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Home , Breast disease, Breast mass, Duct ectasia of breast, Galactorrhea, Mastitis, Nipple discharge

series • CLINICAL PRACTICE Management of benign breast conditions Part 3 – other breast problems

Meagan Brennan, BMed, FRACGP, DFM, FASBP, is a breast physician, NSW Breast Institute, Westmead Hospital, New South Wales. [email protected] Nehmat Houssami, MBBS, FAFPHM, FASBP, PhD, is Associate Clinical Director, NSW Institute, Westmead Hospital, and Honorary Senior Lecturer, Screening and Test Evaluation Program, School of , the University of Sydney, New South Wales. James French, MBBS, FRACS, is a breast and endocrine surgeon, NSW Breast Cancer Institute, Westmead Hospital, New South Wales.

This is the third article in a series of breast disorders with an emphasis on diagnosis and management in the general practice setting. This article discusses conditions that, although less frequently seen in general practice, pose challenges in diagnosis and management.

Nipple discharge Milky discharge (either spontaneous expression by the examining doctor. or on expression) is also physiological during Physiological discharge (ie. discharge on may be: and , and may be prolonged expression only) is from multiple ducts, is • spontaneous (fluid is secreted from the following lactation. milky, green, or yellow in appearance, and nipple without squeezing of the nipple or requires no specific investigation. Checking for Abnormal nipple discharge pressure on the breast) is warranted in women • on expression (fluid is secreted from the Nipple discharge that is spontaneous and presenting with persistent galactorrhoea. nipple only when it is squeezed or there is unrelated to pregnancy or lactation is considered Abnormal discharge (ie. discharge that pressure on the breast). abnormal. In the majority of cases it has a is spontaneous, single duct, and clear or Other important information to characterise benign cause. Spontaneous discharge caused bloodstained) needs investigation. This will nipple discharge includes whether it is unilateral by significant pathology is more likely to be usually include that may include or bilateral, the fluid colour (clear, yellow, milky, unilateral, localised to a single duct, and crystal magnification views behind the nipple, and green, brown, bloodstained) and the number of clear or stained in appearance (Table 1). . Other investigations include: ducts involved (single or multiple). • cytological assessment of nipple fluid Investigation or nipple scrapings (has limited accuracy Physiological nipple discharge A detailed history will provide information and should only be performed selectively Fluid can be obtained from the of 50– about whether the discharge is spontaneous or in women with spontaneous bloodstained 70% of asymptomatic women when massage on expression, and the colour, frequency, and single duct discharge. In this group, the or breast pumps are used.1 This discharge duration of the discharge. finding of malignant cells is highly specific for of fluid from a normal breast is referred to is essential to exclude any associated nipple underlying ) as 'physiological discharge'. It is usually ulceration, change, or . An • ductography/ (may be helpful, yellow, milky, or green in appearance; does attempt to reproduce the discharge by but is not widely available and may be painful not occur spontaneously; and can be seen expressing the nipple is important to assess for the patient). originating from multiple ducts. Physiological the appearance of the fluid and the number of Associated breast lumps, skin or nipple nipple discharge is no cause for concern. ducts fluid is originating from. Often the patient changes, or imaging abnormalities found during Such discharge can sometimes be noted after is able to produce the discharge herself, which the workup for nipple discharge need to be breast compression for mammography. may be less uncomfortable than attempted investigated on their individual merits.

Reprinted from Australian Family Physician Vol. 34, No. 5, May 2005 4 353 Clinical practice: Management of benign breast conditions

