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410 Chapter 10: Breast disorders

Table 10.1 Skin changes suggestive of malignancy
Nipple retraction
Asymmetry of the breast contour
Skin tethering (dimpling or flattening of the skin, best elicited by asking the patient to raise their arms above their head or when
she pushes her hands against her hips)
Paget’s disease–a dry, scaling or red weeping appearance of the nipple
Peau d’orange is a late sign due to oedema of the skin due to obstruction of the lymphatics and has the appearance of orange
peel
Ulceration of the skin is a very late sign seen in women who have neglected the lump

lymphadenopathy or bloody nipple discharge. Skin resolves with rest and nonsteroidal anti-inflammatory
changes suggestive of malignancy are given in drugs. Pain arising from the chest wall may require
Table 10.1. infiltration of local anaesthetic agents and steroids
in severe cases. Breast pain may also be referred pain
Breast pain (mastalgia) fromconditionssuchasangina,pleuralinflammation,
pneumonia and oesophageal inflammation.
Mastalgiaisanypainfeltinthebreast.Athoroughhistory Once underlying pathology has been excluded the ma-
of the pain (documenting the site, onset and relationship jority of patients can be effectively managed with re-
to the menstrual cycle) should be taken. Mastalgia may assurance. Lifestyle changes have been suggested in-
occur premenstrually (cyclical mastalgia) or may be un- cluding the use of a well-fitting sports bra, reduction
related to the menstrual cycle. The history should also of stress, relaxation therapy and dietary manipulation.
include any previous or family history of breast disease Various drug therapies have been shown to be effective
includingcarcinoma.Athoroughbreastexaminationin- including danazol (a synthetic testosterone), tamoxifen
cluding examination of the regional lymph nodes may and bromocriptine although all have significant side ef-
reveal a cyst, an abscess or localised inflammation sec- fects limiting their clinical use. Recent advances include
ondary to mastitis. In non-cyclical mastalgia the chest lisuride (a dopamine agonist with fewer side effects than
wall should also be palpated. bromocriptine) for cyclical mastalgia and the use of top-
Cyclical mastalgia: Most premenopausal women get ical nonsteroidal anti-inflammatory preparations for all

some breast discomfort premenstrually. Symptoms types of mastalgia.
including heaviness, tenderness and increased nodu-
larity of the breast tend to gradually increase dur-
ing the premenstrual period. The symptoms tend to Nipple discharge
subside as menstruation starts and generally resolve
Nipple discharge may arise from single or multiple ducts
within a few days. If no other abnormalities are de-
and be unilateral or bilateral. Causes are given in Table
tected imaging is not normally required for cyclical
10.2.
mastalgia.
Non-cyclical mastalgia may arise from the breast or

from non-mammary causes. True breast pain may be Clinical features
caused by acute mastitis, a breast abscess, fat necrosis There may be a mass palpable, which when pressed pro-
or benign breast disorders. Focal mastalgia may rarely duces the discharge. Even if no mass is palpable, the dis-
be a presentation of breast cancer therefore mammog- charge may come from one duct when one segment of
raphy must be considered for women over the age of the breast is pressed. Lymph nodes should be looked for.
35 years with non-cyclical focal mastalgia.
Non-mammary causes include Tietze’s disease (chos- Investigations

tochondritis) in which patients present with a sharp Any associated breast lump should be investigated (see
pain exacerbated by movement and reproduced by page 412). Unilateral blood-stained discharge is sugges-
pressure on the costochondral junctions. It usually tive of an intraductal papilloma and also requires a triple