musculoskeletal problems)


Weight greater than tolerated by the
stereotactic machine (typically more than
300 lb)


Lesions too close to the chest wall or
axilla to be accessed by the biopsy
needle


Indiscrete lesions or faint
microcalcifications not seen clearly on
stereotactic imaging


Lesions uncomfortably close to blood
vessels or breast implants


Breast compresses to less than 2 cm from
the chest wall
54
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

There are several pathologic results obtained
by stereotactic core-needle biopsy that require a
follow-up wire-localized excision of the area
(Box 3–4). A biopsy demonstrating atypical duc-
tal hyperplasia (ADH), atypical lobular hyperpla-
sia (ALH), or LCIS may harbor an in situ or
invasive component missed by the core-needle
biopsy (Chapter 8). The chance of this occurring
ranges from 4% to 40% depending on the size of
the needle and the number of biopsy specimens
obtained. Papillary lesions diagnosed as benign
papillomas by image-guided biopsy may in
fact be a papillary carcinoma. Likewise, radial
scars may harbor unrecognized atypical hyper-
plasia or malignancy. Some radiologists recom-
mend routine excision of these lesions when
Figure
3–9. Patient
under-
going a stereotactic core breast
biopsy.
Figure 3–10. Triangulation of the depth of a lesion
using two views. (From Bland KI, Copeland EM III. The
breast, 3rd ed. Philadelphia: WB Saunders, 2004.)
BOX 3–4 BENIGN LESIONS FOR
WHICH A WIRE-LOCALIZED BIOPSY
AFTER STEREOTACTIC CORE-
NEEDLE BIOPSY IS RECOMMENDED


Atypical ductal hyperplasia


Atypical lobular hyperplasia


Lobular carcinoma in situ


Sclerosing adenosis (selective)


Papillary lesions (selective vs. routine)


Radial scar (selective vs. routine)


Discordant finding
55
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

diagnosed by core-needle biopsy, whereas some
suggest selective excision based on the degree
of suspicion. Another indication for a follow-up
excisional biopsy is that of a discordant finding,
meaning the histologic findings do not correlate
with the appearance of the lesion on mammog-
raphy. These topics will be discussed later in the
chapter.
Wire-Localized Excisional Biopsy
As discussed, not all nonpalpable lesions are
amenable to an image-guided biopsy, and some
needle biopsies will need follow-up excisional
biopsies to confirm the diagnosis. This is typi-
cally accomplished by a using wire localization
to guide the biopsy. Wire-localized biopsy (also
referred to as a needle-localized biopsy) requires
a
coordination
of
radiology
and
surgery,
although more breast surgeons are performing
their own localizations. Localization involves
placing a rigid introducer needle with a flexible
hooked wire inside of it at the site of the abnor-
mality (or of a clip left after a prior core-needle
biopsy) using either biplanar mammography
or ultrasound. Ultrasound is relatively simpler
and more comfortable for the patient, so if the
lesion is ultrasound visible, this method is pre-
ferred. Sometimes it is difficult to perform a
specimen ultrasound and confirm removal of
the lesion, so it may be wise to place a small clip
in the lesion under ultrasound guidance before
needle localization. In this manner, the speci-
men may be radiographed to confirm removal
of the clip and lesion.
Once the rigid needle is in place, it is with-
drawn, leaving the hooked wire in place. The
hook keeps the wire in place so it is not easily
moved. Even so, the external wire should be
secured to the skin so that it is not dislodged
as the patient travels from radiology to the
operating room. The craniocaudal and medio-
lateral views of the wire in place accompany
the patient to the operating room.
The procedure can be performed under local
anesthesia alone or with local anesthesia and
IV sedation. Care should be taken not to dislodge
the wire when removing the covering dressing
and prepping and draping the breast. The same
principles of incision placement that hold true
for other types of biopsy are in play when
performing a wire-localized biopsy. The incision
should be curvilinear in Langer lines and created
with a subsequent lumpectomy or mastectomy
in mind. The incision should be placed over
the abnormality and not routinely made at the
site of wire entry (Fig. 3–11). Although this may
be acceptable for a superficial lesion, in other
cases this may lead to excessive tunneling to
reach the lesion. This not only results in the
removal of excess tissue but complicates a
subsequent reexcision if cancer is detected.
Instead, the surgeon should use the wire and
images to determine the site of the abnormality
and place the incision directly over this.
The direction of the dissection is determined
by the lesion size, direction of the wire, and
the relative proximity of the wire to the lesion.
Wires placed just posterior to the lesion are
helpful in that the surgeon is assured removal
Figure
3–11. Wire-localized
excisional biopsy. The place-
ment of the incision and direc-
tion
of
the
dissection
are
determined
by
the
location
and direction of the wire and
the relative proximity of the
wire to the lesion. It is usually
best to place the incision over
the
anticipated
site
of
the
abnormality rather than tun-
neling a long distance along
the wire.
56
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

of the lesion by staying just deep to the locali-
zation needle. Once the incision is made, it is
then necessary to identify the shaft of the
lesion and retract it into the wound. Dissec-
tion in the plane facing the wire entry site
allows for simple detection of the wire. Once
identified, it is secured at the site of the paren-
chyma and the distal end of the wire is
brought out into the wound. Failure to ade-
quately secure the wire may result in acciden-
tal dislodgement. Once out, the tissue is
grasped with an Allis clamp. It is preferable to
grab the tissue near the wire but not the wire
itself, because pulling too hard on the clamp
may pull the wire from the specimen. Resec-
tion of the tissue surrounding the wire pro-
ceeds. The relationship between the wire and
the lesion, as demonstrated on mammogra-
phy, will help guide how much tissue to take.
Because the purpose of this operation is solely
diagnostic, every attempt is made to remove
just enough tissue to make the diagnosis. Stay-
ing approximately 1 cm around the wire and
going just past the hook of the wire should
accomplish this, although this depends on
the position of the wire relative to the lesion.
Immediately upon removal of the specimen, it
is held in anatomic position and marked with
orientation sutures. It is also helpful to place
clips at the periphery of the specimen to allow
for orientation of the specimen radiograph.
These may help guide the excision of additional
tissue if the lesion is not present or if margins are
a concern. Before sending the specimen to radi-
ology, it is prudent to examine it along with the
specimen cavity, so that you may gain an idea
of where the lesion might be if it has not been
excised. For example, if on examining the speci-
men you appear to be close to the wire inferiorly,
you can place a small clip at the corresponding
area in the cavity. If the radiograph fails to show
the lesion, you can reexcise that area and send
the second specimen to radiology.
As stated, the specimen is sent to radiology
for confirmation that the lesion in question
was removed. If the wire was dislodged from
the specimen, it should still be sent for confir-
mation that the entire wire was removed. Dur-
ing this time, hemostasis is assured and the
skin closed (it can easily be reopened if addi-
tional tissue needs to be removed). If the abnor-
mality has been removed, the procedure is over.
If the specimen radiograph does not show the
lesion, then additional tissue can be excised
and sent for radiography. As stated, this may
be
greatly
facilitated
by
examining
the
specimen and the cavity before sending it, and
by placing clips on the specimen to orient the
tissue on the x-ray films. If the surgeon does
not know where to reexcise or if a repeated
attempt at reexcision failed to excise the lesion,
intraoperative ultrasound may be used to iden-
tify the lesion, assuming it is ultrasound visible.
If not, it may be prudent to end the case and
plan on a repeat localization and biopsy in the
future. Patients should be counseled that, while
rare, this possibility does exist.
MRI-Guided Biopsy
The use of MRI in the diagnosis and staging of
breast cancer has expanded over the past several
years. MRI is being increasingly used to screen
high-risk women, stage the extent of estab-
lished malignancies, and look for synchronous
cancers in the ipsilateral or contralateral breast.
The pros and cons of MRI for these situations
are discussed in Chapter 2. However, the
increased sensitivity of MRI means that there
will be more lesions detected that are not visible
on mammography and ultrasound. Further-
more, the variable specificity of MRI means
many of these lesions will be benign, and
biopsy is essential before changing surgical
management. This has increased the need for
MRI-guided biopsy. Unfortunately, many insti-
tutions performing MRI do not have the capa-
bility to perform MRI-guided biopsy, leaving
some women in a difficult situation. As com-
pared with mammography or ultrasound, var-
iances in MRI equipment, imaging protocols,
and interpretation criteria make it very difficult
for one institution to evaluate and biopsy a
lesion seen on MRI at a different institution.
For this reason, it is recommended that breast
MRI not be performed at institutions that do
not have the capability to do MRI biopsies.
The first step when a suspicious lesion is
detected on MRI is to repeat mammogram and
ultrasound in the area of the lesion to determine
whether a lesion can be detected. With directed
ultrasound, the lesion can often be identified,
which allows for ultrasound-guided biopsy. If
imaging fails to demonstrate the lesion, MRI-
guided biopsy is indicated. This requires a high-
field-strength magnet (1 to 1.5 T), a specialized
breast coil for imaging, a breast biopsy coil, and
MRI-compatible needles. Before biopsy, an MRI
is obtained that incorporates a copper sulfate
marker that is visible on MRI. In this way, the
lesion’s position can be calculated relative to
the marker using three-dimensional images of
57
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

the breast. The patient is positioned prone with
slight compression (less than necessary for ste-
reotactic biopsy). Needle placement is per-
formed with the patient outside of the magnet
using MRI compatible (titanium) needles. The
patient is then returned to the magnet and
images are obtained for confirmation of needle
placement within the abnormality. Once con-
firmed, sufficient samples are taken outside of
the bore of the magnet and a clip is deployed at
the site, which allows for mammogram-directed
localization in case excision is necessary.
Management of Benign Breast
Masses
As stated earlier, the majority of breast masses
evaluated in the clinic will be benign. Benign
lesions are typically categorized as those with
minimal proliferation, proliferative lesions with-
out atypia, and proliferative lesions with atypia
(Table 3–5). Once the diagnosis is made, the
management
depends
on
the
proliferative
nature of the lesion, the concerns of the patient,
the implications for future risk of breast cancer,
and the possibility of a misdiagnosis. The man-
agement of the most common benign lesions is
discussed here. The management of proliferative
lesions with atypia, which imply an increased
risk of breast cancer, is discussed in Chapter 8.
Fibroadenoma
Fibroadenomas are an extremely common con-
dition of early reproductive life. A fibroadenoma
is a benign tumor that forms from the stroma of
the lobules of the breast. This is why fibroadeno-
mas are most common between the ages of 15
and 25 years, when lobular development is most
active. As opposed to other benign tumors,
fibroadenomas do not tend to continue to grow
progressively. Most reach 1 to 2 cm in size and
then remain stable, or in some cases regress.
Some continue to enlarge. They are very sensi-
tive to hormones, which accounts for why many
women notice that they get larger with the men-
strual cycle and quickly shrink at the conclusion
of menstruation. At menopause, fibroadenomas
may involute, turning into a mass of hyaline
fibrous tissue, possibly with coarse popcorn-like
calcifications.
The typical presentation of a fibroadenoma is
that of a firm, nontender, highly mobile round
or lobulated mass. Often, a breast mass in a
woman younger than 35 years is highly charac-
teristic of a fibroadenoma on physical examina-
tion and breast imaging. On mammography,
fibroadenomas may appear as a well-margin-
ated density against a radiolucent background,
although the dense breast tissue of young
women
often
occlude
the
fibroadenoma
(Fig. 3–12). On ultrasound, the presence of
internal echoes can differentiate between a
fibroadenoma and a cyst (Fig. 3–13). If a mass
in a woman younger than 40 has all of these
characteristics, is a biopsy mandatory? Some
studies have shown that this type of lesion is
benign more than 99% of the time, and so a
small fraction of clinicians opt for careful obser-
vation without biopsy. The patient should
return for a repeat clinical examination in 4 to
TABLE 3–5
Classification of Benign Breast Lesions
Proliferation
Type
Risk
Minimal
Fibrocystic changes
Ductal ectasia
Nonsclerosing adenosis
Periductal fibrosis
Hamartoma
Lipoma
Hematoma
Fat necrosis
Granuloma
Mastitis
Diabetic mastopathy
No increased risk of breast cancer
Proliferative without atypia
Fibroadenoma
Usual ductal hyperplasia
Sclerosing adenosis
Papilloma
Radial scar
Blunt duct adenosis
Small increased risk of breast cancer
Proliferative with atypia
Atypical ductal hyperplasia
Atypical lobular hyperplasia
Lobular carcinoma in situ
Moderate increased risk (see Chapter 8)
58
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

