This document provides guidelines for evaluating and managing benign breast diseases. It discusses conducting a thorough history and physical exam. Imaging studies like mammography and ultrasound may be used. Biopsies should be performed when a mass is solid or abnormalities are found. Specific disorders are addressed, such as evaluating nipple discharge, breast pain, cysts, fibroadenomas, and infections. Management depends on factors like patient age and physical exam findings. The goal is to determine if the abnormality is benign or malignant.

1. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 1
9 BENIGN BREAST DISEASE
Doreen M. Agnese, M.D., F.A.C.S., Stephen P. Povoski, M.D., F.A.C.S., and Wiley W Souba, M.D., Sc.D., F.A.C.S.
.
One in two women will PHYSICAL EXAMINATION
consult a health care A thorough physical examination is an essential second step in
provider for a breast-relat- the evaluation of any patient with a breast complaint. The breasts
ed complaint during her should be inspected for any asymmetry, skin or nipple changes,
lifetime.1 Accordingly, all nipple retraction, erythema, or peau d’orange (orange-peel appear-
clinicians should have a ance). Skin dimpling can be accentuated by having the patient sit
fundamental understand- with her hands pushing against her hips to contract the pectoral
ing of the evaluation and muscles. Each breast should then be carefully palpated from the
management of breast dis- clavicle to below the inframammary fold and from the sternum to
orders. Although most breast complaints do not result in a diag- the posterior axillary line, with careful attention to the subareolar
nosis of cancer, women who present with symptoms suggestive area. Palpation is done with the patient both supine and sitting. If
of a breast disorder experience substantial anxiety and a sense of examination identifies an abnormal area, the location, size, consis-
urgency about their symptoms. Therefore, any woman present- tency, contour, tenderness, and mobility of the abnormality
ing with a breast complaint should receive a comprehensive eval- should be described; a diagram of the lesion may also be made for
uation. The fundamental task facing a physician who is evaluat- future reference. Benign masses tend to have smooth, regular bor-
ing a patient with a breast complaint is to determine whether the ders and are freely mobile. Although certain physical findings
abnormality is benign or malignant. In this chapter, we focus on (e.g., skin changes, irregular borders, firmness, irregular margins,
the evaluation and management of benign breast conditions. and immobility) are associated with a greater likelihood of cancer,
Breast cancer is discussed in greater detail elsewhere [see 3:1 their absence does not exclude the diagnosis of cancer.
Breast Cancer]. The axillary, supraclavicular, and infraclavicular areas should then
be palpated bilaterally for suspicious adenopathy. If enlarged nodes
Clinical Evaluation are discovered, their size, mobility, and number should be record-
ed. Any matting of nodes or fixation of nodes to the chest walls
HISTORY should also be recorded. Tenderness of enlarged nodes may sug-
gest a reactive process and should therefore be recorded as well.
The first step in the eval-
uation of any breast com-
plaint is a complete history. Investigative Studies
The duration of the breast
complaint, any observed IMAGING
changes, and all associated
symptoms should be recorded. Changes in the size or tenderness Mammography
of any palpable abnormalities since their initial discovery are par- The first imaging study employed to evaluate breast abnormal-
ticularly important, and special attention should be paid to how ities is bilateral mammography. Diagnostic mammography is a
these changes may relate to the menstrual cycle. Previous breast more comprehensive examination than screening mammography,
complaints, breast biopsies, and breast operations should also be consisting of multiple specialized images (e.g., magnification views
documented, and pathology reports from any such interventions or spot compression views). Digital mammography is now being
should be obtained. All imaging studies or medical evaluations used with increasing frequency in this setting. It has a number of
that have already been performed should be reviewed.
advantages over film-screen mammography, including lower radi-
Next, the clinician should identify any risk factors for breast
ation doses and easier image storage. Overall, digital mammogra-
cancer that may be present. A reproductive history should be
phy is not significantly better at detecting malignancies, but there
obtained that notes age at menarche, age at menopause, parity,
are certain subgroups that may derive particular benefit from this
and age at first full-term pregnancy. A thorough personal and fam-
modality, including younger women with denser breast tissue.2
ily history of other malignancies, with particular attention to
breast, ovarian, or endometrial cancer, should be obtained. Both Ultrasonography
maternal and paternal family histories play important roles in
Ultrasonography is employed mainly to distinguish cystic from
determining risk. The patient’s use of oral contraceptives, fertility
solid lesions.When the patient has a palpable lesion, direct needle
hormones, or postmenopausal hormone replacement therapy
aspiration, which is both diagnostic and therapeutic, can also be
should be noted as well.
used for this purpose.When the patient has a nonpalpable lesion,
Finally, as with any surgical patient, an overview of the gen-
ultrasonography can determine whether the lesion is cystic and
eral medical history should be obtained that includes current
thus may eliminate the need for additional workup or treatment.
medications, allergies, tobacco and alcohol use, previous surgi-
Ultrasonography is not useful for screening: it fails to detect calci-
cal procedures, medical problems, and a brief social history.
fications, misses a large number of malignancies, and identifies a

2. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 2
Patient presents with breast complaint
The most common presenting problems are
Assessment and • Palpable mass • Normal physical examination with abnormal mammogram
• Vague thickening or nodularity • Nipple discharge • Breast pain
Management of • Breast infection or inflammation
Breast Complaints Evaluate likelihood that lesion reflects cancer and be aware of patient risk
factors for cancer [see Table 2].
