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Breast Pain and Nipple Discharge Philip Turton Consultant Breast, Oncoplastic, and Aesthetic Breast Surgeon Leeds General Infirmary.

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Presentation on theme: "Breast Pain and Nipple Discharge Philip Turton Consultant Breast, Oncoplastic, and Aesthetic Breast Surgeon Leeds General Infirmary."— Presentation transcript:

1 Breast Pain and Nipple Discharge Philip Turton Consultant Breast, Oncoplastic, and Aesthetic Breast Surgeon Leeds General Infirmary

2 Mastalgia alone or in combination with lumpiness is the commonest reason for referral to a breast clinic Pain alone 17% Lumpiness and pain 33% Non painful lump 36% Nipple discharge 5% Family history 3% 50%

3 Breast Pain Theory Theory Imbalance of essential fatty acids Imbalance of essential fatty acids Hormonal stimulation Hormonal stimulation Endogenous sensitivity of some breast lobules Endogenous sensitivity of some breast lobules Almost never associated with malignancy with normal examination Almost never associated with malignancy with normal examination

4 Breast Pain Non breast mastalgia should be differentiated by a good history Non breast mastalgia should be differentiated by a good history Consider: Angina, GS, Cervical spondylosis, Cervical rib, oesophageal erosions, lesions and achalasia, rib fracture, torn/strained muscle, pleuritic pain, pneumonia, pulmonary lesion, Tietz’s syndrome Consider: Angina, GS, Cervical spondylosis, Cervical rib, oesophageal erosions, lesions and achalasia, rib fracture, torn/strained muscle, pleuritic pain, pneumonia, pulmonary lesion, Tietz’s syndrome

5 Non-cyclical pain Unrelated to the menstrual cycle Unrelated to the menstrual cycle Described as tight, burning or sore Described as tight, burning or sore Constant or intermittent Constant or intermittent Usually affects one breast, in a localized area, but may spread more diffusely across the breast Usually affects one breast, in a localized area, but may spread more diffusely across the breast Usually affects postmenopausal women in their 40s and 50s Usually affects postmenopausal women in their 40s and 50s

6 Cyclical Breast Pain Clearly related to the menstrual cycle Clearly related to the menstrual cycle Described as dull, heavy or aching Described as dull, heavy or aching Often accompanied by breast swelling or lumpiness Often accompanied by breast swelling or lumpiness Usually affects both breasts, UOQs, +/- radiates to axilla Usually affects both breasts, UOQs, +/- radiates to axilla Intensifies during the two weeks leading up to the start of your period, then eases up afterward Intensifies during the two weeks leading up to the start of your period, then eases up afterward Usually affects premenopausal women in their 20s and 30s and perimenopausal women in their 40s Usually affects premenopausal women in their 20s and 30s and perimenopausal women in their 40s

7 Mastalgia: Taking a good history Age, FH, parity Previous history of breast problems: cysts, pain, biopsies, cancer, surgery (BBA, BBR, mastopexy) Previous history of breast problems: cysts, pain, biopsies, cancer, surgery (BBA, BBR, mastopexy) Previous breast imaging- what, why and when Previous breast imaging- what, why and when When was last period? When was last period? Menstrual irregularities Menstrual irregularities Usage of OCP, depot, mirena coil, progesterone only pill Usage of OCP, depot, mirena coil, progesterone only pill

8 Breast Pain Assess the pain: pain chart if not straightforward Assess the pain: pain chart if not straightforward Site, type, intensity, duration of symptoms Site, type, intensity, duration of symptoms frequency frequency previous occurrence previous occurrence Current impact on QOL Current impact on QOL Specific concerns eg cancer Specific concerns eg cancer

9 FIGURE 3.1 Back to ContentsBack to Chapter 3 thumbnails

10 FIGURE 3.2 Back to ContentsBack to Chapter 3 thumbnails

11 Examination NB: re-examine after next period if presenting in the week prior to menstruation NB: re-examine after next period if presenting in the week prior to menstruation

12 Examination: Mirror signal manoeuvre!!

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16 Who can be managed initially in primary care Bilateral symmetrical cyclical pain, which resolves following menstruation Bilateral symmetrical cyclical pain, which resolves following menstruation Recent onset breast pain, with normal examination in young patient Recent onset breast pain, with normal examination in young patient Male patients with simple tender gynaecomastia Male patients with simple tender gynaecomastia Normal examination and recent normal breast imaging Normal examination and recent normal breast imaging If in doubt, please refer If in doubt, please refer