6 months and consideration should be made for
repeat ultrasound to assure stability of the lesion.
Most surgeons believe that a biopsy is always
warranted. This can be either a core biopsy or
FNA, depending mostly on the skill of the cyto-
pathologist and the confidence of the surgeon
that the biopsy was truly from the mass. Fine-
needle aspirates typically contain a high number
of ductal and stromal cells. Bare nuclei in stag-
horn configurations are characteristic. If a mass
is confirmed to be a fibroadenoma, the patient
should be followed up with either physical
examination or ultrasound to confirm stability.
If the mass remains stable in size over 2 years,
no
further
follow-up
should
be
necessary.
Although unsuspected cancer can be found
within a fibroadenoma, this is quite rare and
occurs usually in women older than 50 years of
age.
Fibroadenomas either stay stable, decrease in
size, completely resolve, or get larger. Occa-
sionally fibroadenomas can grow quite large.
These are typically referred to as “giant” or
“juvenile”
fibroadenomas.
Occasionally
an
enlarging fibroadenoma can in reality be a
phyllodes tumor. For these reasons, fibroade-
nomas that are rapidly enlarging or that have
enlarged more than 20% while being observed
should be excised. This can typically be done
under local anesthesia, although IV sedation
is helpful when the mass is quite large. When
excising a fibroadenoma, surgeons may mis-
take the dense fibroglandular tissue in a young
woman for the fibroadenoma, and begin the
excision before the tumor is actually reached.
Because there is no need to take a margin of
normal tissue (recurrence is very low), dissec-
tion should continue toward the mass until
the capsule is clearly identified and bulging
into the field. After assuring hemostasis, only
the skin and subcutaneous tissues need be
closed. Closing the defect in the breast paren-
chyma will abnormally distort the breast. The
defect will close naturally over time, even after
the excision of a large fibroadenoma.
Cryoablation has recently been described for
the eradication of fibroadenomas after establish-
ing the diagnosis by core needle biopsy. This is
an office-based, minimally invasive procedure
in which a small probe is placed into the center
A
B
Figure 3–12. Mediolateral-oblique and craniocaudal mammographic views demonstrate circumscribed oval
mass in the upper outer quadrant of the left breast. (Images courtesy of Dr. Alexis Nees, Department of
Radiology, University of Michigan.)
59
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

of the fibroadenoma under ultrasound guidance
(Fig. 3–14). Argon gas flows through the probe,
dropping the temperature of the tip to 196C,
generating an ice ball that encompasses the
mass. After thawing, the probe is removed. Over
time the fibroadenoma resolves spontaneously.
Adenomas can occur in the breast. These are
similar to fibroadenomas (well-circumscribed,
benign) but differ in that they have sparse,
inconspicuous stroma. Tubular adenomas tend
to occur in young women and are similar in
presentation to fibroadenomas—that of a well-
defined, mobile nodule. Lactating adenomas
present as a mobile mass during pregnancy or
in the postpartum period.
Cysts
Cysts
are
extremely
common,
fluid-filled
epithelialized spaces. They are usually multifo-
cal and bilateral and vary greatly in size and
number. They are typically round with a flat-
tened epithelium surrounding fluid that can
range from yellow to green to brown. Whereas
most cysts contain 5 to 10 mL of fluid, some
cysts can contain more than 75 mL. The sur-
rounding stroma is generally fibrotic and can
show an inflammatory infiltrate.
The exact mechanism by which cysts origi-
nate is unclear. With the menstrual cycle, the
breast stroma and epithelium undergo repeated
integrated involution, and cysts appear to be a
by-product of abnormalities of this process.
Cysts originate from the terminal duct lobular
unit or from an obstructed duct. If the stroma
surrounding a lobular unit involutes too quickly,
the epithelial acini remain and can form micro-
cysts. These are the precursors to macrocysts.
Patients may present with a single or multiple
asymptomatic masses or a tender, painful mass.
Cysts are easily taken care of through aspiration.
When a woman presents with a mass in the
breast that is likely a cyst, the first question is
whether to proceed directly to breast imaging
or to aspiration. If directed imaging is immedi-
ately available, many radiologists prefer to image
breast masses before aspiration because the aspi-
ration can produce artifacts that make assess-
ment more difficult. After imaging, the patient
should return to the office for aspiration if the
lesion is a true simple cyst. However, if the cyst
is causing discomfort to the patient and obtain-
ing an image can’t be done that day, it is reason-
able to proceed with aspiration as the first step.
After prepping the breast, a 21-gauge needle
on a 10- or 20-mL syringe is placed into the
cyst. The opposite hand should be used to
secure the mass because it is often quite
mobile. This is greatly facilitated by the use
of devices that hold the syringe and allow for
one-handed aspiration. If the fluid is consis-
tent with a cyst, it should be aspirated until
no more fluid is obtained and the cyst has
completely disappeared. There is no need to
send this fluid for cytology.
Figure 3–14. Cryoablation of a fibroadenoma
(Image courtesy of Sanarus Medical, Inc.)
Figure 3–13. Ultrasound demonstrates a circum-
scribed hypoechoic oval mass with long axis parallel
to the chest wall. Note the associated posterior
shadowing. Pathology from ultrasound-guided core-
needle biopsy confirmed diagnosis of fibroadenoma.
(Image courtesy of Dr. Alexis Nees, Department of
Radiology, University of Michigan.)
60
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

If the fluid that returns is bloody, then after
aspirating 1 to 2 mL for cytology, the aspira-
tion should be stopped. If no fluid returns,
then the procedure can be easily converted to
an FNAB. If after aspiration there is still a resid-
ual mass, the patient should be sent for imag-
ing (if not already done). If a cystic mass is
still present, ultrasound-guided aspiration can
complete the process. If there is a solid compo-
nent, image-guided or open biopsy should be
performed as indicated. If not already done,
the patient should be sent for imaging and
subsequent tissue biopsy of the lesion. The big-
gest risk in aspirating a mass without preproce-
dural imaging is that it might be a complex
cyst or cystic-solid mass that might be a cancer.
Completely aspirating a bloody cyst, leaving no
simple method for identifying the lesion on
imaging or physical examination if the cytol-
ogy is atypical, could lead to trouble in making
a diagnosis. Likewise, ignoring a residual mass
after cyst aspiration could lead to a delay in
diagnosis of a malignant lesion.
It is not uncommon for cysts to recur after
aspiration. A repeat aspiration is reasonable,
assuming the fluid is not bloody and the cyst
continues to completely resolve after aspira-
tion. However, cysts that continue to recur
should be excised.
Lipoma
Lipomas are soft or semifirm, well-marginated
masses that may feel either smooth or lobu-
lated. They are composed of mature fat cells
and may occur anywhere on the body, includ-
ing the breast. The typical physical findings
strongly support the diagnosis, especially if
the mass has been present for a considerable
time or other similar masses are present else-
where in the breast or rest of the body. If phys-
ical examination is consistent with a lipoma,
these may be safely observed. Needle biopsy
is not usually helpful because the mass pro-
vides little resistance to the needle, making it
difficult to be sure the biopsy came from the
mass. The cytology shows normal fat cells, so
it is unclear whether this was a lipoma or the
examiner missed the mass. If there is any ques-
tion about the diagnosis, if the lipoma is
enlarging, or if the patient is bothered by its
presence, excision is recommended. Lipomas
are usually well-circumscribed and can be eas-
ily excised through a small incision. However,
incomplete excision can be associated with
recurrence. Angiolipomas and angiomyolipo-
mas are other benign masses of the breast,
comprised of both fat and mesenchymal tis-
sues, which are also easily taken care of by
complete excision. There is minimal distinc-
tion between these and lipomas.
Hamartoma
Hamartomas are encapsulated tumors that con-
tain an abnormal mix of normal mammary
tissues. They can grow quite large, often pre-
senting as a discrete, mobile mass. On mammo-
grams, hamartomas often have a distinctive
appearance;
they are
smoothly
marginated
and separated from the surrounding breast by
a
lucent
halo
(Fig.
3–15).
This
has
been
described as a “breast within a breast.” If they
are
asymptomatic
and
not
bothering
the
patient, and if a definitive diagnosis can be
made based on mammography and biopsy,
then observation is an option because these
are invariably benign. If the diagnosis is uncer-
tain or if the patient is bothered, excision is
recommended.
Trauma/Hematoma/Fat Necrosis
Many women will sustain a trauma to the
breast that will leave a mass in the breast,
either a hematoma or fat necrosis. Hematomas
typically present as the result of trauma or iat-
rogenic injury. Spontaneous hematomas are
extremely rare. The mass is typically painful
and associated with ecchymosis. One of the
biggest mistakes that can be made is to assume
that a mass present in the breast after a trauma
is a hematoma and to ignore it. Often a minor
trauma will simply alert a patient to the pres-
ence of a mass that was there before the event.
This is especially true if there is ecchymosis
associated with the mass.
If a hematoma is obvious, such as that caused
by an iatrogenic injury, the hematoma will
resolve with time. Treatment includes a good
supportive bra and analgesics. Expanding hema-
tomas require surgical evacuation and hemosta-
sis. Likewise, conservative management of a
hematoma after a reported trauma is reasonable
if the storymatches the physicalfindings. Imme-
diate imaging can be painful and it is reasonable
to avoid it. However, careful follow-up is manda-
tory to assure that the hematoma is resolving. If
there is any question of a residual mass or a fail-
ure to resolve, imaging and biopsy is recom-
mended. Likewise, if the story and the findings
raise any suspicion of malignancy, a thorough
evaluation is warranted.
61
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

Fat necrosis is the result of saponification of
fat after trauma. Fat necrosis is relatively
uncommon but can often be confused for an
invasive cancer. Sometimes, fat necrosis is
found in the acute setting, with an identifiable
traumatic event associated with it. Biopsy at
this time will show the characteristic inflam-
matory changes with a preponderance of lym-
phocytes and histiocytes. Often, however, the
later stages of fat necrosis may present as a
mass in the breast without any recalled trauma
by the patient. At this later stage, the predom-
inant histologic finding is collagenous scar,
with granular histiocytes surrounding oil cysts.
Oil
cysts
contain
the
free
lipid
material
released by lipocyte necrosis.
As with hematoma, if there is a strong history
for trauma along with characteristic imaging
(e.g., an oil cyst), then observation is reason-
able. However, if there is any question of possi-
ble malignancy, and with fat necrosis it is
often difficult to differentiate the two without
histology, then biopsy is warranted.
Diabetic Mastopathy
Diabetic mastopathy is a breast mass consisting
of fibrous breast tissue associated with long-
standing type 1 or type 2 diabetes. The lesion is
a combination of connective tissue overgrowth,
lobular atrophy, and infiltration of predomi-
nately
B
lymphocytes. A
classic
histologic
feature is fibroblasts set within a keloid-like
dense fibrous stroma. The exact mechanism
remains unknown and is not related to poorcon-
trol of the diabetes. In fact, these changes can
sometimes be seen in patients without diabetes.
Diabetic mastopathy often presents as a
slightly irregular, dense mass. This can be dif-
fuse and bilateral. Mammography is often nor-
mal but ultrasound features are worrisome for
malignancy. Core biopsy is recommended for
definitive diagnosis because surgical excision
is not recommended if the diagnosis is con-
firmed on needle biopsy. Excision is associated
with a high rate of recurrence.
Sclerosing Adenosis and Radial
Scar
There are several benign findings of the breast
that are generally categorized as proliferative
lesions without atypia. These include usual duc-
tal hyperplasia, intraductal papillomas, scleros-
ing adenosis, and radial scars. Although these
lesions are all benign, they may be associated
with an increased risk of developing breast can-
cer, approximately 1.5 to 2.0 times that of the
general population. Sclerosing adenosis is a distor-
tion of epithelial, myoepithelial, and stromal
elements arising in a terminal duct lobular unit.
It is often an incidental finding but may present
as a mammographic finding or occasionally a
palpable mass (which is often referred to as an
A
B
Figure 3–15. Mediolateral-oblique and craniocaudal mammographic images demonstrate circumscribed
mixed density fat-containing mass. This is a fibroadenolipoma or breast hamartoma. (Images courtesy of
Dr. Alexis Nees, Department of Radiology, University of Michigan.)
62
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