Palpable mass Abnormal mammogram after Vague thickening or nodularity
normal breast examination
Factors increasing suspicion of Factors increasing suspicion of
malignancy: Factors increasing suspicion of malignancy:
• Skin dimpling malignancy: • Skin changes
• Palpable axillary nodes • Previous normal mammogram • Asymmetry between right and left
• Mass with irregular borders • Localized soft tissue mass breast
• Increasing age • Stellate-appearing lesion • No generic hormonal changes
Determine whether mass is cystic • Clustered microcalcifications (e.g., pregnancy, beginning or
or solid. ceasing contraception)
• Palpable axillary nodes
Order mammogram if patient is > 35
yr or > 30 yr with a family history of
breast cancer.
Mass is cystic Mass is solid Mammogram Mammogram
is suspicious is not
suspicious
If fluid is bloody Obtain tissue
or mass remains diagnosis Perform biopsy Thickening is Thickening is
after aspiration, by means of (open or Follow up with
suspicious not suspicious
obtain tissue fine-needle stereotactic or mammograms
diagnosis. If aspiration, ultrasound-guided every 6 mo for
not, follow up core-needle). 2 yr. Perform open Reexamine
core-needle,
as for asimple biopsy (FNA patient after 2
or open
cyst. is not menstrual
surgical biopsy.
appropriate). cycles.
If area resolves,
provide routine
follow-up. If
lesion persists
or worsens,
perform open
biopsy.
Malignancy is present No malignancy is present
Treat as appropriate Continue routine screening, as
[see 3:1 Breast Cancer]. appropriate for patient's age.

3. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 3
Work up patient:
• History, with particular attention to risk factors for breast cancer
• Physical examination
• Imaging studies (e.g., mammography)
Initiate evaluation of specific breast problem.
Nipple discharge Breast pain Breast infection or inflammation
Factors increasing Factors increasing suspicion of Factors increasing suspicion of
suspicion of malignancy: malignancy: malignancy:
• Bloody discharge • Abnormal skin changes • No elevation of white blood cell
• Unilateral discharge • Noncyclic pain count
• Palpable mass (see Order mammogram if pain is • No response to antibiotics
facing page) noncyclic and patient is > 35 yr or • Symptoms not associated with
• Abnormal mammogram > 30 yr with a family history of breast lactation
(see facing page) cancer.
High-risk patients
without symptons
Mammogram Mammogram is normal, and Perform risk assessment (e.g.,
is abnormal, physical examination yields using Gail or Claus model).
or palpable normal results Consider genetic testing
mass is for risk gene mutations.
detected Offer comfort, reassure, and perform Discuss risk with patient.
follow-up examination in 2 mo. Select treatment option:
Work up as If pain resolves or there is still no
1. Close surveillance
indicated for palpable abnormality, reassure further
palpable mass and follow up routinely. If there is a 2. Prophylactic mastectomy
or abnormal palpable abnormality, obtain tissue 3. Chemoprevention with
mammogram. diagnosis. tamoxifen or participation
in chemoprevention trial
Discharge is Discharge is not
suspicious suspicious
(physiologic Patient is Patient is not lactating
Order discharge lactating
mammogram. or galactorrhea) Incise and drain any
Perform biopsy Give oral abscesses, and give
of any lesions If discharge is antibiotics antibiotics to cover skin
found. physiologic, reassure to cover gram- organisms (including
If a single duct is patient; no further positive cocci, anaerobes).
the source of the treatment is needed. use warm If there is no response to
pathologic If galactorrhea soaks, and short course of antibiotics,
discharge, is present, initiate attempt to rule out inflammatory
excise duct. If appropriate workup keep breast carcinoma; perform
source of (serum prolactin emptied. biopsy, including skin.
discharge can levels, thyroid
If abscess If infection is chronic,
only be localized function tests, and
forms, incise excise subareolar
to a quadrant, MRI if necessary).
and drain. duct complex.
excise ducts in
that quadrant.

4. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 4
great deal of normal breast texture as potential nodules. It is use- the aspirate is not bloody, the fluid should not be sent for cytolog-
ful, however, for directing fine-needle aspiration (FNA) biopsy or ic analysis, because it is unlikely to yield a diagnosis of cancer. If
core-needle biopsy (CNB) of the lesions that it does visualize. the aspirate is bloody, it should be sent for cytologic examination,
and tissue sampling should be considered (with biopsy or excision
Magnetic Resonance Imaging of any residual solid component). Complex cysts with indistinct
The main approved use of magnetic resonance imaging in the walls or intracystic solid components are more likely to be associ-
workup of breast disease is for identification of leaks in silicone ated with carcinoma; therefore, imaging-guided aspiration, biopsy,
breast implants, because it is capable of detecting the ruptured sil- or both should be performed.