17 Treatment Educate and Reassure Educate and Reassure Refit bra if obvious problem/ sports bra helps in short term Refit bra if obvious problem/ sports bra helps in short term Topical NSAID gel Topical NSAID gel Avoid caffeine completely Avoid caffeine completely Evening primrose oil: 1gm od or BD for minimum of 3-months, with good compliance Evening primrose oil: 1gm od or BD for minimum of 3-months, with good compliance If on HRT- reduce If on HRT- reduce If recently started COCP - reassure If recently started COCP - reassure If mirena/prog only pill, consider other If mirena/prog only pill, consider other

18 Breast Pain Who to refer: “anything atypical” Who to refer: “anything atypical” 1. Pain associated with definite signs: eg dominant or discrete lump, palpable focal thickening: will have triple assessment 1. Pain associated with definite signs: eg dominant or discrete lump, palpable focal thickening: will have triple assessment 2. Patients who have previously had breast cancer 2. Patients who have previously had breast cancer Rib met, lung met, LR Rib met, lung met, LR 3. Persisting pain, same quadrant for 3- months 3. Persisting pain, same quadrant for 3- months Mammo + targetted USS Mammo + targetted USS normal or B9 changes carries almost 100% negative predictive value. Core of any focal area but is uncommon normal or B9 changes carries almost 100% negative predictive value. Core of any focal area but is uncommon

19 Hospital Treatment of Severe Mastalgia Tamoxifen 10-20mg OD, 4-months Tamoxifen 10-20mg OD, 4-months Use on days 5 to 21 of cycle most effective Use on days 5 to 21 of cycle most effective S/E hot flushes, vaginal dryness S/E hot flushes, vaginal dryness Very rare: DVT Very rare: DVT

20 Treatment Danazol 100mg tds, 4-months Danazol 100mg tds, 4-months Inhibits pituitary gonadotrophins (FSH & LH) Inhibits pituitary gonadotrophins (FSH & LH) Stimulates androgenic pathways Stimulates androgenic pathways S/E: acne, oily skin, hirsuitism, weight gain, voice change, thrombosis S/E: acne, oily skin, hirsuitism, weight gain, voice change, thrombosis

21 Treatment Bromocriptine 2.5mg OD, 4-months Bromocriptine 2.5mg OD, 4-months Stimulates dopamine receptors in the brain and inhibits release of prolactin Stimulates dopamine receptors in the brain and inhibits release of prolactin Avoid in post-partum period (MI, CVA, HT) Avoid in post-partum period (MI, CVA, HT) S/E drowsiness, headache, postural hypotension, nausea, dizziness, dry mouth, fibrotic reactions S/E drowsiness, headache, postural hypotension, nausea, dizziness, dry mouth, fibrotic reactions

22 Treatment GnRH analogues, GnRH analogues, Decrease FSH/LH (after initial surge) Decrease FSH/LH (after initial surge) S/E: Hot flushes, sweating, vaginal dryness, loss of libido S/E: Hot flushes, sweating, vaginal dryness, loss of libido

23 Breast Pain Treatment of non-cyclical breast pain Treatment of non-cyclical breast pain Usually as for cyclical Usually as for cyclical More likely to use oral NSAID early on More likely to use oral NSAID early on Often due to duct ectasia; more common after menopause Often due to duct ectasia; more common after menopause Is there a chance that cancer can be present? Is there a chance that cancer can be present? Rare in absence of palpable thickening, or lump. Rare in absence of palpable thickening, or lump. Ensure breast looks & feels normal, and no obvious palp LN Ensure breast looks & feels normal, and no obvious palp LN Repeat examination after 6-weeks Repeat examination after 6-weeks

24 Questions?

25 Nipple Discharge Causes Causes Physiological Physiological Duct ectasia Duct ectasia Mild inflammation Mild inflammation Post-partum Post-partum Papilloma Papilloma DCIS, Inv ca DCIS, Inv ca Abscess Abscess Very rare: endocrine cause, joggers nipple Very rare: endocrine cause, joggers nipple Papillomas and duct ectasia commonly arise in the sub areola segment

26 Duct ectasia An aberration of development & involution An aberration of development & involution Women >50 Women >50 Nipple discharge, retraction, doughy palpable mass Nipple discharge, retraction, doughy palpable mass Discharge cheesy/ white Discharge cheesy/ white Slit-like nipple retraction Slit-like nipple retraction Management conservative or surgical Management conservative or surgical Surgical = total duct excision Surgical = total duct excision