adenosistumor or nodular adenosis). The stroma
of sclerosing adenosis is fibrotic or sclerotic,
hence the name. Its appearance and sometimes
histology may be confused with invasive cancer,
although an experienced pathologist should be
able to differentiate the two.
Radial scars may also be incidental findings,
but more commonly present as either palpable
masses or as a spiculated density on mammogra-
phy. It is because the lesions are spiculated that
they are difficult to differentiate from cancer.
They incorporate several very deformed lobular
units around a major stem of the ductal system,
which is the likely origin of the abnormality.
The
exact
pathogenesis
of
radial
scars
is
unknown. They are characterized by a central
scar from which these elements radiate. On gross
examination, they are irregular, gray-white, and
indurated with central retraction. This appear-
ance is very similar to scirrhous carcinoma. His-
tologically,
they
show
focal
dense
fibrosis
associated with centrifugal dispersion of epithe-
lium. They are sometimes fixed to the overlying
skin, further raising the suspicion of cancer.
Both radial scars and sclerosing adenosis
may be involved by atypical hyperplasia, LCIS
or even DCIS or invasive cancer, although this
is rare. It is clear that both lesions increase the
subsequent risk of breast cancer. However, the
presence of a radial scar may be a stronger risk
factor than that of sclerosing adenosis, with an
increased risk of 3.0 compared with 1.5 for
adenosis. Radial scars with atypical hyperplasia
have a relative risk of 5.8, which increases to
8.8 if the lesions are greater than 4 mm. Some
investigators have suggested that radial scars
may be precursors to cancer, citing the similar
appearance, the correlation of size with risk,
and the occasional finding of atypia, in situ
or invasive disease within a radial scar. How-
ever, there is no clear evidence that these are
premalignant lesions.
Because both of these lesions appear suspi-
cious on mammography, biopsy is mandated.
The biggest question is whether needle biopsy
is adequate. If a core-needle biopsy is performed
and the results show sclerosing adenosis or
radial scar, should a subsequent wire-localized
excisional biopsy be performed to rule out an
underlying atypical hyperplasia, DCIS, or inva-
sive cancer? This depends on the appearance
of the lesion on mammography, whether
the entire lesion and/or calcifications were
removed by the percutaneous biopsy, and the
histopathologic evaluation. For sclerosing ade-
nosis, if the mass is circumscribed or indis-
tinctly
marginated
and
the
core
biopsy
demonstrates sclerosing adenosis, then it may
be reasonable to watch this. If it is enlarging,
however, on short-term follow-up mammo-
gram, excision is warranted. If it is a speculated
mass, if there are fine linear or branching calci-
fications or calcifications in a segmental or lin-
ear distribution, or if the biopsy suggests radial
scar, excision is recommended. For this reason,
when radial scar is suspected at presentation, it
is prudent to proceed directly to excisional
biopsy, forgoing core-needle biopsy. Although
there may be some cases in which a radial scar
diagnosed by needle biopsy may be observed,
this requires careful review and communication
between the radiologist, the pathologist, the
surgeon, and the patient.
Although the presence of these lesions does
increase the risk of breast cancer, in the absence
of atypia, the magnitude of this risk probably
does not justify risk reduction counseling.
If atypia is present, the patient should be
referred for counseling and consideration of
chemoprevention.
Papilloma and Papillomatosis
Papillary lesions of the breast are not well
understood because they are relatively uncom-
mon and incorporate a spectrum of lesions.
These include single benign papillomas, papil-
lomatosis, atypical papillomas, papillary DCIS,
and invasive papillary carcinoma. Papillomas
appear to be formed from hyperplasia of the
duct epithelium supported by a fibrovascular
core. This results in a pedunculated, friable
tumor within the duct. They grow to about
1 cm in size, dilating the duct, and the friable
epithelium often bleeds, causing a spontane-
ous bloody nipple discharge. Sometimes a pal-
pable mass can be felt near the nipple, and
gentle pressure on it causes the discharge.
They are primarily in one duct, usually in the
major ducts beneath or within a few centi-
meters of the nipple, but they can be more dis-
tant, multiple, or in both breasts. When
papillomas are located in the periphery of the
breast and are associated with the terminal
duct-lobular units, they are usually multiple
and are often labeled as diffuse papillomatosis.
Whereas papillomas can present clinically as a
palpable mass or bloody nipple discharge, they
may also be clinically occult, detected as an
abnormal density on breast imaging.
For the patient who presents with clinical
symptoms, ultrasound can often demonstrate
the lesion, as well as the dilated duct (Fig. 3–16).
Ductography is the besttest, whichdemonstrates
63
3—THE BREAST MASS, BREAST BIOPSIES, AND BENIGN LESIONS OF THE BREAST

a filling defect within the ductal system after
cannulating and injecting the duct in question
with radiocontrast (Fig. 3–17). They may also be
diagnosed by ductoscopy in the patient with a
bloody nipple discharge (see Chapter 5).
Even though papillomas are benign, they
can be associated with an increased risk of a
subsequent breast cancer. The likelihood of a
future breast cancer correlates with the degree
of atypia. The presence of a single papilloma
without atypical hyperplasia carries little risk
of cancer. The presence of atypical hyperplasia
in the epithelium or the presence of multiple
papillomas (for which atypia is more com-
monly seen) may be associated with a higher
risk of cancer. Juvenile papillomatosis (Swiss
cheese disease) affects young women (mean
age 23) and features atypical hyperplasia and
multiple lesions. This is associated with a high
risk of cancer; in 4% of patients cancer is
found concurrently with the papillomatosis.
Clinically occult papillary lesions diagnosed
by core-needle biopsy are rare, representing less
Figure 3–16. Transverse ultrasound image shows
dilated duct with intraductal mass. Pathology con-
firmed papilloma. (Image courtesy of Dr. Alexis Nees,
Department of Radiology, University of Michigan.)
A
B
Figure 3–17. A, Image from ductogram demonstrates filling defect with “cut-off sign.” Pathology at excision
demonstrated papilloma. B, Ductogram demonstrates multiple intraductal filling defects. Pathology demon-
strated high nuclear grade ductal carcinoma in situ. (Images courtesy of Dr. Alexis Nees, Department of
Radiology, University of Michigan.)
64
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

than 0.2% of core-needle biopsies. When the
lesion was subsequently excised, cancer was
revealed in 0% to 50% of cases, usually, but not
always, among papillomas containing atypia.
For this reason, it is generally recommended that
any papillary lesion diagnosed by core-needle
biopsy be excised to rule out malignancy.
Likewise, for patients with symptomatic
papillomas, treatment is complete excision. If
the lesion can be localized by physical exami-
nation, imaging, or ductoscopy, then just the
duct containing the papilloma can be excised.
In the patient with bloody nipple discharge
but no identifiable mass, a complete duct exci-
sion may be necessary. This will not only
secure the diagnosis and rule out malignancy,
but also eliminate the discharge. If there is no
atypia associated with the lesion, no further
treatment
is
necessary.
However,
for
the
patient with associated atypia, risk reduction
counseling should be considered. In this case,
the benefits of chemoprevention may be com-
parable to patients with ADH, although there
is not enough data to be sure of this.
Suggested Readings
1. Carty NJ, Carter C, Rubin C, et al. Management of
fibroadenoma of the breast. Ann R Coll Surg Engl
1995;77:127.
2. Courtillot C, Plu-Bureau G, Binart N, et al. Benign
breast diseases. J Mammary Gland Biol Neoplasia.
2005;10(4):325–d335.
3. Gordon PB, Gagnon FA, Lanzkowsky L. Solid breast
masses diagnosed as fibroadenoma at fine-needle
aspiration biopsy: Acceptable rates of growth at
long-term follow-up. Radiology 2003;229:233.
4. Hartmann LC, Sellars TA, Frost MH. Benign breast
disease and the risk of breast cancer. N Engl J Med
2005;353:229.
5. Hartmann LC, Sellers TA, Frost MH, et al. Benign
breast disease and the risk of breast cancer. N Engl
J Med 2005;353:229.
6. Ibarra JA. Papillary lesions of the breast. Breast J
2006;12(3):237–251.
7. Kaufman CS. Office-based cryoablation of breast
fibroadenomas: 12-month followup. J Am Coll Surg
2004;198:914.
8. Kudva YC, Reynolds CA, O’Brian T, Crotty TB.
Mastopathy
and
diabetes.
Curr
Diabetes
Rep
2003;
3(1):56–59.
9. Littrup PJ, Freeman-Gibb L, Andea A, et al. Cryo-
therapy for breast fibroadenomas. Radiology 2005;
234:63.
10. Santen RJ, Mancel R. Benign breast disorders. N
Engl J Med 2005;353:275.
11. Sydnor MK, Wilson JD, Hijaz TA, et al. Underesti-
mation of the presence of breast carcinoma in pap-
illary lesions initially diagnosed at core-needle
biopsy. Radiology 2007;242:58.
12. Valdes EK, Feldman SM, Boolbol SK. Papillary
lesions: A review of the literature. Ann Surg Oncol
2007;14:1009.
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4
Breast Pain and Fibrocystic
Disease
ETIOLOGY OF CYCLIC
MASTALGIA
EVALUATION OF BREAST PAIN
TREATMENT OPTIONS
Reassurance
Nonhormonal Therapies
Hormonal Therapies
Surgery for Mastalgia
Breast Pain and Fibrocystic Disease: Key Points
Understand the various etiologies of breast pain and the differences
in presentation of cyclic mastalgia, noncyclic mastalgia and
extramammary pain.
Appreciate the suggested relationships between fibrocystic disease,
hormones, and dietary factors.
Describe the thorough evaluation of the woman with breast pain.
Develop an algorithm for the treatment of the woman with cyclic mastalgia.
Breast pain is a frequent reason for office visits to
family doctors, internists, gynecologists, and
surgeons. It is common in women, but occasion-
ally occurs in men. Depending on the popula-
tion studied and how breast pain is defined,
more than half the population has at least mild
symptoms of breast pain. Fortunately, only a
small percentage of patients with breast pain
seek treatment. The role of the diagnostician is
to determine whether this pain is pathologic or
physiologic, related to hormonal fluctuation,
and whether the severity warrants therapy.
Although breast pain is rarely associated with
malignancy and is usually self-limited, it is of sig-
nificant concern to patients. Mild breast pain
spontaneously resolves in 9 out of 10 patients,
and even severe breast pain resolves in more
than half of patients.
There
are
three
categories
of
mastalgia:
cyclic
mastalgia,
noncyclic
mastalgia,
and
extramammary pain (Box 4–1). Cyclic breast
pain is typically an extreme form of the nor-
mal breast fullness present in the late luteal
phase of the cycle.
67

Etiology of Cyclic Mastalgia
The exact etiology of breast pain remains in
question. Mastalgia is often referred to as a
component of “fibrocystic disease,” although
this nomenclature is confusing. For one thing,
fibrocystic changes in the breast are normal
and so it is misleading to refer to this as a dis-
ease. Postmortem studies show that fibrocystic
changes occur in most if not all women. It also
suggests that there is a histologic change that
occurs in the breast that triggers the pain.
However, findings such as fibrosis, adenosis,
and lymphoid infiltration have not correlated
with clinical episodes, nor have histologic dif-
ferences been observed between symptomatic
and asymptomatic women.
What is clear is the hormonal nature of cyclic
mastalgia. It does not occur until after menar-
che, usually (although not always) resolves at
menopause, and clearly fluctuates with the
reproductive cycle. However, the exact hor-
monal influences that lead to mastalgia remain
theoretical at best (Box 4–2). Differences in hor-
mone levels between symptomatic and asymp-
tomatic women have been variable, and in
cases where an abnormality is present, symp-
toms do not necessarily resolve with correction.
Prolactin is a strong suspect in the develop-
ment of mastalgia because it is involved in
growth and secretory differentiation of the
breast and is episodic and circadian. In addition,
prolactin levels and effects can be influenced by
changes in estrogen and progesterone, so that a
more complex interaction of these hormones
may be a cause, explaining why levels may not
always correlate with symptoms. Finally, exoge-
nous factors associated with mastalgia can
impact prolactin levels, accounting for their
connection.
The association between caffeine and “fibro-
cystic changes” or mastalgia has been long
known, and it is believed that this works
through
cyclic
adenosine
monophosphate
(cAMP). Increased cAMP leads to increased cel-
lular proliferation in the breast and perhaps
pain.
Although
caffeine
does
not
directly
impact cAMP, it can increase catecholamines,
which do increase cAMP. Patients with mastal-
gia may have an increased sensitivity to cate-
cholamines, with higher levels of b-adrenergic
receptors. Catecholamine levels can also be
increased by nicotine, tyramine, and stress,
both physical and emotional.
There may also be an association between
fat and breast pain. At first, it was thought that
increased body weight led to increased estrogen
levels and thus breast pain. However, it may be
more related to an imbalance in the ratio of
saturated to unsaturated fatty acids. Many
women with breast pain have lower levels of
the plasma essential fatty acid gamma-linolenic
acid (GLA). This may be due to the inhibition of
the conversion of linoleic acid and GLA by high
levels of saturated fats. This deficiency of essen-
tial fatty acids could affect the breast cell mem-
brane
receptors,
leading
to
this
increased
sensitivity. It is for this reason that decreased
intake of saturated fats and supplementation
of GLA may help
manage mastalgia (see
Nonhormonal Therapies).
Evaluation of Breast Pain
The evaluation of breast pain should always
begin with a thorough history and physical
examination. It is important to characterize the
pain as carefully as possible, starting with
whether it is cyclic or noncyclic in relation to
the menses. When is the peak of the pain? Estab-
lish the type of pain, its typical duration, the
location within the breast, and whether it is uni-
lateral or bilateral. Is the pain generalized
throughout the breast or is it focal within one
spot. Cancer must be considered in the patient
with a persistent, well-localized pain. You should
also document the extent to which mastalgia
disrupts the patient’s normal lifestyle.
It is also critical to determine whether the
pain is preceded by any specific movement or
BOX 4–1 CATEGORIES OF BREAST
PAIN


