6 Nipple discharge

Definition
Any fluid (which may be physiological or pathological) emanating from the nipple.
KEY POINTS
• Milky discharge is rarely pathological.
• Purulent discharge is usually benign.
• Bloody discharge is often associated with neoplasia.
• If a lump is present, always investigate ‘for the lump’ rather than ‘for
the discharge’.
Differential diagnosis
Physiological discharges
Milky or clear
• Lactation.
• Lactorrhoea in the newborn (‘witches’ milk’).
• Lactorrhoea at puberty (may be in either sex).
Pathological dischargcs
Serous yellow-green
• Fibrocystic disease: cyclical, tender, lumpy breasts.

• Mammary duct ectasia: usually multiple ducts, intermittent, may be associated with low-grade mastitis.
Bloody
• Duct papilloma: single duct, ?retro-areolar, ‘pea-sized’ lump.
• Carcinoma: ?palpable lump.
• Mammary duct ectasia: usually multiple ducts, intermittent,
may be associated with low-grade mastitis.
Pus ± milk
• Acute suppurative mastitis: tender, swollen, hot breast, multiple ducts discharging.
• Tuberculous (rare): chronic discharge, periareolar fistulae,
‘sterile’ cultures on normal media.

KEY INVESTIGATIONS
• MC+S: acute mastitis, TB (Lowenstein—Jensen medium, Ziehl—Neelsen
stains).
• Discharge cytology: carcinoma.
• Mammography: tumours, fibrocystic disease, ?ectasia.
• Ductal excision: maybe needed for exclusion of neoplasia.

5 Breast pain

Definition
Mastalgia is any pain felt in the breast. Cyclical mastalgia is pain in the breast which varies in association with the menstrual cycle. Non-cyclical mastalgia is pain in the breast which follows no pattern or is intermittent.
KEY POINTS
• Mastalgia is commonly due to disorders of the breast or nipple tissue
but may also be due to problems in the underlying chest wall or overlying
skin.
• Pain is an uncommon presenting feature of tumours but any
underlying mass should be investigated as for a mass (see Chapter 4).
• Always look for an associated infection in the breast.
• Mammography should be routine in women presenting over the age of
45 years to help exclude occult carcinoma.
Important diagnostic features
Non-breast conditions
• Tietze’s disease (costochondritis): tenderness over medial ends of ribs, not limited to the breast area of the chest wall, relieved by NSAIDs.
• Bomholm’s disease (epidemic pleurodynia): marked pain with no physical signs in the breast, worse with inspiration, no chest disease underlying, relieved with NSAIDs.
• Pleurisy: associated chest thfection, pleural rub, may be bilateral.
• Angina: usually atypical angina, may be hard to diagnose, previous history of associated vascular disease.
Mastalgia due to breast pathology
Mast itis! breast abscess
• During lactation: red, hot, tender lump, systemic upset.
Treatment: aspirate abscess (may need to be repeated), do not stop breast feeding, oral antibiotics.

• Non-lactational abscesses: recurrent, associated with smoking, associated with underlying ductal ectasia.
Treatment: aspirate or incise and drain abscess, give oral antibiotics, stop smoking, prophylactic metronidazole for recurrent sepsis.
Jn,fècted sehaceous cyst
Single lump superficially in the skin of the periareolar region, previous history of painless cystic lump.
Treatment: excise infected cyst.
Fibrocystic disease
Irregular, ill defined, may be associated lumps, tender more than very painful.
Mastalgia without breast pathology
Pain often felt throughout the breast, often worse in the axillary tail, moderately tender to examination.
Treatment for cyclical mastalgia: ‘y linoleic acid (evening primrose oil), danazol, tamoxifen.
Treatment for non-cyclical mastalgia: NSAIDs, ylinoleic acid.

KEY INVESTIGATIONS
Non-breast origin
Chest X-ray, EGG (exercise)
Breast pathology
• ENAC (MC+S): associated palpable lump, ?fibrocystic disease,
?mastitis/abscess.
• Ultrasound (young women/dense breasts) or mammography (older
women/small breasts).
Mastalgia without breast pathology
Mammography in women over 45 years

4 Breast lump

Definition
A breast lump is defined as any palpable mass in the breast. A breast lump is the most common presentation of both benign and malignant breast disease. Enlargement of the whole breast can occur either uni- or bilaterally, but this is not strictly a breast lump.
KEY POINTS
• The commonest breast lumps occurring under the age of 35 years are
fibroadenomas and fibrocystic disease.
• The commonest breast lumps occurring over the age of 50 years are
carcinomas and cysts.
• Pain is more characteristic of infection/inflammation than tumours.
• Skin/chest wall tethering is more characteristic of tumours than benign
disease.
• Multiple lesions are usually benign (cysts orfibrocystic disease).

Differential diagnosis
Swelling of the whole breast
Bilateral
• Pregnancy, lactation.
• Idiopathic hypertrophy.
• Drug induced (e.g. stilboestrol, cimetidine).

Unilateral
• Enlargement in the newborn.
• Puberty.

Localized swellings in the breast
Mast itis! breast abscess
• During lactation: red, hot, tender lump, systemic upset.
• Tuberculous abscess: chronic, ‘cold’, recurrent, discharging
sinus.

Cysts
• Galactocele: commoner postpartum, tender but not inflamed,
milky contents.
• Fibrocystic disease: irregular, ill defined, often tender.
Solid lumps
Benign include:
• Fibroadenoma: discrete, firm, well defined, regular, highly
mobile.
• Fat necrosis: irregular, ill defined, hard, ?skin tethering.
• Lipoma: well defined, soft, non-tender, fairly mobile.
• Cystosarcoma phylloides: wide surgical excision (10% are
malignant).
Malignant include:
• Carcinoma
early: ill defined, hard, irregular, skin tethering late: spreading fixity, ulceration, fungation, ‘peau d’orange’.
Swellings behind the breast
• Rib deformities, chondroma, costochondritis (Tietze’s disease).

KEY INVESTIGATIONS
• ENAC: tumours, fibroadenoma, fibrocystic disease, fat necrosis, mastitis.
• Ultrasound: fibroadenoma, cysts, tumours (best for young women/
dense breasts).
• Mammography: tumours, cysts, fibrocystic disease, fat necrosis.
• Biopsy (‘Trucut/open surgical): usually provides definitive
histology (may be radiologically guided if lump is small or
impalpable—detected by mammography as part of breast screening
programme).