icone membrane within the silicone gel. MRI also plays a role in
distinguishing benign from malignant lesions, though its sensitivi- Solid Masses
ty and specificity in this setting are still being assessed. MRI after If a discrete mass in the breast is believed to be solid, either on
injection of gadolinium contrast enhances many malignant lesions the basis of ultrasonographic findings or because attempts at
in relation to normal breast parenchyma. This technique also aspiration yield no fluid, a tissue diagnosis is necessary to rule
enhances some benign lesions (e.g., fibroadenomas), but gadolin- out malignancy. Physical examination alone is insufficient: it cor-
ium does appear to enhance malignant lesions more rapidly and rectly identifies masses as malignant in only 60% to 85% of
often to a greater extent. cases.4 Furthermore, experienced examiners often disagree on
whether biopsy is needed for a particular lesion: in one study,
Other Modalities four surgeons unanimously agreed on the necessity of biopsy for
Nuclear medicine studies, such as sestamibi scintimammogra- only 11 (73%) of 15 palpable masses that were later shown by
phy and positron emission tomography or mammography (PET biopsy to be malignant. Tissue diagnosis may be accomplished
or PEM), remain primarily investigational tools. At present, there by means of FNA biopsy, CNB, or open surgical biopsy [see 3:5
is no proven role for thermography or xerography in the evaluation Breast Procedures].
of breast problems.
Fibroadenoma Fibroadenomas are benign tumors that
BIOPSY
show evidence of both connective tissue and epithelial prolifera-
Breast biopsies should be performed percutaneously whenever tion. They are most commonly diagnosed in women in their 20s
possible.3 For a palpable lesion, either FNA biopsy or CNB is or 30s. Their characteristic clinical presentation is that of a well-
appropriate. For a nonpalpable lesion, an imaging-guided tech- circumscribed, smooth, rubbery, mobile mass. Mammography is
nique is advisable. Either stereotactic or ultrasound-guided percu- generally not required for a young woman with the classic clinical
taneous core biopsy is less invasive and more expedient than open presentation but should be obtained when the diagnosis is being
biopsy. With any imaging-guided approach, however, it is impor- considered in an older woman. Ultrasonography may be quite use-
tant to confirm that the interpretation of the imaging abnormality ful in this setting. On sonograms, these lesions generally appear as
agrees with the pathologic analysis of the specimen. Follow-up oval or rounded hypoechoic masses with regular margins.
should be based both on the pathologic findings and on the If the findings from ultrasonography and clinical examination
appearance of the breast abnormality on diagnostic imaging. are consistent with a fibroadenoma, then the lesion can safely be
followed clinically with serial sonograms, breast self-examination
(BSE), or both. If the lesion enlarges, biopsy may be required. If
Management of Specific there is any question, a core biopsy may be performed. If the pres-
Breast Problems ence of a fibroadenoma is confirmed, clinical follow-up is appro-
priate, provided that the lesion does not enlarge. If the fibroadeno-
PALPABLE MASS
ma enlarges, excision is required to rule out phyllodes tumor (see
The workup and man- below). Of course, nonenlarging fibroadenomas may also be
agement of a discrete breast excised, either percutaneously (with vacuum-assisted core biopsy
mass are governed by the [VACB] devices) or via an open surgical approach. In addition,
age of the patient, the phys- cryoablation of fibroadenomas has yielded favorable outcomes at
ical characteristics of the some centers.5,6
palpable lesion, and the patient’s medical history.The likelihood of
malignancy is greater when the patient is 40 years of age or older, Phyllodes tumor The phyllodes tumor is a rare fibroepithe-
when the mass has irregular borders, or when skin dimpling or lial breast lesion that clinically mimics a fibroadenoma. Most phyl-
enlarged axillary nodes are present [see 3:1 Breast Cancer]. A pre- lodes tumors present as palpable, solitary, well-defined, mobile,
biopsy mammogram is indicated for women older than 35 years and painless breast masses. With the widespread availability of
and for those younger than 35 years who have a strong family his- screening mammography, an increasing number of these tumors
tory of premenopausal breast cancer. are being discovered mammographically. Large phyllodes tumors
may be associated with visible venous dilation in the skin overlying
Cystic Masses the tumor. Axillary nodal metastasis rarely occurs (< 5% of cases).
Cysts are a common cause of dominant breast lumps, particu- Tumors are classified histologically as low, intermediate, or high
larly in premenopausal women. They can often be differentiated grade on the basis of five criteria: stromal cellularity, stromal atyp-
from solid lesions by means of ultrasonography. Sonographically, ia, the microscopic appearance of the tumor margin (infiltrating,
simple cysts tend to be oval or lobulated and anechoic, with well- effacing, or bulging), mitoses per 10 high-power fields, and the
defined borders. For asymptomatic simple cysts, no further inter- macroscopic size of the tumor. Structural7 and cytogenetic8 stud-
vention is required. For symptomatic cysts, FNA is appropriate. If ies of constituent cells have demonstrated similarities between
the mass does not disappear completely after aspiration, then fibroadenomas and phyllodes tumors, and there is evidence that
biopsy of any residual solid component should be performed. If certain fibroadenomas develop into phyllodes tumors. FNA is

5. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 5
Table 1 American College of Radiology Breast ing mammogram is the most common initial presentation for
Imaging Reporting and Data System (BIRADS) women with breast cancer. In the Breast Imaging Reporting And
Data System (BIRADS), developed by the American College of
Radiology, six different assessments (numbered 0 through 5) are
Category Assessment Description/Recommendation used in the interpretation of a screening mammogram [see Table 1].11
Women with either a negative or a benign assessment (category 1 or
Additional imaging evaluation
0 Additional imaging recommended 2) should undergo routine screening mammography in 1 to 2 years.
required
Women with a possibly benign assessment (category 3) should
Nothing to comment on; routine undergo a repeat study in 6 months, at which time the mammo-
I Negative finding
screening recommended
graphic abnormality is assessed for stability.