Cyclical breast pain


Noncyclic breast pain


Extramammary pain
BOX 4–2 THEORIES OF HORMONAL
LINKS TO MASTALGIA


Excessive estrogen


Deficient progesterone


Changes in progesterone/estrogen ratio


Abnormalities in receptor sensitivity


Abnormalities in follicle stimulating
hormone/luteinizing hormone levels


Low androgen levels


High prolactin levels
68
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

position and if there was a history of trauma or
overexertion, specifically of the pectoral mus-
cle group. Is there a concurrent neck problem?
Are there any associated symptoms such as
fever, cough, shortness of breath, pain radiat-
ing down the arm, numbness or tingling, or
erythema? The patient’s past medical history,
including medications, should be obtained.
Did the pain begin after a recent birth, preg-
nancy loss or termination, or beginning of
the use of oral contraceptive pills or hormone
replacement therapy? It is also important to
determine
the
patient’s
primary
concerns,
including concerns about malignancy, how
the pain affects her, and what she has done
to alleviate the pain to date.
Approximately two thirds of patients will
have cyclic breast pain while one third will
have noncyclic pain, which may be either
related to the breast or to the chest wall
(Box 4–3). For women with noncyclic pain,
the location of the pain may help elicit the
source. Forty percent of women with noncy-
clic breast pain have a musculoskeletal cause.
Pain in the inner quadrants is often related to
the chest wall, possibly secondary to an over-
exertion injury or strain of the pectoral mus-
cle. Sometimes this pain can be reproduced
by having the woman place her hand flat on
the iliac wing and pushing inward. Other
sources of chest wall pain are costochondritis
(Tietze’s syndrome) or arthritis, all of which
can cause peristernal discomfort. Direct pres-
sure on the sternum can reproduce this pain.
Most of these patients can be successfully
treated with oral or topical nonsteroidal anti-
inflammatory drugs (NSAIDs).
Noncyclic pain located in the lower outer
quadrant of the breast may be secondary to
vertebral,
spinal,
or
paraspinal
problems.
A radiculopathy can lead to both pain and
hyperesthesia in this area, and women often
describe a burning pain. A respiratory infec-
tion may cause an intercostal neuralgia. If the
pain is on the right, gallbladder disease must
be included in the differential, and if it is on
the left, a cardiac source must be considered.
A careful review of systems can help rule these
in or out and the appropriate workup can be
initiated.
Cyclic mastalgia is usually first seen during
the third decade of life. Many patients describe
the pain as dull, burning, throbbing, or ach-
ing, usually starting in the upper, outer quad-
rant of the breast. Even though both breasts
can be involved, patients often claim one
breast is worse than the other. Sometimes a
shooting pain radiating to the arm and axilla
may be present. This might be secondary to
glandular pressure on the intercostobrachial
nerve. The pain usually starts about 5 days
before the menstrual cycle, although some
women have constant pain, which worsens at
this time.
Physical examination should begin with
gentle palpation of the breasts because deep
palpation
may
be
uncomfortable
for
the
patient and may limit the rest of the examina-
tion. The goal of the examination is to identify
other signs that may suggest malignancy, such
as an associated mass, skin changes, or nipple
discharge. If the pain is localized, attention
should be focused on this area to exclude a dis-
crete pain. If the pain is reproducible with pal-
pation, it is helpful to have the patient roll to
one side so that the breast tissue falls away
from the chest wall. It then might be possible
to determine whether the pain is arising from
the underlying rib.
Radiology has a limited role in the evalua-
tion of breast pain. Because most women are
young, mammography is limited. However,
women older than age 35 years who have not
had a recent screening mammogram should
obtain one. Women younger than 35 years
with physical findings or a strong family his-
tory of breast cancer should also undergo
mammography. Ultrasound is helpful in char-
acterizing a mass at the site of the pain, but
in the absence of a palpable finding, is rarely
of value. It can be considered when the breast
pain is focal. Fine-needle aspiration biopsy of a
BOX 4–3 POSSIBLE CAUSES OF
NONCYCLIC BREAST PAIN
Breast
Cysts
Focal or periductal mastitis
Mondor’s disease (sclerosing
periphlebitis)
Ill-fitting brassiere
Trauma
Hidradenitis suppurativa
Chest wall
Costochondritis
Diffuse or localized lateral chest
wall pain
Radicular pain from cervical arthritis
Other
Lung disease
Hiatal hernia
Gallbladder disease
Ischemic heart disease
69
4—BREAST PAIN AND FIBROCYSTIC DISEASE

focal source of pain can theoretically be used,
but it is associated with extremely low yield
and is probably more beneficial in reassuring
the patient. If a spinal source is suspected,
x-rays of the neck and back may be helpful.
Laboratory tests are rarely useful.
Treatment Options
Reassurance
If the pain seems to be musculoskeletal in
nature, further workup and treatment recom-
mendations should be initiated based on the
likely source. For primary breast pain, if the clin-
ical examination and imaging studies are nega-
tive, then simple reassurance that the pain is
unlikely to be secondary to breast cancer will
provide
adequate
relief
for
most
women
(Fig. 4–1). It can be helpful to ask women with
cyclic pain to record the occurrence and sever-
ity of breast pain. By doing so, the woman often
notes aggravating factors that she had not pre-
viously noted, and she can eliminate them.
Cyclic mastalgia will spontaneously resolve
within 3 months in approximately one fourth
of patients, and noncyclic mastalgia will spon-
taneously resolve in half. In a study of large
referral clinics, 85% of women were comfort-
able with watchful waiting after their anxiety
about malignant disease was alleviated. The
other 15% requested treatment. Several minor
recommendations
may
help
a
significant
number of women alleviate the pain.
Nonhormonal Therapies
After assuring women that their pain is unlikely
to represent an underlying malignancy, the first
steps to alleviate the pain should be simple
(Box 4–4). Application of either warm com-
presses or ice packs may be helpful. A support-
ive brassiere can be extremely effective. Precise
fitting of a brassiere to provide support for pen-
dulous breasts may provide pain relief. The use
of a sports bra during exercise or excessive activ-
ity has been shown to reduce pain related to
breast movement. Analgesics, both acetamino-
phen and NSAIDs, can help. These may be
administered orally or topically.
Dietary changes can also be helpful. Caf-
feine has often been described as an aggra-
vating factor for fibrocystic disease of the
breasts, and avoidance of caffeine is one of
the first recommendations made to patients.
However, the relationship between methyl-
xanthines and cyclic mastalgia is not quite
straightforward. Based on evidence that cAMP
levels were elevated when the breasts were
swollen and painful, women with “fibrocystic
disease” were asked to avoid agents that acti-
vate cAMP. Primarily, this involved avoidance
of methylxanthine-containing products, such
as coffee, tea, colas, and chocolate. Indeed, in
many women, the pain begins to resolve after
Complete history and physical
Mammography if over 35
Consider U/S for focal pain
Abnormal
Normal
REASSURANCE
Work-up of
breast mass,
nipple discharge,
etc. as indicated.
Recommend
lifestyle and
dietary changes
Moderate to
severe pain
persists after
6 months
Consider
pharmaceutical/
hormonal therapy
Figure 4–1. Approach to the patient with breast
pain. Mammography should be obtained in any
woman older than 35 and women younger than 35
if they have a family history or physical finding.
Ultrasound may be considered if the pain is focal. If
no abnormality is found, reassurance is the first step,
followed by simple lifestyle and dietary changes.
Patients with severe cyclic mastalgia or mastalgia
unresponsive to conservative treatment should be
considered for hormonal therapy.
BOX 4–4 LIFESTYLE AND
NUTRITIONAL CHANGES
RECOMMENDED FOR MASTALGIA
Lifestyle
Stop smoking
Better fitting bra
Sports bra during exercise
Weight loss and exercise
Stress management
Analgesics, either topical or oral
Nutritional
Avoidance of methylxanthines (coffee,
tea, chocolate, cola)
Diminish dietary fat intake
Gamma-linolenic acid (evening
primrose oil)
70
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

a few months and stays away as long as methyl-
xanthine is avoided. It is important to inform
women that it may take up to 6 months to see
a resolution of symptoms after eliminating
methylxanthines. However, in other women,
even after total abstention from methylxan-
thines, the symptoms recur or never resolve.
One reason for this may be that women
deprived of methylxanthines may eat more
foods containing tyramine (e.g., cheese, wine,
beer, spices, nuts, mushrooms, and bananas).
As discussed earlier, both methylxanthines
and tyramines can elevate serum catechola-
mines. In addition to methylxanthines and tyr-
amines, catecholamines can also be elevated by
nicotine, stress, and other hormones. Therefore
avoiding all the agents that increase catechol-
amine levels would be extremely difficult.
While avoiding caffeine may help some women
control their breast pain and may be recom-
mended as a first step, it may only benefit a
minority of patients. Nicotine also increases
epinephrine levels and stimulates cAMP. Smok-
ing cessation should always be strongly recom-
mended as a method to reduce mastalgia, as
much for palliation of the breast pain as the
countless other reasons to not smoke. Emo-
tional and physical stresses can also reactivate
symptoms.
There is better evidence that reduction in
dietary fat intake can alleviate breast pain.
However, it may also take up to 6 months to
see the results. In one study, a significant
reduction in breast pain was found among
women who could reduce their dietary fat con-
tent to 15% of total calories. Although this
may have additional side benefits to health,
long-term dietary changes may be difficult for
patients to maintain.
A commonly recommended treatment for
cyclic mastalgia is evening primrose oil. Even-
ing primrose oil is one of the richest sources
of essential fatty acids. It contains 72% linoleic
acid and 7% GLA. Its use is based on the obser-
vation
that
women
with
mastalgia
had
increased proportions of saturated fatty acids
and reduced proportions of essential fatty
acids.
In
some
observational
studies,
the
response rate has been reported between 45%
to 97% of women, and one randomized trial
of 73 patients showed significant improve-
ment from treatment with evening primrose
oil. However, other randomized trials have not
shown a benefit. Although the data supporting
its use could be stronger, given the relative
safety and minimal adverse effects, evening
primrose oil should be thought of as first-line
therapy. For evening primrose oil to work best,
it should be combined with a diet low in
saturated fats. It also takes time to see the
benefit, so therapy should be continued for at
least 6 months. The usual dose is 1500 to
3000 mg daily in divided doses. Evening prim-
rose oil usually comes in capsules of 500 mg,
meaning patients would take three to six pills
a day, which can be difficult for patients.
Vitamin E has been promoted as a mastalgia
cure; however, a double-blind randomized trial
showed no significant effect. Likewise, vitamin
B6 is alleged to improve mastalgia, but a rando-
mized trial with a crossover design failed to
find any significant difference between vitamin
B6 and placebo. Other commonly recom-
mended interventions for which there is little
evidence include calcium, vitamin A, selenium,
rose hips, soy, and diuretics.
Hormonal Therapies
If the cyclic mastalgia is not sufficiently relieved
by the aforementioned interventions, pharma-
ceutical intervention can be considered. This
should be a rare situation, however. The first step
is to identify a possible exogenous source and
modifying it. For premenopausal women, this
may involve lowering the dose of estrogen in
their oral contraceptives or changing to a formu-
lation containing 19-norprogestogens, which
have androgenic properties. For postmeno-
pausal women, this might involve lowering the
dose of estrogen in their hormone replacement
therapy or switching to raloxifene (Evista), a
selective estrogen receptor modifier. Progestins
administered during the luteal phase or the addi-
tion of an androgen to estrogen-replacement
therapy can also be helpful.
Danazol is an attenuated androgen that is
effective in relieving breast pain in more than
90% of cases and is the only Food and Drug
Administration (FDA)–approved drug for the
treatment of “fibrocystic breast disease.” It
functions by decreasing ovarian function by
suppressing gonadotropin release by the pitui-
tary gland. Danazol is used at a dose of 200 to
400 mg daily, or only during the luteal phase
of
the
menstrual
cycle
in
premenopausal
women. Relief typically comes within a month
of using the drug. However, the side effects at
higher doses are often as distressing as the
breast pain and include headaches, nausea,
depression, muscle aches, menstrual irregular-
ity, weight gain, acne, oiliness of the hair,
decreased breast size, hirsutism, voice change,
increased libido, and dyspareunia. Almost two
71
4—BREAST PAIN AND FIBROCYSTIC DISEASE