there is not a rapid clinical response to Table 1. Causes of abnormal nipple discharge or if there is a firm, discrete lump palpable in the breast. If a breast • Duct ectasia – a benign condition with dilatation and of the ducts under the nipple, usually causes a bilateral yellow, green, or brown discharge from is suspected, an ultrasound examination multiple ducts should be performed. Any localised collection • Duct papilloma – typically causes a clear or bloodstained discharge. Papillomas are of or infected should be aspirated usually benign but may rarely be associated with breast cancer and therefore are to dryness. This is usually performed under always surgically removed ultrasound guidance, and aspiration may • Nipple eczema – eczema or dermatitis affecting the skin of the nipple, particularly if need to be repeated every few days. The infected, can cause a weeping, crusty, nipple discharge aspirate should be sent for microbiological • Breast cancer – breast cancer is an uncommon cause of nipple discharge. Only about assessment. In cases that do not resolve with 3% of women with breast cancer have nipple discharge, and most of these have other repeated aspiration, admission to hospital for symptoms such as a lump or newly in addition to the discharge.3 Cancer that causes nipple discharge is more likely to be in situ than invasive cancer intravenous antibiotics and surgical drainage • Paget disease – a particular clinical presentation of breast cancer causing a blood may be required. stained nipple discharge with ulceration and erosion of the nipple Nonlactational may be associated • Hyperprolactinaemia – high levels may cause galactorrhoea. Aetiology with underlying cysts. The clinical presentation includes endocrine causes, eg. pituitary and disease; and drug causes, eg. oral is similar to that of lactational mastitis and contraceptives, therapy, antiemetics, , cocaine, and stimulants treatment is with antibiotics. Periductal mastitis is an inflammatory Management document episodes of discharge in a diary condition that presents with nipple redness may also be helpful. and discharge. It occurs in young women, and Physiological nipple discharge requires no is associated with smoking in 90% of cases.4 specific treatment. The patient can be reassured Inflammatory breast conditions Recurrent episodes of periductal mastitis that it is not cancer. She should be advised to Breast infection and inflammation may result are common and may necessitate surgical stop expressing as this causes more secretions from several benign conditions. excision of the nipple ducts. Surgery is often to be produced, and she should return for complicated by poor wound healing. Mastitis further assessment should the discharge become spontaneous or bloodstained. The most common condition is lactational Investigation A spontaneous, bloodstained, single duct mastitis. This usually presents in the first Lactational mastitis may be treated with discharge that can be reproduced on clinical few weeks of , with breast antibiotics without investigation provided there examination must be managed surgically with , swelling, lump or lumps, and redness is close clinical surveillance with investigation duct exploration/ (even in the of the skin overlying the breast infection/ (usually breast ultrasound) if symptoms do not presence of normal imaging). While the likelihood abscess. Lactational mastitis is a bacterial resolve in 24–48 hours. of breast cancer remains small in this group, infection usually caused by Nonlactational inflammatory breast with benign pathology such as a papilloma far aureus. Poor positioning and poor attachment symptoms should be investigated as any other more likely, surgical duct exploration is essential of the during feeding, along with breast symptom. Lesions found to be benign as investigation with imaging and cytology is milk stasis, contribute to the infection. on initial assessment should be followed to unable to fully exclude malignancy. Lactational mastitis requires prompt treatment complete clinical and imaging resolution. Surgery (major duct excision) is also with antibiotics. First line antibiotics include: Inflammatory breast cancer an option for managing the persistent • oral flucloxacillin or 500 mg four discharge from duct ectasia if the discharge is times per day for 10 days, or This is a specific clinical presentation of breast troublesome for the patient. This should only be • cephalexin 500 mg four times per day for cancer that should be considered in the offered to women who are not contemplating 10 days.2 differential diagnoses of every inflammatory breastfeeding in the future. Where there are systemic symptoms or breast condition. Inflammatory carcinoma Where the history suggests spontaneous significant cellulitis, intravenous antibiotics represents 1–4% of breast , and has discharge, but clinical and imaging evaluation is may be needed. Continued frequent feeding a particularly poor prognosis.5 The classic normal and there is no evidence of discharge from the affected breast, with advice on infant presentation is one of rapid onset of breast when pressure is applied to the nipple/ positioning and attachment form an important mass, pain, breast enlargement, and skin region, then clinical follow up in 2–3 months part of management. changes (red or purple, and 'orange peel' in is recommended. Asking the patient to Breast abscess should be considered if appearance). Axillary lymph node involvement