27 Nipple Discharge Taking a History When When Spontaneous, or on Squeezing Spontaneous, or on Squeezing Frequency & duration Frequency & duration Consistency & quantity: spotting on bra, or staining through to blouse Consistency & quantity: spotting on bra, or staining through to blouse Blood stained Blood stained Current medication: phenothiazines, haloperidol, methyldopa Current medication: phenothiazines, haloperidol, methyldopa

28 Colour Usually always insignificant: multi-duct Usually always insignificant: multi-duct Brown and haem negative Brown and haem negative Green Green White, creamy White, creamy Investigate: single duct Investigate: single duct Brown and haem negative but persistent Brown and haem negative but persistent Brown and haem positive Brown and haem positive Serous Serous Blood stained Blood stained Galactorrhea Galactorrhea NB: Use the standard urinalysis sticks

29 History Associated breast symptoms or signs Associated breast symptoms or signs Any lump Any lump Any changes near the NAC Any changes near the NAC Nipple inversion, nipple eczema Nipple inversion, nipple eczema Adjuncts to assess risk Adjuncts to assess risk Parity Parity FH of breast or ovarian ca FH of breast or ovarian ca Previous breast problems, abnormal breast biopsies Previous breast problems, abnormal breast biopsies For galactorrhea: amenorrhea/headache/visual For galactorrhea: amenorrhea/headache/visual

30 Examination Apart from the nipple discharge, examination is usually normal Apart from the nipple discharge, examination is usually normal Look for the rarely associated signs of a sinister cause Look for the rarely associated signs of a sinister cause Indrawing, lump, sub-areola thickening Indrawing, lump, sub-areola thickening

31 Advise to cease expression Mammogram/USS if persists Review in 2-3 months If persistent bilateral, do serum prolactin Investigate further in breast clinic Investigation of new nipple discharge

32 Investigation Nipple fluid: haem test Nipple fluid: haem test If positive do Hadfields procedure If positive do Hadfields procedure Nipple fluid: smear onto a slide for cytology- Nipple fluid: smear onto a slide for cytology- Epithelium should not be seen ie should be “negative for epithelial cells” Epithelium should not be seen ie should be “negative for epithelial cells” If positive for epithelial cells indicates higher possibility of papilloma or DCIS, therefore do Hadfields procedure to send tissue to pathologist If positive for epithelial cells indicates higher possibility of papilloma or DCIS, therefore do Hadfields procedure to send tissue to pathologist

33 Investigation >35: Mammo and USS of NAC >35: Mammo and USS of NAC <35: USS of NAC <35: USS of NAC Guided biopsy Guided biopsy Eg USS guided core or FNAC of ?intraduct papilloma Eg USS guided core or FNAC of ?intraduct papilloma NB: Any clinically palpable lump must always be biopsied even if mammo and USS are normal NB: Any clinically palpable lump must always be biopsied even if mammo and USS are normal

34 Treatment Diagnostic Surgery Diagnostic Surgery Uncommon: microdochotomy/Ductoscopy Uncommon: microdochotomy/Ductoscopy “Hadfield’s Procedure” “Hadfield’s Procedure” Sub areola excision of the major breast ducts, which is sent for histology Sub areola excision of the major breast ducts, which is sent for histology S/E: nipple sensation, nipple necrosis, infection S/E: nipple sensation, nipple necrosis, infection Therapeutic operation Therapeutic operation Where results of Hadfields procedure show DCIS/Inv ca: Usually mastectomy & IBR Where results of Hadfields procedure show DCIS/Inv ca: Usually mastectomy & IBR

35 Treatment of non-significant nipple discharge Advise not to squeeze the nipple to look for further discharge Advise not to squeeze the nipple to look for further discharge If persists and is nuisance can refer for further investigation If persists and is nuisance can refer for further investigation Would tend to do a therapeutic Hadfields Would tend to do a therapeutic Hadfields Ie the purpose is to stop the discharge with the operation instead of doing it for diagnostic assessment alone Ie the purpose is to stop the discharge with the operation instead of doing it for diagnostic assessment alone

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39 Key Points Breast Pain: Breast Pain: Most do not need referring, reassure, educate Most do not need referring, reassure, educate Refer: not settling, focal nodularity, lump Refer: not settling, focal nodularity, lump Nipple Discharge: Nipple Discharge: Most are physiological or duct ectasia Most are physiological or duct ectasia Refer: watery or blood stained Refer: watery or blood stained Handouts: please me on Any breast related queries: NHS secretary: Angela Mathie:

40 Normal left breastSpiculate mass right breast

41 USS of Right Breast Cancer, and USS core, confirming needle through lesion

42 MRI of Right Breast Cancer, revealing multifocality

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45 Biopsy: The Mammotome

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48 Handouts: please me on Any breast related queries:


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