thirds of patients experience side effects, many
of whom discontinue therapy, and symptoms
often recur within 12 months of discontinuing
therapy. To help minimize side effects and avoid
symptoms from recurring, the drug can be grad-
ually weaned (100 mg twice daily for 2 months,
then 100 mg/day for 2 months, then 100 mg
every other day or 100 mg/day only during
the second half of the menstrual cycle). If the
reductions are well tolerated, the drug can be dis-
continued. If after 2 months there is no resolu-
tion, the dose can be increased to 200 mg twice
daily. Therapy should not continue longer than
6 months.
Bromocriptine is a long-acting dopaminergic
drug that suppresses prolactin and has been
studied as a treatment for mastalgia. At a dos-
age of 7.5 mg/day for 3 months, bromocrip-
tine can improve mastalgia in many women,
and this remains after discontinuing the drug.
Bromocriptine is not as effective as danazol.
Common side effects
include nausea and
vomiting and dizziness. This often leads to dis-
continuation, although these side effects can be
reduced by using a gradual buildup of doses
over 2 weeks. However, recent reports of serious
side effects of bromocriptine (when used to stop
lactation), including seizures, strokes, and even
death, have raised concerns. Bromocriptine is
no longer FDA approved for lactation cessation
and is not FDA approved for mastalgia. New
long-lasting selective dopamine agonists are
presently being studied.
Tamoxifen has also been used to treat moder-
ate to severe breast pain. In the International
Breast Cancer Intervention study, which exam-
ined tamoxifen as adjuvant therapy for breast
cancer (see Chapter 17), a side benefit was the
efficacy of this drug in relieving mastalgia.
Some clinicians recommend a dose of 10 mg
daily for 3 to 6 months, or only during days 5
to 25 of the menstrual cycle. Several trials have
subsequently shown the benefit of tamoxifen
compared to placebo in treating mastalgia.
Using a dose of 20 mg, as is done for the treat-
ment of cancer, has not been shown to improve
efficacy. The benefits must be weighed against
the known risks and side effects of Tamoxifen,
which include hot flashes, vaginal discharge,
and an increased risk of thrombophlebitis or
endometrial cancer.
Gonadotropin-releasing hormone agonists
have also been used successfully for severe
pain. Goserelin (Zoladex) has been reported
as effective in up to 80% of women. However,
the menopausal symptoms and effects on
bones limit its use to short-term trials and only
in severe cases that did not respond to other
interventions. Only short courses of luteiniz-
ing
hormone-releasing
hormone
analogues
should be used for very severe cases of mastal-
gia not responding to other therapies.
Progesterone cream and oral progestin have
been examined, as have oral contraceptives
using a combination of estrogen and progesto-
gen, and have been reported to relieve symp-
toms of mastalgia, but most trials have been
disappointing.
Surgery for Mastalgia
Although mastectomy (or quadrantectomy in
women with focal symptoms) has been used
in the past for the treatment of severe, incapa-
citating mastalgia that has not responded to
other therapies, its use should be strongly dis-
couraged. Most patients will continue to have
pain after surgery.
Suggested Readings
1. Bundred N. Breast pain. Clin Evid 2005;14:2190–2199.
2. Carmichael AR, Bashayan O, Nightingale P. Objec-
tive analyses of mastalgia in breast clinics: Is breast
pain questionnaire a useful tool in a busy breast
clinic? Breast 2006;15(4):498–502.
3. Colak T, Ipek T, Kanik A, et al. Efficacy of topical
nonsteroidal antiinflammatory drugs in mastalgia
treatment. J Am Coll Surg 2003;196:525.
4. Gumm R, Cunnick GH, Mokbel K. Evidence for the
management of mastalgia. Curr Med Res Opin
2004;20(5):681–684.
5. Olawaiye A, Withiam-Leitch M, Danakas G, Kahn K.
Mastalgia: A review of management. J Reprod Med
2005;50(12):933–939.
6. Plu-Bureau G, Le MG, Sitruk-Ware R, Thalabard JC.
Cyclical mastalgia and breast cancer risk: Results of
a French cohort study. Cancer Epidemiol Biomarkers
Prev 2006;15:1229.
7. Smith RL, Pruthi S, Fitzpatrick LA. Evaluation and
management
of
breast
pain.
Mayo
Clin
Proc
2004;79:353.
8. Srivastava A, Mansel RE, Arvind N, et al. Evidence-
based management of mastalgia: A meta-analysis of
randomised trials. Breast 2007;16(5):503–512.
72
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

5
Management of Nipple
Discharge
NIPPLE ASPIRATE FLUID IN THE
NONLACTATING BREAST
ABNORMAL DISCHARGE OF THE
NIPPLE
Endocrine Causes of Nipple
Discharge
Breast Conditions Causing
Nipple Discharge
CLINICAL EVALUATION OF THE
PATIENT WITH NIPPLE
DISCHARGE
Ductal Lavage and Ductoscopy
DUCT EXCISION
Management of Nipple Discharge: Key Points
Understand the differences between normal and abnormal
discharges from the nipple.
Describe the features of nipple discharge that raise concern for
malignancy.
Describe the thorough history and examination of the woman with
nipple discharge.
Develop an algorithm for the diagnostic workup of the woman
with abnormal nipple discharge.
Describe how a duct excision is performed and when it is indicated.
After breast pain and a breast mass, nipple dis-
charge is the third most common complaint
related to the breast for which women seek
medical attention. Approximately 5% to 7% of
women referred to breast clinics have symp-
tomatic nipple discharge. Although this may
be a highly concerning symptom for women,
it is very rarely a sign of malignancy. More than
half of women in their reproductive years are
able to express some fluid from the nipple. The
overwhelming majority of women with symp-
tomatic
nipple
discharge
have
underlying
benign disease. Only a very small percentage of
women with nipple discharge are found to have
an underlying malignancy. Nipple discharge is
present in roughly 10% to 15% of women with
73

benign breast disease. It is very rare for cancer
to present only as nipple discharge (less than
1% to 2% of cancers). If nipple discharge is asso-
ciated with cancer, there is most often an
associated mass on physical examination or
mammography. The dilemma of the clinician is
to determine which patients with nipple dis-
charge can be safely observed, and which require
further evaluation and what that evaluation
should consist of.
Nipple Aspirate Fluid in the
Nonlactating Breast
As stated, most women in the reproductive years
can express some fluid from their nipples and
this is normal. The breast is a modified apocrine
gland whose ultimate function is lactation.
However, the nonlactating breast does have
secretory activity. This is not clinically appre-
ciated by patients because the lactiferous sinuses
are often plugged by keratotic material. How-
ever, if the plugs are removed and the nipples
aspirated, fluid can be obtained in a large major-
ity of women. Some investigators have thought
that this nipple aspirate fluid (NAF) could poten-
tially be used to diagnose breast cancer at an
early stage or to assess and individual woman’s
risk of breast cancer.
NAF varies in color and consistency depend-
ing on its composition. The color can range
from clear to black, with descriptions of yellow,
dark yellow, tan, brown, or green discharge
being common. Nipple discharge can also be
red or maroon if blood is present, or white if
the discharge is milk or infectious. NAF is a
secretion of both endogenous and exogenous
substances (Box 5–1). In comparing the serum
levels of these exogenous substances to the
levels in NAF, it is evident that the breast is a
true secretory organ. It is possible that the
increased concentrations of these agents in
NAF may contribute to breast cancer develop-
ment. Also within the fluid are exfoliated epi-
thelial cells and hematogenous cells.
The cellular components of NAF may be
reflective
of
benign
or
malignant
disease
within the breast. For this reason, there has
been considerable interest in the evaluation
of NAF as a screening or diagnostic test. Some
have compared this to a “Pap smear for the
breast.” This has been limited, however, by
difficulties in not only obtaining adequate
volumes of NAF to evaluate, but also in the cel-
lularity of the fluid. The cytologic appearance
of cells in the NAF can be characterized by a
system similar to that of ductal changes seen
on biopsy (Table 5–1). Differences in the cytol-
ogy of NAF between “normal” women and
women with benign disease can be seen. This
includes both benign disease that is not asso-
ciated with an increased risk of cancer (e.g.,
fibrocystic disease, apocrine metaplasia, duct
ectasia, fibroadenomas, and mild hyperplasia)
and those diseases that are associated with an
increased risk (atypical hyperplasia). These
changes include increased cellularity and a
BOX 5–1 COMPOSITION OF NIPPLE
ASPIRATE FLUID
ENDOGENOUS COMPONENTS
Lactose
b-lactalbumin
Immunoglobulin
Cholesterol
Fatty acids
EXOGENOUS COMPONENTS THAT CAN BE
FOUND
Nicotine
Caffeine
Pesticides
Technetium
Barbiturate
CELLULAR COMPONENTS
Benign ductal epithelial cells
Squamous epithelial cells (rare)
Transitional cells (rare)
Apocrine metaplastic cells (very rare)
Foam cells
Neutrophils
Lymphocytes
Histiocytes
TABLE 5–1
Terminology for Cytologic
Classification of Nipple Aspirate Fluid
Benign,
nonproliferative
Ductal epithelial cells or
apocrine metaplastic cells
within normal limits
Mild hyperplasia
Minimal cellular changes,
slight cellular and nuclear
enlargement, papillary or
apocrine metaplastic
changes
Moderate
hyperplasia
Moderate cellular changes,
increased cell and nuclear
size and increased nuclear-
to-cell-size ratio, chromatin
granularity
Atypical
hyperplasia
Marked cellular changes but
not frank malignancy
Malignant cells
Unequivocal nuclear features
of malignancy
74
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

greater prevalence of duct epithelial cells and
duct cells in groups. Apocrine metaplastic cells
are more common while fewer foam cells are
seen. Only rarely does the cytology of NAF
from women with benign breast disease corre-
late with a specific lesion, with the possible
exception of a papilloma. However, the cyto-
logic analysis of NAF can often reveal the pres-
ence of cells exhibiting signs of moderate or
marked hyperplasia. This can possibly be used
to assess risk (see Chapter 8).
Abnormal Discharge of the
Nipple
Endocrine Causes of Nipple
Discharge
Abnormal nipple discharge may be a response
to elevated levels of prolactin. In this case, the
discharge is commonly bilateral, spontaneous,
and white (galactorrhea). Prolactin is signifi-
cantly elevated during pregnancy and particu-
larly in the postpartum/nursing period. Milk
production can continue for up to 1 year fol-
lowing weaning. However, it can also be mildly
elevated during sleep and during the later follic-
ular and luteal phase of the menstrual cycle.
Prolactin can also be mildly elevated with
exercise, stress, as a response to high-protein
meals, and with either excessive breast stimula-
tion or orgasm. However, a variety of hormones
and neurotransmitters act to inhibit prolactin
production
(primarily
dopaminergic)
and
maintain normal levels.
If this balance is thrown off, either by exces-
sive prolactin production or diminished inhibi-
tion, the end result is galactorrhea. Because the
breast lacks the ability to provide efferent feed-
back to the pituitary, even a small transient
elevation in prolactin can lead to galactorrhea.
Overproduction may come from a pituitary
adenoma (prolactinomas) or ectopic produc-
tion from other tumors. Because high levels
of prolactin can also result in oligomenorrhea
or anovulation by suppressing gonadotropin-
releasing hormone, patients with a history of
galactorrhea and oligomenorrheashould be con-
sidered highly likely to have a prolactinoma.
Hypothyroidism results in elevated levels of
thyrotropin-releasing
hormone,
which
can
result in pituitary lactotroph stimulation and
decreased clearance of prolactin. Oral contra-
ceptives have a similar effect. Other drugs that
have
an
antidopaminergic
effect
can
also
result in increased prolactin release (Box 5–2).
Several
medical
conditions
can
lead
to
increased prolactin levels (Box 5–3). Finally,
chronic breast stimulation can cause increased
levels of prolactin. These include manipula-
tion by the woman or her partner, contact
with clothing, or chest trauma, including
burns and herpes zoster.
Breast Conditions Causing Nipple
Discharge
As opposed to external stimuli, which usually
results in bilateral nipple discharge, a variety
of intrinsic breast conditions can cause nip-
ple discharge, which is more commonly uni-
lateral. The three most common lesions are
duct
ectasia,
intraductal
papillomas,
and
fibrocystic
changes;
however,
nipple
dis-
charge can be
secondary to intraductal or
invasive (usually papillary) carcinoma.
BOX 5–2 MEDICATIONS THAT CAN
CAUSE NIPPLE DISCHARGE


Oral contraceptives, estrogen,
progestin, danazol


Tricyclic antidepressants (amitriptyline,
desipramine, doxepin, imipramine,
nortriptyline)


Anti-hypertensives (reserpine,
methyldopa, verapamil, calcium channel
blockers)


Phenothiazines (acetophenazine,
chlorpromazine, ruphenazine,
perphenazine, prochlorperazine,
promethazine, thioridazine,
trifluoperazine, triflupromazine)


Butyrophenones (droperidol, haloperidol)


Antiemetics (metoclopramide, sulpiride)


Opiates, codeine, heroin, marijuana


Cimetidine


L-arginine


Digitalis


Amphetamines
BOX 5–3 MEDICAL CONDITIONS
ASSOCIATED WITH ELEVATED
PROLACTIN LEVELS


Chronic renal failure


Hypothyroidism


Herpes zoster (shingles)


Hypernephroma
75
5—MANAGEMENT OF NIPPLE DISCHARGE

Fibrocystic changes, both proliferative and
nonproliferative, can result in nipple discharge.
This is typically multiductal and more often
expressed than spontaneous. The discharge is
typically serous or light green. Many of these
patients have other symptoms of fibrocystic
changes, including dense, “lumpy” breast tissue
and cyclic mastalgia.
Duct ectasia is a dilation of the duct wall asso-
ciated with a loss of elastin within the walls and
the presence of inflammatory cells (primarily a
plasma cell infiltrate) and fibrosis around the
walls. It is found in about 15% to 20% of
women with symptomatic nipple discharge.
The cause is unknown (see Chapter 6). The peak
incidence is in women older than 50 years
although it is not uncommon in premenopau-
sal women. The discharge can be white, dark
green or black, but can be bloody or purulent.
Duct ectasia is a completely benign lesion that
has no connection to cancer. Although changes
may sometimes be seen on imaging, typically
duct ectasia is radiographically occult.
Papillomas are benign lesions of the epithe-
lium, growing within the ducts. Most often
these are solitary, growing within the major
ducts near the nipple, most located within 1
to 2 cm of the areolar edge within the major
ducts. Grossly, this lesion appears as a small,
fragile, finger-like growth within the lumen
of the duct. The discharge is most commonly
spontaneous and easily reproducible. Intraduc-
tal papillomas are the most common cause of
bloody nipple discharge.
Clinical Evaluation of the
Patient with Nipple Discharge
In
addition
to
the
standard
information
regarding breast cancer risk, the history should
cover the details of the discharge, including
whether it is unilateral or bilateral, whether it
is spontaneous or elicited, and the nature of
the discharge (Box 5–4). Whether the dis-
charge is spontaneous or not is a crucial
question. As the popularity of self breast exam-
ination increases, more women will present
with discharge that they express themselves.
Because nonspontaneous expression of non-
bloody nipple discharge is not associated with
breast cancer, these patients can be reassured
that this is a normal physiologic finding.
Whether there is itching or burning pain of
the nipple in association with the discharge is
important, because this might be associated
with infection or duct ectasia, or with a skin
process involving the nipple. In regard to the
discharge itself, the patient should describe
the color (white, green, yellow, brown, red)
and consistency (serous, watery, serosangui-
nous). A complete reproductive and endocrine
review of systems and list of current medica-
tions should be obtained. The patient should
be queried about recent trauma, possible stimu-
lation, and drug use. Other symptoms that may
be suggestive of an endocrine source should be
elicited on the review of symptoms, including
double vision, headaches, polyuria, polydipsia,
fatigue, heat/cold intolerance, nervousness or
restlessness, weight loss/gain, change in appe-
tite, decreased libido, infertility, amenorrhea,
and the likelihood of pregnancy.
Physical
examination
should
begin
with
examination of the nipples. Sometimes a nipple
discharge is actually an exudate related to skin
irritation from inverted nipples, eczematoid
lesions, trauma, or herpes simplex infections.
Even though these are not associated with
BOX 5–4 HISTORY IN THE PATIENT
WITH NIPPLE DISCHARGE


How frequent is the discharge?