Negative mammogram, but In general, whenever the radiologist states that a lesion identi-
interpreter may wish to describe
2 Benign finding
a finding; routine screening fied on mammography is suspicious, a tissue diagnosis should be
recommended obtained, preferably by means of mammographically guided
stereotactic CNB [see 3:5 Breast Procedures].
Very high probabillity of benignity;
3 Probably benign finding short-interval follow-up suggest-
ed to establish stability VAGUE THICKENING OR
NODULARITY
Probability of malignancy; biopsy
4 Suspicious abnormality Normal breast texture is
should be considered
often heterogeneous, par-
Abnormality highly sugges- High probability of cancer; appro-
5
tive of malignancy priate action should be taken ticularly in premenopausal
women. Consequently,
vague thickenings or ten-
usually nondiagnostic, primarily because of the difficulty of der or nontender areas of
obtaining adequate numbers of stromal cells for cytogenic analy- nodularity are frequently
sis. On core biopsy, it may be impossible to distinguish a phyllodes detected by the patient or the clinician. It is important to distin-
tumor from a fibroadenoma. Although most phyllodes tumors guish this vague breast thickening or nodularity from a discrete or
have minimal metastatic potential, they have a proclivity for local dominant breast mass. A dominant breast mass is defined as a dis-
recurrence and should be excised with at least a 1 cm margin. crete lump that is distinctly different from the surrounding breast
Local recurrence has been correlated with excision margins but tissue. Overall, approximately 10% of dominant breast masses are
not with tumor grade or size.9 The most common site of metasta- malignant.
sis from malignant phyllodes tumors is the lungs (via the In clinical practice, the first step in evaluating a nodular area is
hematogenous route). to compare it with the corresponding area of the opposite breast.
The diagnosis of phyllodes tumor should be considered in all Symmetrical tender nodularity—for example, in the upper outer
patients with a history of a firm, rounded, well-circumscribed, solid quadrant of both breasts—is rarely pathologic. These areas often
(i.e., noncystic) lesion in the breast. Because phyllodes tumors represent fibrocystic changes that may resolve with time and thus
mimic fibroadenomas, they are often subjected to percutaneous should be followed clinically. Asymmetrical areas of vague thick-
biopsied or enucleated with a close margin. If percutaneous biop- ening in premenopausal women should be reexamined after one
sy has been performed, wide-margin excision should follow. If the or two menstrual cycles. If the asymmetrical thickening persists,
original percutaneous biopsy was consistent with fibroadenoma the possibility of malignancy is increased, and biopsy should be
and the lesion increases in size on follow-up examination or ultra- performed. Women 35 years of age or older who have not had a
sonography, excision should be performed. If, after excisional biop- mammogram in the past 6 months should undergo mammogra-
sy, examination of the permanent section shows that an adequate phy to rule out synchronous lesions. The accuracy of a negative
margin was not obtained, the patient should undergo reexcision to FNA biopsy in the presence of a vague thickening (as opposed to
obtain wider margins and avoid a 15% to 20% recurrence rate. If a discrete mass) is questionable; therefore, open biopsy is general-
a simple excision cannot be accomplished without gross cosmetic ly required for adequate sampling.
deformity or if the tumor burden is too large, a simple mastectomy
NIPPLE DISCHARGE
should be performed. In certain circumstances, radiation therapy
may have a role to play in the management of patients with phyl- Nipple discharge is a
lodes tumor. Chemotherapy, which is reserved for patients with common breast complaint,
metastatic disease, is based on guidelines for the treatment of sar- occurring in approximately
comas, rather than breast adenocarcinomas. 20% to 25% of women.12 It
may be classified as physio-
ABNORMAL SCREENING logic discharge, pathologic
MAMMOGRAM discharge, or galactorrhea.
The increased use of Although the actual inci-
screening mammography dence of malignancy in women with nipple discharge is low, this
has led to a dramatic rise in complaint produces significant anxiety among women because of
the number of nonpalpable the fear that it may be a harbinger of breast cancer. Galactorrhea
breast lesions that call for tis- can be a complex diagnostic challenge for the clinician; a thorough
sue acquisition. Generally, history, a focused physical examination, and appropriately chosen
5% to 10% of all screening investigative studies are required for diagnosis.
mammograms are abnormal, and 10% of women with abnormal Nipple discharge should be evaluated with respect to its dura-
mammograms have breast cancer.10 Currently, an abnormal screen- tion, character (i.e., bloody, nonbloody, or milky), location (i.e.,

6. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 6
unilateral or bilateral), and precipitating factors (i.e., whether it and biopsy of the mammary ducts possible.13 Flexible fiberoptic
is spontaneous or expressed). Because endocrine disorders (e.g., ductoscopy [see 3:5 Breast Procedures] may permit direct identifica-
hypothyroidism and hyperprolactinemia) can produce galactor- tion and treatment of pathologic conditions affecting the ducts. At
rhea, symptoms indicative of these conditions (e.g., lethargy, present, this technology is available only at a few centers, and as
constipation, cold intolerance, and dry skin) should be looked with all new technologies, there is a learning curve associated with
for.The patient should also be questioned about symptoms of an its use. Further experience with ductoscopy is required to deter-
intracranial mass, such as headache, visual field disturbances, mine its precise role in the evaluation and management of nipple
and amenorrhea. discharge.