354 3Reprinted from Australian Family Physician Vol. 34, No. 5, May 2005 Clinical practice: Management of benign breast conditions

is almost universal. Breast imaging may reveal Table 2. Causes of gynaecomastia subtle changes of increase in skin thickness and increase in tissue density rather than the Physiological causes classic features of breast cancer such as a • Infancy – 60–90% of have transient gynaecomastia due to oestrogenic spiculated lesion with microcalcification.5 stimulation from the mother and placenta (resolves neonatally) Infective conditions should be followed to • Puberty – 30–60% of boys develop transient gynaecomastia (usually develops after complete clinical and imaging resolution, and the age of 10 years and resolves by age 17 years) where an infective lesion does not resolve, or • Aging – gynaecomastia is seen in an increasing number of normal adult men with does not behave as expected, the diagnosis increasing age (65% at age 80 years)6 of inflammatory breast cancer should be Pathological causes considered. Inflammatory symptoms should • Drug induced (therapeutic drugs) – androgens, anabolic steroids, oestrogens and be investigated as with other breast symptoms oestrogen agonists, cyproterone, , digoxin, spironolactone with imaging followed by fine needle or • Drug induced (drugs of abuse) – alcohol, amphetamines, , marijuana core biopsy of any abnormalities. Where there • Liver cirrhosis are significant skin changes such as erythema • Malnutrition or an 'orange peel' appearance, skin biopsy • Primary or secondary may confirm the diagnosis of inflammatory • Testicular tumours breast cancer. • Hyperthyroidism • Renal disease Gynaecomastia • Idiopathic – in 25% of cases of gynaecomastia, no specific cause is identified Gynaecomastia is the benign proliferation of glandular tissue of the male breast. Most patients with gynaecomastia are asymptomatic. luteinising hormone cancer should be considered. As with all breast Symptomatic patients may present with • testicular ultrasound, and symptoms, the GP's role involves excluding breast or nipple pain or tenderness, breast • abdominal computerised tomography (CT). cancer and providing an explanation of the enlargement, or a breast lump. Causes of patient's condition and appropriate reassurance. gynaecomastia are outlined in Table 2. Management Conflict of interest: none declared. Investigation Treatment is not required in asymptomatic References Investigation aims to distinguish patients. In those complaining of significant 1. DeVane GW. Breast dysfunction: and gynaecomastia from male breast cancer. On , tenderness, or embarrassment, mastalgia. In: Blackwell RE, Grotting JC, editors. clinical examination, gynaecomastia is usually treatment may be indicated including: Diagnosis and management of . Massachusetts: Blackwell Science, 1996;19–43. subareolar, often bilateral, and rubbery in • stopping any drugs that may be causing 2. Spicer WJ, Christiansen K, Currie BJ, et al. texture. Breast cancer in men is more likely gynaecomastia Therapeutic guidelines: . North Melbourne: to be eccentric in location, unilateral, and firm • subcutaneous mastectomy (surgery to Therapeutic Guidelines Ltd, 2003;226. 3. Houssami N, Irwig L, Simpson J, McKessan M, or hard. Nipple retraction, discharge, or skin remove all of the glandular breast tissue) Blome S, Nookes J. The Sydney Breast Imaging dimpling may be present. • medical therapy (eg. tamoxifen, clomiphene Accuracy Study: comparative sensitivity and speci- In general, gynaecomastia may be citrate).6 ficity of mammography and sonography on young women with symptoms. AJR 2003;180:935–940. investigated with triple testing (clinical and Conclusion 4. Hughes LE, Mansel RE, Webster DJT. Benign disor- imaging assessment, and fine needle biopsy) ders and diseases of the breast. 2nd ed. London: WB as with any female breast symptom. However, Nonlactation inflammatory breast conditions, Saunders, 2000. biopsy may not be warranted where there are nipple discharge, and gynaecomastia are less 5. Parker LM, Boyages J, Eberlein TJ. Inflammatory carcinoma of the breast. In: Harris JR, Hellman S, typical clinical and imaging findings, or where common breast symptoms in the general Henderson IC, Kinne DW, editors. Breast diseases. there is an obvious cause. Further investigation practice setting than breast lumps or breast pain, Philadelphia: JB Lippincott, 1992;775–82. is directed by symptoms, and may include: but nonetheless cause considerable in 6. Braunstein GD. . In: Harris JR, Lippman ME, Morrow M, Hellman S, editors. • a thorough drug history patients and can pose challenges in diagnosis Diseases of the breast. Philadelphia: Lippincott- • clinical examination for goitre, liver disease, and management. Infective conditions should Raven, 1996;54–60. AFP abdominal masses, testicular masses be followed to complete resolution, and where • blood tests for human choriogonadotropin an infective or inflammatory condition does not Correspondence (hCG), oestradiol, testosterone, and resolve, the diagnosis of inflammatory breast Email: [email protected]

Reprinted from Australian Family Physician Vol. 34, No. 5, May 2005 4 355