Is it spontaneous or do you elicit it?


What color is it (white, green, yellow,
brown, red, maroon)?


What consistency is it (serous, watery,
serosanguinous)?


Is there blood in it?


Is it unilateral or bilateral?


Does it come from just one duct or
multiple ducts?


Has there been recent trauma or
infection?


Breast cancer risk factors (age of
menarche, menopause, childbearing,
estrogen use, family history)


Thorough past medical history


Signs and symptoms of thyroid disease
(weight gain/loss, cold/heat intolerance,
tachycardia)


Visual field defects (pituitary tumor?)


Infertility, oligomenorrhea, amenorrhea,
acne, facial hair (hyperandrogenism or
hyperprolactinemia)


Polyuria, polydipsia


Complete list of medications (including
over-the-counter and “natural”
medications)


Possibility the patient may be pregnant
76
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

cancer, it is also important to rule out Paget
disease as a source of a nipple exudate (see Chap-
ter 11). Tubular swellings called “varicocele
lesions” of the breast may be palpable below
the nipple-areolar complex, and are often asso-
ciated with duct ectasia. The next step is to deter-
mine which duct (or ducts) is producing the
discharge. Bilateral discharge or discharge from
multiple ducts within one breast are very rarely
malignant, whereas discharge from a single duct
is more worrisome. Single duct discharge can
usually be expressed when pressure is applied
to a trigger point. With the patient supine and
the arm over the head, apply pressure at various
points around the areola until discharge is
expressed. You should carefully document this
point
because
this
may
be
important
in
planning subsequent surgery. The discharge
can easily be tested for the presence of heme by
laboratory test sticks (Hemoccult). In some cases,
the discharge can also be easily collected on a
glass slide for cytology. The slide is held at the
opening of the duct and while applying pressure
to cause discharge, the slide is moved across the
surface of the nipple to make a thin spread. It
can be immediately fixed. If more discharge can
be expressed, several smears should be prepared
because the last few drops are usually more
cellular. The remainder of the breast should be
carefully examined for the presence of a mass
or other signs of malignancy.
The next step is typically mammography
and ultrasound, particularly in age-appropriate
patients.
Mammogram
is
indicated
in
all
women with a unilateral, spontaneous nipple
discharge, including women younger than 35
years. Ultrasound is recommended in addition
to mammogram. However, both studies are
usually
negative.
Ultrasonography
may
or
may not reveal dilated ducts with an intralum-
inal lesion (Fig. 5–1). The utility of magnetic
resonance imaging (MRI) for the patient with
a nipple discharge of high suspicion has
been suggested, but data are limited on its
utility in this situation. It may be a consider-
ation in the high-risk woman presenting with
nipple discharge or when the cytology is posi-
tive and the remainder of the workup is
negative.
The remainder of the workup depends on the
findings on history and physical examination
(Fig. 5–2). A mass identified on examination
or mammography should be biopsied. Patients
who likely have discharge associated with
fibrocystic changes can be reassured and man-
aged conservatively. These include patients
with bilateral or unilateral multiductal dis-
charge that is serous or light green, especially
if they have other symptoms of fibrocystic
changes on examination (e.g., nodularity, pre-
menstrual lumpiness, and discomfort). Patients
with discharge that is multifocal, sticky, and
A
B
Figure 5–1. Radial and antiradial images demonstrate a mildly dilated duct in axial and longitudinal projec-
tions. (Images courtesy of Dr. Alexis Nees, Department of Radiology, University of Michigan.)
77
5—MANAGEMENT OF NIPPLE DISCHARGE

multicolored (including dark green or black,
but heme-negative) most likely have duct ecta-
sia and can also be safely observed. Surgery in
these cases is reserved for palliation because
continued discharge can be distressing and
inconvenient to many patients. If there is obvi-
ous blood in the discharge or if the Hemoccult
is positive, patients will require further evalua-
tion and ultimately surgery.
Patients with bilateral white discharge consis-
tent with galactorrhea should have a workup
for the source of hyperprolactinemia. Both pro-
lactin levels and thyroid function tests should
be obtained. If the patient is taking a medica-
tion known to increase prolactin, it should be
discontinued if possible. Because transient ele-
vations of prolactin can be seen with trauma
or stimulation, the patient may be advised to
avoid these to determine whether there is
resolution of the discharge. If hyperprolactine-
mia is persistent, an MRI of the brain should
be obtained to rule out a prolactinoma.
Finally, there is the patient with unilateral,
uniductal spontaneous discharge. This is other-
wise known as pathologic discharge. It may or
may not contain blood. A unilateral, spontane-
ous clear discharge from one duct is still suspi-
cious, even if no blood is present. However,
women with pathologic nipple discharge are
still highly likely to have benign disease, with
half having an intraductal papilloma, 15% to
20% having duct ectasia, and only about 10%
having carcinoma. Although there are many
modalities available to evaluate this condition
further, most do not have the sensitivity or
specificity to completely rule out malignancy,
so almost all of these patients ultimately require
a duct excision for diagnosis.
Patient with nipple discharge
Work-up of mass
Reassurance
Mgmt of
fibrocystic
disease
Bloody,
guaiac
positive or
spontaneous
Thyroid function tests
Prolactin level
Evaluation and
treatment of
hyperprolactinemia
Thyroxine
replacement
Reassurance
Mgmt of fibrocystic
disease
No mass
Localized excision
Central duct excision
Short-term followup
Close follow-up
Central duct excision
Mass
identified
Multifocal
Unifocal
Consider ductography
or ductoscopy
Normal or not done
Resolution
No resolution
OR*
Lesion identified
↑ Prolactin
↑ Thyrotropin
Unilateral
Bilateral
Galactorrhea
Clear
History and physical
mammogram
subareolar ultrasound
Figure 5–2. Approach to the patient with nipple discharge. Bilateral discharge is rarely malignant and may
represent fibrocystic disease or galactorrhea. For the latter, thyroid function tests and a prolactin level should
be obtained. Unilateral, single duct discharge is concerning if it is bloody or spontaneous. Whereas cytology,
ductography, or ductoscopy may be helpful, duct excision may ultimately be necessary to rule out cancer.
Recent studies suggest that if the mammogram and ultrasound are negative, the likelihood of malignancy
may be low enough to warrant short-term follow-up rather than proceeding to central duct excision.
78
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

Testing the nipple discharge for the presence
of occult blood by means of Hemoccult is
inexpensive, so it is hard to argue against
performing it during physical examination.
Any patient with occult blood requires duct
excision
for
definitive
diagnosis,
although
most cases of bloody nipple discharge are sec-
ondary to intraductal papillomas and not
malignancy. The results of Hemoccult evalua-
tion are useful to rule out occult blood with
the dark, multifocal discharge associated with
duct ectasia. In this case, a negative result
may allow the patient to avoid a duct excision.
However,
with
unifocal,
spontaneous
dis-
charge, the sensitivity of Hemoccult is not
high enough for a negative result to preclude
the need for surgery. Cytologic examination
of the discharge, as described, may be useful
if the fluid shows cancer, but this is rare and
the high false-negative rate precludes using
cytology to exclude cancer. Thus, cytology
may be useful but does not preclude a biopsy
if negative.
Ductography is often the next test obtained
in the woman with pathologic nipple dis-
charge. This procedure involves anesthetizing
the breast (using topical agents such as EMLA
cream [2.5% lidocaine and 2.5% prilocaine] or
injectable agents) followed by duct cannulation
with a small nylon catheter or needle. A water-
soluble contrast agent is then injected into the
duct and mammograms are obtained immedi-
ately (Fig. 5–3). Several studies have shown that
an abnormal ductogram does not preclude the
presence
of
cancer,
however.
Therefore
a
woman with a suspicious nipple discharge and
a normal ductogram still requires biopsy to rule
out cancer. One advantage to obtaining a
ductogram may be the combination of wire
localization and ductography to localize a
lesion seen on ductogram. Ductography can
also sometimes be used to estimate the extent
of a lesion seen on imaging.
Ductal Lavage and Ductoscopy
Newer modalities are playing an emerging role
in the evaluation of nipple discharge. Ductal
lavage is a procedure that involves eliciting
cells from one or more ducts using catheteriza-
tion and irrigation of the duct followed by
cytopathologic
evaluation
(Fig.
5–4).
This
technique is currently being evaluated as a
screening test for asymptomatic women, and
there are minimal data on its sensitivity and
specificity in women with pathologic nipple
discharge.
A more promising technology is that of duc-
toscopy. Mammary ductoscopy involves the
insertion of a microendoscope into the duct to
directly visualize the ductal lining of the breast
(Fig. 5–5). This also allows for the retrieval of
epithelial cells by lavage. Albeit relatively new
in the United States, this has been used in
Europe and Japan for several years. The newest
generation of microendoscope, the ViaDuct
mammary ductoscope (Acueity, Larkspur, CA)
Figure 5–3. Craniocaudal view from normal ducto-
gram. (Image courtesy of Dr. Alexis Nees, Depart-
ment of Radiology, University of Michigan.)
Figure 5–4. Ductal lavage. A small catheter is
inserted into one or more ducts, allowing the irriga-
tion of the duct. The retrieved fluid is then sent for
cytopathologic evaluation.
79
5—MANAGEMENT OF NIPPLE DISCHARGE

is now approved by the Food and Drug Admin-
istration for human use. It has a slim diameter
(0.9 mm) consisting of an outer sheath for
insufflation and aspiration surrounding a fiber-
optic core, which connects to a video system.
The procedure can be performed in an office
setting with minimal discomfort after per-
forming a nipple block with topical EMLA
cream for 30 minutes and either an intradermal
injection of lidocaine around the nipple-areola
complex or intraductal lidocaine. In the case
of ductoscopy for nipple discharge, it may be
advisable to do the procedure in the operating
room so that it may be combined with an exci-
sion of any pathology identified. After expres-
sing the nipple discharge so that the ductal
orifice can be identified, the opening is dilated
and the ductoscope advanced under direct
visualization (Fig. 5–6). Ductal washings are
obtained by aspirating fluid. If any pathology
is identified, these can be marked for immediate
excision or future image-guided biopsy.
Although ductoscopy has been promoted
for use in patients with known cancer under-
going lumpectomy or as a screening test in
high-risk individuals, the largest experience
has been in the evaluation of pathologic nip-
ple discharge. The ductal dilation associated
with pathologic nipple discharge makes it eas-
ier to introduce the ductoscope and many of
the patients have an intraductal papilloma
that is easily localized and excised (Fig. 5–7).
If a point of interest is seen, the light can be
seen in the skin of the breast (if the room is
dark) and can be marked to guide a subsequent
excision.
Duct Excision
If a lesion is noted on physical examination,
mammogram, ductography, or ductoscopy, it
should be the target of a biopsy. However, this
still leaves many women with a suspicious dis-
charge and no specific area of abnormality. In
a patient with a worrisome discharge, duct exci-
sion has been considered the gold standard
and is generally recommended. This procedure
is
both
diagnostic
and
therapeutic.
This
Figure 5–5. The ductoscope is inserted into the
duct for both direct visualization and lavage. (Images
courtesy of Acueity, Inc.)
A
B
Figure 5–6. Ductoscopic images of normal ducts. (Images courtesy of Acueity, Inc.)
80
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