Numerous medications are associated with galactorrhea, includ- After a thorough history, a focused physical examination, and
ing various antidepressants (e.g., fluoxetine, buspirone, alprazolam, appropriate diagnostic studies, pathologic nipple discharge that
and chlorpromazine). Other classes of drugs associated with nip- persists should be treated surgically. Operative therapy can
ple discharge include antihypertensives, H2-receptor antagonists, resolve the discharge and provide a diagnosis. Excision of a duct
and antidopaminergic medications (e.g., metoclopramide). or ducts can usually be performed with the patient under local
A focused physical examination is the next step in the evalua- anesthesia supplemented with intravenous sedation (so-called
tion of nipple discharge; obviously, a detailed breast examination monitored anesthesia care [MAC]).The traditional surgical man-
is essential. If nipple discharge is not immediately apparent, the agement of pathologic nipple discharge is a central, or major, duct
clinician should attempt to elicit the discharge by gently squeezing excision, which effectively removes all of the central lactiferous
the nipple.The clinician should then attempt to determine whether ducts and sinuses, thereby preventing further discharge [see 3:5
the discharge is limited to a single duct or involves multiple ducts. Breast Procedures]. Single-duct excision, or microdochectomy, can
Attention should also be paid to any physical findings suggestive be performed when the offending duct is clearly identified. The
of endocrine imbalance, such as thyromegaly (hypothyroidism) or advantage of this latter procedure is that it conserves breast tissue
visual field deficits (prolactinoma). and causes only minimal deformity; the nipple-areola complex
Nipple discharge is physiologic during pregnancy, developing as remains intact, so that the patient retains the ability to breast-
early as the second trimester and sometimes continuing for as long feed. The main disadvantage of single-duct excision is that the
as 2 years post partum. Therefore, evaluation of nipple discharge discharge may be more likely to recur than it would be after cen-
in women of childbearing years should include a pregnancy test. tral duct excision.
Elevated thyroid-stimulating hormone (TSH) levels associated
BREAST PAIN
with hypothyroidism can increase prolactin secretion and produce
galactorrhea. Accordingly, women with nipple discharge should Breast pain, or mastal-
undergo thyroid function testing.When the level of suspicion for a gia, is one of the most com-
prolactinoma is sufficiently high, the serum prolactin level should mon symptoms for which
be checked. If the serum prolactin level is elevated, MRI of the women seek medical atten-
head (i.e., of the sella turcica) is indicated to determine whether a tion. At present, the causes
prolactin-secreting pituitary tumor is present. of breast pain are poorly
Mammography is the first imaging study performed to evaluate understood. Although pain
nipple discharge. It may reveal nonpalpable masses or microcalci- is not usually a presenting symptom for breast cancer, it still war-
fications that necessitate biopsy. Because most pathologic causes rants a comprehensive evaluation.The elements of the history that
of nipple discharge are located close to the nipple, magnification are important in the evaluation of breast pain are the location,
views of the retroareolar region may help identify the underlying character, severity, and timing of the pain. Breast pain occurring
condition. The absence of any mammographic abnormalities, in a predictable pattern just before the menstrual cycle is called
however, should not lead to a false sense of security; further eval- cyclical mastalgia and is probably hormonally mediated. Notably,
uation is still required. however, several studies have shown no differences in circulating
The role of exfoliative cytology in the management of nonlacta- estrogen levels between women with mastalgia and pain-free con-
tional galactorrhea is unclear. Although cytology can be diagnos- trol subjects. It has been postulated that in women with breast
tic of cancer, its utility is limited by its low sensitivity, and at pre- pain, progesterone levels may be decreased or prolactin release
sent, it generally is not recommended.The high false-negative rate may be increased in response to thyrotropin-releasing hormone.14
mandates further evaluation when the cytologic findings are neg- Although histologic findings consistent with cysts, apocrine meta-
ative or nondiagnostic. Discharge that is bloody, unilateral, and plasia, and ductal hyperplasia have been noted in the breasts of
spontaneous is more likely to yield a diagnosis of cancer, though women with mastalgia, there is no convincing evidence that any of
the incidence is still quite low. these pathologic changes actually cause breast pain.
Ductography, or galactography, consists of mammography per- Mammography and physical examination usually yield normal
formed after the offending lactiferous duct has been cannulated results in patients with breast pain. The likelihood of malignancy
and filled with a contrast agent. It can be performed only when is increased when a patient with mastalgia is postmenopausal and
active discharge is present and when the secreting duct can be not taking estrogens or when the pain is associated with skin
identified and accessed. Not infrequently, ductography is techni- changes or palpable abnormalities; however, these situations are
cally impossible, or else the images are uninterpretable as a conse- uncommon.
quence of incomplete ductal filling or contrast extravasation. For most women with breast pain, treatment consists of reliev-
Solitary papillomas, the most common cause of abnormal nipple ing symptoms and reassuring the patient that the workup has not
discharge, typically appear as a ductal cutoff or filling defect on identified an underlying breast carcinoma. Nonsteroidal anti-in-
ductography. Unfortunately, a normal ductogram does not flammatory drugs and supportive bras are helpful. Several lifestyle
exclude a pathologic condition, and as with a normal mammo- interventions have been proposed as effective breast pain treat-
gram, further evaluation is still required. ments. Dietary recommendations, such as avoidance of methyl-
Advances in endoscopic technology have made visualization xanthines (found in coffee, tea, and sodas), are not evidence

7. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 7
based.15 However, oral ingestion of evening primrose oil has been areolar duct complex and intravenous antibiotic coverage, infec-
reported to produce significant or complete pain relief in about tions recur in some patients; excising the nipple and the areola can
50% of women with cyclic mastalgia.16 treat these.21
For the rare patients who have severe pain that does not
MAINTENANCE OF HEALTH: BREAST CANCER SCREENING
respond to conservative measures, administration of hormones
or drugs may be appropriate. Danazol has been successful In the absence of a specific breast complaint, patients at risk for
against breast pain and should be considered the first-line agent, breast cancer may be identified through screening. The three main
though its androgenic effects may be troubling to many methods of breast cancer screening are BSE, clinical breast exami-
women.17 Bromocriptine (a prolactin antagonist) and tamoxifen nation (CBE), and screening mammography.22 American Cancer
have also been used to treat mastalgia.18 Pharmacotherapy for Society screening guidelines for women aged 40 years and older
mastalgia is contraindicated in patients who are trying to specify that mammography and CBE should be included as part of
become pregnant. an annual health examination.23 In addition, health care providers
should tell women about the benefits and limitations of BSE, stress-
BREAST INFECTION OR
ing the importance of promptly reporting any new breast symptoms.
INFLAMMATION
Breast infections can be Breast Self-Examination
divided into two general In BSE, the patient herself inspects and palpates the complete
categories: (1) lactational breast and the axilla. Given that women themselves detect many
infections and (2) chronic breast tumors, one might reasonably assume that BSE instruction
subareolar infections asso- would improve breast cancer detection.There is, however, no con-
ciated with duct ectasia. clusive evidence that BSE is of significant value in this regard.
Both cellulitis and abscesses Many self-detected tumors are in fact found incidentally, not dur-
may occur in lactating women, either during weaning or when ing BSE. In addition, the best technique for BSE and the optimal
engorgement occurs. In the absence of an abscess, breast infec- frequency have not been established.The American Cancer Society
tions are treated by (1) giving oral antibiotics that cover gram-pos- recommends monthly self-examination as part of a breast cancer
itive cocci, (2) applying warm packs to the breast, and (3) keeping screening process that includes mammography and CBE.23
the breast emptied.Weaning is not necessary, because the infant is
not adversely affected by nursing from an infected breast.19 A Clinical Breast Examination
diagnosis of mastitis in a nonlactating woman must be viewed In CBE, a qualified health care professional carries out a com-
with suspicion, and the possibility of inflammatory breast cancer plete examination of the breast and the axilla. As with BSE, there
must be excluded. Inflammatory breast cancer is a clinicopatho- is little conclusive evidence indicating that annual or semiannu-
logic variant of breast cancer that is clinically characterized by the al CBE increases breast cancer detection rates.24 Nevertheless,
rapid onset of erythema, edema, and increased temperature in the we believe that it is prudent for the clinician to include CBE as
breast, with or without a palpable mass.The diagnosis is made by part of the physical examination performed on every female
means of a skin biopsy; the pathologic hallmark is tumor cell inva- patient.
sion of the dermal lymphatics.
Once a breast abscess forms, however, surgical drainage is Screening Mammography
necessary. Because of the network of fibrous septa within the There has been considerable debate regarding the value of
breast, breast abscesses in lactating women rarely form fluctuant screening mammography.The studies done to date suffer from flaws
masses. The clinical picture of breast erythema, tenderness, in the conduct of the trials and in the methods used to analyze the
fever, and leukocytosis establishes the diagnosis. Ultrasound- data. This state of affairs has led not only to uncertainty among
guided percutaneous drainage in conjunction with administra- practitioners but also to confusion among patients. Nevertheless,
tion of appropriate antibiotics may be attempted. If this measure screening mammography is recommended by several profession-
is unsuccessful, open drainage will be required. For optimal al societies, including both the American Cancer Society and the
abscess drainage, general anesthesia is usually necessary because National Cancer Institute (NCI). The NCI continues to evaluate
of the tenderness of the affected area and the amount of manip- data from ongoing studies and to promote and fund research
ulation necessary to break up the loculated abscess cavity. As aimed at developing more effective screening tools and strategies.
with any abscess, a culture should be performed and the cavity In a statement from January 31, 2002, the NCI made the follow-
should be packed open. ing recommendations25:
Nonlactational infections of the breast often present as chronic
relapsing infections of the subareolar ducts associated with 1. Women 40 years of age and older should be screened every 1
periductal mastitis or duct ectasia.These infections usually involve to 2 years with mammography.
multiple organisms, including skin anaerobes.20 Retraction or 2. Women who are at higher than average risk of breast cancer
inversion of the nipple, subareolar masses, recurrent periareolar should seek expert medical advice about whether they should
abscesses, or a chronic fistula to the periareolar skin may result, as begin screening before 40 years of age and about the frequen-
may palpable masses and mammographic changes that mimic cy of screening.
carcinoma. In the acute phase of infection, treatment entails inci- A woman should continue to undergo screening mammogra-
sion, drainage, and administration of antibiotics that cover skin phy as long as she is in reasonably good health and would be a
organisms, including anaerobes. In cases of repeated infection, the candidate for treatment if cancer were detected. Thus, although
entire subareolar duct complex should be excised after the acute no specific age has been established as a definitive cutoff point
infection has completely resolved, with antibiotic coverage provid- beyond which screening yields no benefit,26 patients with comor-
ed during the perioperative period. Whether drain placement is bidities whose life expectancy is shorter than 5 years would not be
necessary remains debatable. Even after wide excision of the sub- expected to benefit from routine mammography.

8. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 8
High-Risk Patients Most of the carcinomas that develop after a biopsy showing LCIS
Despite significant pro- are of ductal histology.43 The increased risk of subsequent carcino-
gress in management, at ma is equally distributed between the breast undergoing biopsy
least one third of women and the contralateral breast and is thought to be between 20% and
with breast cancer will ulti- 25% in patients with LCIS and no other risk factors; it may be
mately die of their disease. additive with other risk factors (see above).
This harsh reality has led to Genetic testing and the use of mathematical models have signif-
efforts aimed at providing icantly improved our ability to define breast cancer risk. The Gail
primary prevention to high- model,44 which relies on data from the Breast Cancer Detection
risk women.Various factors that place women at increased risk for Demonstration Project, and the Claus model,45 which relies on
breast carcinoma have been identified [see Table 2].27 These risk data from the Cancer and Steroid Hormone Project, are two of the
factors include increasing age; mutations in breast cancer risk tools that have been used to make this determination. At present,
genes (including BRCA1 and BRCA2, PTEN, and p53) and other there are three treatment options for women at high risk for breast
factors related to a family history of breast cancer28; hormonal and cancer: (1) close surveillance, (2) prophylactic mastectomy, and
reproductive factors, including early menarche, late menopause, (3) chemoprevention with tamoxifen, raloxifene, or other agents in
nulliparity, the absence of lactation,29 and the use of exogenous the setting of a clinical trial. Currently, no evidence-based conclu-
hormones27,30-35; environmental factors, including diet and the sions can be made as to which of these management strategies is
lifestyle characteristic of developed Western nations36-38; certain superior. Research involving high-risk women includes few ran-
pathologic findings within breast tissue, including previous breast domized, controlled trials, and many reports are based on uncon-
cancer and various premalignant lesions (e.g., ductal or lobular trolled studies of selected populations with varying degrees of
hyperplasia with atypia and lobular carcinoma in situ [LCIS]39-41); breast cancer risk. Although most women at high risk choose the
and certain nonbreast malignancies, including ovarian and option of close surveillance, the growing body of data on chemo-
endometrial carcinomas. Previous exposure to radiation, especial- prevention and prophylactic mastectomy may increase selection of
ly in the area of the chest wall, should also be considered. the other two options.
Recognition of risk factors facilitates appropriate screening and For women with LCIS or a family history of breast carcinoma,
clinical management of individual patients. It must be recognized, surveillance should include twice-yearly physical examinations.
however, that many women in whom breast cancer develops have Mammography should be performed annually after the diagnosis
none of the known risk factors for breast carcinoma. The absence of LCIS or atypical hyperplasia. For women with a family history
of these risk factors should not prevent full evaluation or biopsy of of breast cancer, mammography should be performed annually,
a suspicious breast lesion. beginning at least 5 years before the earliest age at which cancer
Approximately 10% of all breast cancers are hereditary.42 was diagnosed in a relative and in any case no later than the age of
Hereditary breast cancer is characterized by early age at onset, 35 years.46 For women who carry BRCA1 or BRCA2 mutations
bilaterality, autosomal dominant transmission through either the and other women from families with an autosomal dominant pat-
maternal or the paternal line, and familial association with tumors tern of breast cancer transmission, annual mammographic screen-
of other organs, particularly the ovary and the prostate gland. ing should begin at least 10 years before the earliest age at which
Therefore, an accurate and complete family history is essential for the cancer was diagnosed in a relative and no later than 25 years
quantifying a woman’s genetic predisposition to breast cancer.
Questions about breast cancer in family members should go back
several generations and should extend to third-degree relatives,
with age at diagnosis recorded if available. Similarly, any family Table 2 Risk Factors for Breast Cancer
history of ovarian or other cancers (particularly those that devel-
oped when the relative was young) should be recorded, along with Increasing age
age at diagnosis. Any personal history of cancer should be record- White race
ed, with particular attention paid to breast, ovarian, and endome- Age at menarche ≤ 11 years
trial cancers. Admittedly, it is not always possible to obtain com- Age at menopause ≥ 55 years
plete and precise family history data, whether because of time con- Nulliparity
straints or because of family issues such as premature deaths, small Age at first pregnancy ≥ 30 years
Absence of history of lactation
family size, and distant or broken families.