recommendation is based on the 3% to 10%
incidence of finding occult cancer in patients
with worrisome discharge. However, much of
these data were collected when breast imaging
was not as sensitive. With improved mammog-
raphy and the use of subareolar ultrasound,
more recent studies suggest that patients with
single duct, spontaneous discharge or guaiac-
positive discharge have a very low risk of malig-
nancy when all imaging studies are negative.
Close observation with short-term follow-up
to determine whether the discharge resolves
may be reasonable. However, if the discharge
fails to resolve, duct excision should be per-
formed. The procedure may also be considered
for palliative reasons, even if malignancy is
not suspected.
A circumareolar incision is marked to encom-
pass one-third to one-half the circumference of
the areola. When more than 50% is included,
one risks devascularization. Placing the incision
in the inferior aspect of the areola minimizes
the risk of decreasing nipple sensation. Lido-
caine is infiltrated into the skin at the site of
the incision and underneath the areola. After
making the incision, the skin of the areola is ele-
vated with a skin hook so that dissection can be
carried out under gentle tension. Dissection
with blunt tenotomy scissors elevates the areola
to the area directly behind the nipple.
Every attempt should be made to identify
the involved duct. A large dilated duct can
often be identified during dissection behind
the nipple. If not, a small lacrimal duct probe
can be placed through the involved duct via
the skin opening. If this fails to work, methy-
lene blue can be injected into the duct; this is
preferably done before making the skin inci-
sion. Once identified, the duct should be dis-
sected free and divided between clamps. This
should be done close to the nipple if possible
because small papillomas can occur in this
location. The duct should then be traced deep-
er into the breast with a small cone of sur-
rounding tissue, getting slightly wider as the
dissection continues. Approximately 3 cm of
duct and surrounding breast tissue should be
excised. Once the duct is excised, the surgeon
should apply pressure to the trigger point and
around the areola to confirm that there is no
continued discharge. This can also be done
from within the wound by milking the other
ducts toward the nipple. If the involved duct
cannot be identified, a complete duct excision
can be performed by encircling all of the major
ducts (Fig. 5–8). Approximately 2 to 3 cm of
the deep breast tissue should be excised with
the ducts. If needed, a purse-string suture can
be placed below the nipple to avoid nipple
Figure 5–7. Ductoscopic image of an intraductal
papilloma. (Images courtesy of Acueity, Inc.)
A
Figure 5–8. A, Technique for single duct excision.
(Continued)
81
5—MANAGEMENT OF NIPPLE DISCHARGE

inversion. Once it is assured that there is no
further discharge and hemostasis has been
achieved, the skin can be reapproximated with
small, interrupted absorbable sutures.
Suggested Readings
1. Carty NJ, Mudan SS, Ravichandran D, et al. Pros-
pective study of outcome in women presenting
with nipple discharge. Ann R Coll Surg Engl
1994;76:387.
2. Escobar PF, Crowe JP, Matsunaga T, Mokbel K. The
clinical applications of mammary ductoscopy. Am
J Surg 2006;191(2):211–215.
3. Gray RJ, Pockaj BA, Karstaedt PJ. Navigating murky
waters: A modern treatment algorithm for nipple
discharge. Am J Surg 2007;194(6):850–855.
4. Hussain AN, Policarpio C, Vincent MT. Evaluating
nipple
discharge.
Obstet
Gynecol
Surv
2006;
61(4):278–283.
5. Nelson RS, Hoehn JL. Twenty-year outcome follow-
ing central duct resection for bloody nipple dis-
charge. Ann Surg 2006;243:522.
6. Richards T, Hunt A, Courtney S, Umeh H. Nipple
discharge: A sign of breast cancer? Ann R Coll Surg
Engl 2007;89(2):124–126.
7. Sakorafas GH. Nipple discharge: Current diagnostic
and
therapeutic approaches.
Cancer
Treat
Rev
2001;27(5):275–282.
8. Santen RJ, Mansel R. Benign breast disorders. N
Engl J Med 2005;353:275.
9. Simmons R, Amadovich T, Brennan M, et al. Non-
surgical evaluation of pathologic nipple discharge.
Ann Surg Oncol 2003;10:113–116.
10. Vargas HI, Vargas MP, Eldrageely K, et al. Outcomes
of clinical and surgical assessment of women with
pathological
nipple
discharge.
Am
Surg
2006;
72(2):124–128.
B
Figure 5–8—cont’d
B, Technique for central duct excision.
82
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

6
Infectious and Inflammatory
Diseases of the Breast
MASTITIS
Management
BREAST ABSCESS
RECURRING SUBAREOLAR
ABSCESS
Pathophysiology
Workup
Treatment
GRANULOMATOUS MASTITIS
Infectious and Inflammatory Diseases of the Breast:
Key Points
Review the clinical presentation and management of mastitis.
Describe the differences in presentation and treatment of a simple
breast abscess versus a recurrent subareolar abscess.
Develop an algorithm for treating the patient with a recurrent subareolar
abscess and appreciate when and what type of surgery is indicated.
Describe the differential diagnosis and the diagnostic workup of the woman
suspected to have granulomatous mastitis.
Mastitis
Mastitis is an infection of the breast that
occurs most commonly among women who
are breast feeding. Three percent to 10% of
lactating women may develop signs or symp-
toms of mastitis. Mastitis may be more com-
mon in lactating women who have had a
previous episode of mastitis, women with
cracks or sores on their nipple, older women,
and
professional
women.
When
mastitis
occurs in lactating women, it is referred to as
puerperal mastitis. Nonpuerperal mastitis may
also occur as a result of trauma, possibly fibro-
cystic disease or sometimes an unrecognized
etiology.
Patients typically present with a hard, warm,
red, tender, swollen area of one breast. They
may
have
associated
fever,
shakes,
chills,
83

myalgia, and malaise. Staphylococcus aureus is
the most common causative organism but
streptococci, coagulase-negative staphylococci,
and Escherichia coli may also be cultured from
infected patients.
Management
History
and
physical
examination
should
focus on identifying a likely etiology for the
mastitis, as well as the risk of breast cancer.
The possibility of inflammatory breast cancer,
though unlikely, must be kept in mind, partic-
ularly in women with nonpuerperal mastitis
with no clear etiology. Some lactating women
present with plugged ducts or galactoceles.
These may be hard masses in the breast, with
or without erythema or associated pain or
fever. Imaging findings are relatively nonspe-
cific. However, ultrasound of the breast is use-
ful in identifying an underlying abscess and
possibly
guiding
intervention
(see
later)
(Fig. 6–1).
If no abscess is detected on either physical
examination or ultrasound, then management
is conservative. Antibiotics (dicloxacillin or
cloxacillin, 250 mg orally four times a day for
10 to 14 days) should be initiated. Culturing
the milk or any purulent nipple discharge for
antibiotic
sensitivities
may
help
guide
a
change if the patient does not respond. The
patient should be advised to rest, continue
nursing, and use warm compresses and short-
acting nonsteroidal antiinflammatory agents
for pain control. If no response is seen within
24 to 48 hours, coverage should be switched
to cephalexin or amoxicillin with clavulanate,
or should be based on the sensitivities of
culture.
Any abscess needs specific attention (see
later). If patients fail to respond, or if they
respond but mastitis recurs, this may be a sign
of lactational problems, but it could also indicate
inflammatory breast cancer (see Chapter 19).
Breast imaging, biopsy of the skin and of any
underlying mass to rule out cancer should be
considered.
Breast Abscess
Epidermal inclusion cysts can occur in the skin
of the breast because they can occur anywhere.
However, because they often present as a
“breast mass,” they often invoke a higher
degree of anxiety. Epidermal inclusion cysts
are typically subcutaneous masses fixed to
the dermis. Examination usually reveals an
overlying
pore
and
keratinaceous
material
can often be expressed. These show up on
mammography as a discrete density, although
careful directed imaging with a lead marker
over the palpable abnormality can help differ-
entiate this from a suspicious lesion within the
parenchyma.
Often these inclusion cysts become infected,
typically with S. aureus. Clinically, this pre-
sents as a tender, warm, erythematous mass.
Patients may report a previous spontaneous
drainage of the cyst with improvement in
symptoms. Management is aimed at resolution
of the acute infection followed by surgical
resection to prevent recurrence. If only inflam-
mation is present, oral antibiotics with warm
soaks is appropriate. If an abscess is present,
incision and drainage is indicated with evacua-
tion of the “pasty” contents. Once the acute
infection resolves, the patient is often left with
a small indurated area with an overlying scar.
Because these are susceptible to repeated cycles
of inflammation and infection, they should be
excised electively.
Peripheral breast abscesses develop in about
5% to 10% of women with mastitis, possibly
because of a delay in diagnosis or inadequate
therapy. These are different from the subareolar
Figure 6–1. This ultrasound image shows a hetero-
geneous, predominantly hypoechoic mass with thick
internal septations and overlying skin thickening.
This corresponded to a breast abscess, which was
percutaneously
drained
by
the
breast
surgeon.
(Image courtesy of Dr. Alexis Nees, Department of
Radiology, University of Michigan.)
84
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

abscesses discussed below (Table 6–1). The
presentation is similar to that of mastitis (pain,
erythema, tenderness) but with a palpable fluc-
tuant mass. There is usually a precedent history
of lactation or trauma, although this is not
always the case. In some cases, the mass may
not have been palpable but was detected by
ultrasound in a mastitis patient.
Management
consists
of
antibiotics
and
drainage. However, many of these can be suc-
cessfully treated by needle aspiration rather
than incision and drainage. Ultrasound guid-
ance for the aspiration is preferred to ensure
complete aspiration of the abscess. When nee-
dle aspiration is not possible, or not effec-
tive, incision and drainage may be necessary.
The operation should be performed in the
operating room with sedation because local
anesthesia for an abscess is difficult to achieve.
The incision is placed directly over the abscess,
where the skin is thinnest. Cultures should be
obtained. All loculations should be disrupted
and the wound irrigated with saline. A small
sample of the abscess wall should be sent for
pathology study to rule out cancer, even
though this is extremely unlikely, especially
among lactating women. The wound is packed
with gauze and allowed to heal by secondary
intent. Antibiotics need only be continued
until the local inflammation resolves and the
patient has remained afebrile for 3 days.
Women who are lactating will have questions
regarding continued breast-feeding. Most anti-
biotics are safe during breast-feeding, but this
should be confirmed. Nursing should continue
on the opposite side. If the incision does not
interfere with the ability of the infant to latch
on, breast-feeding may also continue on the
affected side. If it does interfere, then a breast
pump should be used for several days until
enough healing has occurred to allow nursing.
The patient may notice milk draining from the
abscess cavity, but the antiinfectious properties
of breast milk may actually accelerate healing.
Recurring Subareolar Abscess
One of the most frustrating entities to deal
with in breast surgery is that of the recurring
subareolar abscess. The disease is characterized
by a recurring abscess not associated with lac-
tation. Over the years, this condition has gone
by many names, reflecting a lack of under-
standing
(Box
6–1).
Recurring
subareolar
abscess appears to represent the most extreme
form of duct ectasia. Many women have mam-
mary duct ectasia, which can be either asymp-
tomatic or present with nipple discharge,
nipple crusting, pain, or induration. It is
believed that subareolar abscesses and recur-
ring subareolar abscesses are the result of the
introduction of bacteria into the diseased
ducts. It is estimated that approximately 30%
of women have some degree of disease of the
ducts, although much of this is asymptom-
atic
(detected
on
autopsy
or
incidentally
during biopsies for other findings). Approxi-
mately 6% to 7% of women have symptom-
atic
benign
duct
disease,
accounting
for
approximately 20% of all benign conditions
of the breast. The incidence of subareolar
abscesses or periareolar fistulae is estimated to
be about 1.2%.
TABLE 6–1
Features of Peripheral
Breast Abscess versus Subareolar
Breast Abscess
Peripheral
Breast
Abscess
Subareolar
Breast
Abscess
Preceding
history
Lactation,
trauma
None; patients are
often smokers
Site
Periphery of
breast
Periareolar
Organism
Staphylococcus
aureus
Multiple aerobic
and/or
anaerobic
species
Treatment
High likelihood
of resolution
with
aspiration/
antibiotics or
incision and
drainage
Multiple
recurrences
after antibiotics
or incision and
drainage
BOX 6–1 NAMES USED TO
DESCRIBE RECURRENT SUBAREOLAR
ABSCESS
Mastitis obliterans
Chronic pyogenic mastitis
Stale milk mastitis
Involutional mammary duct ectasia with
periductal mastitis
Comedomastitis
Periductal mastitis
Fistulae of lactiferous ducts
Zuska’s disease
Squamous metaplasia of mammary ducts
Mammary duct–associated inflammatory
disease sequence (MDAIDS)
85
6—INFECTIOUS AND INFLAMMATORY DISEASES OF THE BREAST