? Prolonged use of oral contraceptives before first pregnancy
It is difficult for practicing surgeons to stay current with the
Use of postmenopausal estrogen or progesterone replacement,
explosive growth of knowledge related to the genetics of breast especially if prolonged
cancer.Two genes—BRCA1 and BRCA2—account for the major- Use of other hormones, fertility regimens, or diethylstilbestrol
ity of hereditary breast cancers and are associated with increased Mutations in breast cancer risk genes, including BRCA1 and BRCA2,
risks of other cancers, most notably ovarian cancer; mutations in PTEN, and p53
other genes (e.g., p53 and PTEN) may also confer an increased Family history of breast cancer: multiple affected relatives, early
onset, bilaterality
risk of breast cancer. Specific founder mutations in BRCA1 and
Family history of ovarian cancer: multiple affected relatives, early
BRCA2 occur within certain ethnic groups (e.g., Ashkenazi onset
Jews).42 Tests that detect mutations in these genes are commercial- Pathologic findings that indicate increased risk (e.g., atypical hyper-
ly available. Whether to pursue genetic testing and how to inter- plasia, lobular carcinoma in situ, proliferative fibrocystic disease)
pret the results are complex issues. Accordingly, clinicians should Previous breast cancer
consult a professional genetics counselor if the option is available. Previous breast problems
It is now generally accepted that LCIS is a predictor of Previous breast operations
increased risk of subsequent invasive breast carcinoma rather than Previous exposure to radiation
a marker of the site at which the subsequent carcinoma will arise.

9. © 2007 WebMD, Inc. All rights reserved. ACS Surgery: Principles and Practice
3 BREAST, SKIN, AND SOFT TISSUE 9 Benign Breast Disease — 9
of age.46 Several studies have demonstrated that MRI is an excel- risk women. Long-term follow-up data are now available from the
lent screening tool in women at high risk for the subsequent devel- Royal Marsden randomized, double-blinded tamoxifen breast
opment of breast cancer.47-50 This finding has led to the incorpo- cancer prevention trial54 and the International Breast Cancer
ration of annual MRI into the current screening recommenda- Intervention Study (IBIS-1),55 both of which report a statistically
tions for any woman with a BRCA mutation, any untested first- significant reduction in the incidence of ER-positive breast cancer
degree relative of a BRCA carrier, and anyone whose lifetime risk that persists for at least 10 years.
exceeds 20% to 25%.51 In addition, MRI should be performed Concerns about the side effects of tamoxifen have generated
annually in all persons who have undergone irradiation of the interest in the use of selective estrogen receptor modulators
chest between the ages of 10 and 30 years and all those with Li- (SERMs) as chemopreventive agents. One such SERM, ralox-
Fraumeni syndrome (p53 mutation carriers) or Cowden syn- ifene, has been approved by the FDA for the treatment of post-
drome (PTEN mutation carriers). menopausal osteoporosis and is known also to exert beneficial
Chemoprevention may be defined as the use of nutrients or effects on lipid profiles.The Study of Tamoxifen And Raloxifene
pharmacologic agents to augment physiologic mechanisms that (STAR) trial, a randomized, double-blind trial whose purpose
protect against the development of malignancy. Chemopreventive was to compare the effectiveness of raloxifene with that of
strategies are designed either to block the initiation of the carcino- tamoxifen in postmenopausal women at increased risk for breast
genic process or to prevent (or reverse) the progression of the pre- cancer, demonstrated that raloxifene was as effective as tamox-
malignant cell to an invasive cancer.52 Chemoprevention began ifen in reducing the risk of invasive breast cancer and possessed
with the development of the antiestrogen tamoxifen. The efficacy a superior side effect profile.56 It is noteworthy, however, that
of tamoxifen in ER-positive breast cancer patients was recognized raloxifene was not found to prevent noninvasive breast cancers
early on, but its chemopreventive potential was not established in this trial.
until some time later. There are several newer agents that may also possess some
The first study to be published on breast cancer chemopreven- capacity for breast cancer chemoprevention. Aromatase
tion was the NSABP P-1 trial, in which women at increased risk inhibitors, which are used to treat ER-positive breast cancers,
for breast cancer were randomly assigned to receive either tamox- reduce the risk of contralateral cancers and may have a role to play
ifen, 20 mg/day, or placebo.53 Increased risk was determined on in chemoprevention. In addition, gonadotropin-releasing hor-
the basis of (1) age greater than 60 years, (2) a 5-year predicted mone agonists, monoterpenes, isoflavones, retinoids, rexinoids,
incidence of breast cancer of at least 1.66% (determined accord- vitamin D derivatives, and inhibitors of tyrosine kinase are all
ing to Gail’s criteria), or (3) a personal history of LCIS. After a undergoing evaluation in clinical or preclinical studies with a view
median follow-up period of 55 months, the overall risk of breast to assessing their potential chemopreventive activity.Whether any
cancer was reduced by 49% in the tamoxifen group, and the risk of these compounds will play a clinically useful role in preventing
of noninvasive breast cancer was reduced by 50%. The reduction breast cancer remains to be seen.
in breast cancer risk was limited to ER-positive breast cancers. Long-term results of prophylactic mastectomy in high-risk
Several adverse side effects were noted in the tamoxifen group, the women indicate that breast cancer risk was reduced by at least
most worrisome of which were a threefold increase in the inci- 90% in women at high or very high risk who underwent this pro-
dence of endometrial cancer, a higher incidence of deep vein cedure, compared with women who did not.57,58 There is, howev-
thrombosis and pulmonary embolism, and a higher incidence of er, no clear consensus on the indications for risk-reduction
stroke. The Food and Drug Administration (FDA) found the surgery; the benefits of prophylactic mastectomy must be weighed
results of the NSABP P-1 trial to be compelling enough to war- against the irreversibility and the psychosocial consequences of
rant approval of tamoxifen as a chemopreventive agent in high- the procedure.
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