The clinical presentation of this form of sub-
areolar abscess is different from that of the typ-
ical breast abscess, which occurs primarily in
lactating women. These can occur anywhere
in the breast and are typically not periareolar
(see earlier). In contrast, the abscesses related
to duct ectasia are almost always periareolar.
It typically occurs in young women, with a
mean age of 34 years, most of whom are smo-
kers. Patients usually present initially with the
rapid onset of acute breast pain, tenderness,
and a palpable mass in the central subareolar
region. Although this is thought to be related
to duct ectasia, many women may have had
subclinical or asymptomatic disease and so a
history of nipple discharge or other symptoms
may not be present. The patient may present
to the surgeon during this acute phase or with
a chronic fistula. The fistula is usually an
established fistula at the vermilion border,
although it may be at the base of the nipple.
This usually represents multiple inadequate
attempts at treatment.
Many women report a history of symptoms
that
resolve
with
treatment
or
spontane-
ously, followed by an asymptomatic period
lasting months to years, and then recurrence.
Patients may be extremely frustrated with the
chronic nature of this process, or from being
passed from one doctor to another without
resolution.
Pathophysiology
As described in Chapter 1, the lobules of the
breast drain into minor intralobular ducts,
which subsequently drain into 16 to 18 major
mammary ducts. As each major mammary
duct converges centrally at the base of the nip-
ple, they dilate to form a secretion-storing
lactiferous ampulla. These are located immedi-
ately below the nipple-areolar complex. From
the ampulla, these ducts then exit via an open-
ing at the apex of the nipple. There is a con-
stant discharge from the orifices of these
ducts onto the nipple. This is either impercep-
tible or may dry into a scarcely discernible
crust that is usually brushed away by clothing.
The ducts are lined by a double layer of cells,
an inner cuboidal (low columnar) epithelium
and an outer myoepithelial layer. However,
the final few millimeters of the intranipple
ducts are lined by a stratified squamous epi-
thelium. It is believed that the underlying
problem with duct ectasia and recurrent subar-
eolar abscesses is epidermalization of the duc-
tal columnar epithelium and the obstruction
of the duct secondary to squamous metaplasia.
At first, when the ducts begin to epidermalize,
there may be discharge from one or more
ducts, nipple retraction, or subareolar indura-
tion.
As
the
disease
progresses,
there
is
increased production of keratin that leads to
obstruction of the ducts. This leads to duct
dilation secondary to accumulation of the nor-
mal secretory material. Ultimately, this can
lead to the rupture of the thinned epithelial
lining, exposing the surrounding tissues to
the luminal contents. Keratin is irritating and
can lead to an inflammatory response. The
resultant inflammation can lead to a periduc-
tal lymphocytic infiltrate (sometimes predo-
minated by plasma cells). This setting is ideal
for bacterial growth. The bacteria may be aero-
bic or anaerobic, coming from skin, endoge-
nous breast flora, or oral contamination of
the nipple. As opposed to other forms of breast
abscess, which are almost always S. aureus,
cultures of subareolar abscesses often contain
multiple organisms (Box 6–2). If bacteria do
colonize this tissue, an abscess or fistula can
occur.
So what causes epidermalization of the ducts
and squamous metaplasia? Although the exact
process by which this occurs is unclear, there
are several factors that have been found to be
associated with this process. There may be hor-
monal influences related to prolactin or estro-
gen levels. Vitamin A deficiency is a likely
suspect because this also leads to keratinizing
squamous metaplasia on multiple mucosal sur-
faces. Experimental evidence shows that vita-
min A has a significant biologic effect on the
epithelial
differentiation
and
proliferation.
Vitamin A deficiency also impairs blood clear-
ance of bacteria and phagocytic activity, and
thus may also be a contributing factor to
infection.
The causative factor with the strongest link
to both squamous metaplasia and recurrent
BOX 6–2 BACTERIA THAT MAY BE
INVOLVED WITH RECURRING
SUBAREOLAR ABSCESS
Anaerobic peptostreptococci
Bacteroides
Diphtheroids
Staphylococcus epidermidis
Staphylococcus aureus
Proteus
Lactobacilli
Streptococcus viridans
86
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

subareolar abscesses is smoking. The incidence
of disease rises dramatically with smoking and
with the degree of smoking (heavy versus
light). Ninety percent of patients with recur-
rent breast abscess had been exposed to ciga-
rette smoke for many years before the onset
of symptoms. Although the association is
extremely strong, the mechanisms by which
smoking
induces
squamous
metaplasia
remains unclear (Box 6–3).
Workup
When seeing a patient with a subareolar
abscess, it is important to document any pre-
ceding events and a history of similar symp-
toms. In addition to finding out whether
the patient is breast-feeding, has there been
any recent trauma? Does the patient have
other disease of the breast, such as fibrocystic
disease or previous cancer? How long have
the symptoms been present and how has this
been treated in the past (antibiotics, incision
and drainage)? Has this ever occurred in the
opposite breast? It is crucial to document
smoking history. On physical examination,
there may be an acute abscess with tender-
ness, erythema, induration, or fluctuation,
or there may be a draining periareolar fistula.
Compression of the nipple-areolar complex
with the finger and thumb may reveal subar-
eolar masses. Both breasts should be exam-
ined to assess symmetry. The diagnosis is
made
primarily
by
history
and
physical
examination. If a mass is present, then mam-
mography
and
ultrasound
should
be
obtained. In the absence of a mass, mammog-
raphy should still be obtained to rule out an
underlying cancer, especially in women older
than 35 years.
Treatment
The treatment of subareolar abscesses is pri-
marily surgical. Antibiotic treatment alone is
rarely effective, resulting in complete response
in less than 3% of patients. For the patient
being
seen
acutely,
the
initial
treatment
depends on the presenting symptoms. If the
patient has an acute abscess as characterized
by a fluctuant, tender, erythematous mass,
incision and drainage is indicated, followed
by a 2-week course of antibiotics consisting of
a cephalosporin and metronidazole. Although
this can be done in the office, it is best per-
formed in the operating room under anesthe-
sia to ensure complete drainage. If it is to be
done in the office, remember that lidocaine is
seldom effective for providing analgesia sec-
ondary to the low pH of the inflamed tissue.
It is important to culture the pus for both aer-
obic and anaerobic bacteria because the type
of bacteria involved helps confirm the diagno-
sis. The wound should be amply irrigated and
wicked open. If the patient presents in the
early stages, with an indurated mass without
fluctuance, then just the 2 weeks of antibiotics
should be given. Heat packs may be applied for
comfort.
For many breast abscesses, the use of nonop-
erative therapy consisting of percutaneous
fine-needle aspiration, followed by antibiotics,
has been advocated. This is a reasonable
approach for nonsubareolar abscesses, but is
not indicated for this clinical scenario. It is
important to keep in mind that for subareolar
abscesses, antibiotics and incision and drain-
age are only temporizing measures. Because
this is primarily a disease process of the ducts,
treatment that does not address the ducts is
unlikely to work.
Once the acute
infectious process
has
been
addressed,
definitive
surgical
treat-
ment will involve excision of either the
entire involved duct or multiple ducts. For
the patient with an initial presentation, the
involved duct should be excised via ductect-
omy. Using either intravenous sedation with
local
anesthetic
or
general
anesthesia,
a
radial incision is made starting in the mid-
dle of the nipple and encompassing the
abscess cavity or fistula tract (Fig. 6–2).
Injecting the fistula tract with 1% methylene
blue before beginning can help identify
the involved duct. The nipple is splayed
open and the duct identified and dissected
out. After excising the entire duct, the inci-
sion is closed. Subcutaneous sutures are
BOX 6–3 METHODS BY WHICH
SMOKING MAY BE ASSOCIATED
WITH RECURRENT SUBAREOLAR
ABSCESS


Direct cellular injury of ducts by
metabolites in the glandular secretions


Reduction of bioavailability of estrogen
by 2a-hydroxylation of estradiol or
inhibition of the aromatase-catalyzed
conversion of testosterone to estrogen


Effect of nicotine on prolactin levels


Altered composition of endogenous flora
in the breast
87
6—INFECTIOUS AND INFLAMMATORY DISEASES OF THE BREAST

placed at the apex of the nipple, the base
of the nipple, and the vermilion border of
the areola. Sometimes it is useful to place a
purse-string or Z-suture at the base of the
nipple to evert it, especially in women who
have a retracted nipple. If there is any con-
cern regarding ongoing infection, a wick
may be placed in the subareolar defect and
brought out beyond the vermillion border.
This is then changed daily. The patient
should be placed on a 10- to 14-day course
of antibiotics postoperatively.
For patients with recurrent disease, it may be
necessary to perform a duct excision. This can
be performed either through a radial incision
or a circumareolar incision. If a chronic abscess
or fistula is present at the time of the surgery,
this must be excised en bloc with the ducts,
and may change the choice of incision. The
areola is raised using a knife or Metzenbaum
scissors. The major ducts are separated from
the base of the nipple by passing a curved for-
ceps around the nipple base and dividing the
ducts with a knife. The nipple base is then
excised to remove all duct tissue. Although a
complete excision of the ducts is the goal, there
is a risk in devascularizing the nipple skin. A
purse-string or Z-suture should be inserted
through the nipple base to maintain eversion,
but not so tightly as to cause necrosis. The sub-
areolar duct system is then dissected out from
the underlying breast tissue. The subareolar
dead space may be obliterated with interrupted
absorbable suture and the skin is then reap-
proximated. Patients should be placed on anti-
biotics postoperatively (Fig. 6–3).
Granulomatous Mastitis
Granulomatous mastitis is a relatively uncom-
mon disease that involves the development of
an inflammatory mass in the breast that may be
difficult to differentiate from malignancy. There
are several agents that may induce a granuloma-
tous mastitis (Table 6–2). Idiopathic granuloma-
tous mastitis (IGM) is a diagnosis of exclusion,
once other sources have been ruled out.
IGM predominantly occurs in women in
their third or fourth decade, although it has
been reported in older patients. Patients typi-
cally present with a firm breast mass, often
associated with inflammation of the overlying
skin. It may be bilateral. It is readily mistaken
for nonpuerperal mastitis, a breast abscess, or
carcinoma. The exact pathogenesis is not clear.
One hypothesis is an autoimmune reaction to
extravasated secretions from lobules. IGM has
been associated with other autoimmune dis-
eases such as erythema nodosum, Wegener’s
granulomatosis, giant cell arteritis, and polyar-
teritis nodosa, although most women with
IGM show no systemic immune abnormalities.
The goal of the clinician is to rule out both
cancer and other sources of mastitis. As with
any breast mass, this begins with a thorough
history,
physical
examination,
and
breast
imaging. Often prolactin levels are elevated
in association with IGM, and these should
be
measured
because
antiprolactin
therapy
may be a consideration. Radiologic findings
include nodular opacities on mammography
and hypoechoic nodules on ultrasonography.
Occasionally imaging shows multiple clustered,
A
B
Figure 6–2. A, The entire abscess, fistula cavity, and involved duct is excised. B, After resection, the skin is
reapproximated at the crown of the nipple, the base of the nipple, and the periareolar border.
88
SURGICAL FOUNDATIONS: ESSENTIALS OF BREAST SURGERY

contiguous hypoechoic lesions that may suggest
GM, but usually the radiologic findings, like the
physical findings, are worrisome for malignancy.
Ultimately, the diagnosis comes down to a
biopsy. Histology shows a predominantly lobu-
lar inflammatory process. Core biopsy typically
demonstrates a noncaseating granulomatous
granuloma, giant cells, chronic inflammation,
microabscesses, and necrosis. Tissue should
be sent for acid-fast bacillus and fungal stains to
rule out tuberculosis or nocardia. An incisional
biopsy may be necessary to obtain adequate
tissue. Fine-needle aspiration biopsy is useless.
Once cancer has been definitively ruled out,
the optimal management is unclear. If the
diagnosis is confirmed by core-needle biopsy,
excision might not be necessary if the mass is
asymptomatic. In this case, careful follow-up
to ensure that the area is not getting bigger is
necessary. If the mass is painful or enlarging,
or if an adequate diagnosis could not be made
on core biopsy alone, complete excision may
Patient with Breast Abscess
Peripheral Breast Abscess
U/S guided
aspiration
Operative I & D
Operative I & D
Antibiotics
History, Physical, Ultrasound
Amenable to Aspiration?
Successful?
Yes
No
Subareolar Breat Abscess
I & D
Antibiotics
Excision of abscess
cavity and involved
duct
Acutely inflamed?
Yes
No
Yes
No
Observation
Complete duct
excision with fistula
tract and abscess
Successful?
Recurrence
Yes
Figure 6–3. Approach to the patient with a breast abscess. A peripheral breast abscess may be aspirated
but may require an incision and drainage. Subareolar breast abscesses are slightly trickier. If acutely inflamed,
incision and drainage and antibiotics are indicated. Further surgery will then be necessary to prevent recur-
rence, including excision of the entire cavity with the involved duct. Recurrent disease may require a central
duct excision.
TABLE 6–2
Granulomatous Mastitis
Sarcoidosis
Noncaseating granulomas between and within lobules.
Histology is diagnostic (epithelioid granulomas and giant cells with no central necrosis).
Most often associated with sarcoidosis of the lungs.
Tuberculosis
Caused by Mycobacterium tuberculosis. Now quite rare.
Acid-fast bacteria can be seen in special stains.
Antituberculous therapy is often effective.
Dirofilaria
tenuis
A nematode in the United States responsible for breast nodules.
Transmitted to humans by insect bites.
Can be seen on histologic sections after excision.
Nocardia
asteroides
Fungal infection associated with chronic abscess in the breast.
Stains for fungi reveal nocardial organisms.
Antifungal therapy is often effective.
Foreign
material
Paraffin, injected directly into the breast for augmentation, can cause hard masses and
chronically draining sinuses.
Silicone gel, also injected directly into the breast, can cause hard masses within the breast.
89
6—INFECTIOUS AND INFLAMMATORY DISEASES OF THE BREAST