CHAPTER 5 Breast lumps and nipple discharge

From 80% to 90% of all breast lumps are found by the woman or her partner before diagnosis through clinical breast examination (CBE) or mammography. The three most common breast lumps are fibroadenomas, fibrocystic breast changes, and breast carcinoma. Fibroadenomas are benign solid tumors most frequently seen in women younger than 30 years. Fibrocystic breast changes are a heterogeneous group of nonproliferative changes of stromal and/or glandular elements of the breast tissue that includes benign cysts, diffuse and localized nodularity, nipple discharge, and breast tenderness. Fibrocystic symptoms are seen with great frequency in women ages 30 to 50 years but less often in those who are menopausal.

Breast carcinoma is the most common cancer in women and the second leading cause of cancer-related death. The risk of breast cancer in women rises steadily with age and accelerates rapidly after the age of 50. Although benign conditions that affect the breast are more common, the presence of a lump raises legitimate fears. The goal of the assessment process is to reach a diagnosis that addresses the possibility of breast cancer.

Nipple discharge is a common complaint among postmenarchal female clients. It is often related to pregnancy, recent breastfeeding, or estrogenic medications. In women who are not lactating, nipple discharge is most frequently caused by intraductal papilloma, duct ectasia, or cancer. Nipple discharge is more commonly caused by benign lesions than by cancerous ones. Physiological stimulation (e.g., sucking, pregnancy, mechanical stimulation) of the breasts can produce discharge, as can breast trauma and inflammation (e.g., herpes zoster, mammoplasty), pituitary disorders (e.g., irradiation of pituitary), or tranquilizing drugs (e.g., phenothiazines, methyldopa).

Diagnostic reasoning: focused history for breast lumps

Is this lump likely to be malignant?

Key questions

How long has the lump been present?

Is the lump changing (e.g., getting bigger, worse, or more painful)?

Is the lump in one breast only or are there lumps in both breasts?

When was your last menstrual period?

Is there any discharge from the nipple?

Have you recently been treated for a breast infection?

Duration and growth

The primary presenting complaint of a malignant lesion is that of a single, hard, painless lump in the breast that is unchanged by the cyclic hormonal milieu. A change from the patient’s normal physical findings is the most persuasive criterion for considering a diagnosis of breast cancer.

Malignant lumps are more likely to be new lumps that show progressive increase in size. The lump grows until there is an alteration in the contour of the breast tissue. An unchanged lump of long duration (years) is almost always benign. Half of all newly appearing benign cysts resolve within two or three menstrual cycles.

Unilateral versus bilateral

Breast lumps found bilaterally in identical quadrants of the breast are more likely to be benign. A solitary unilateral lump, although usually a cyst, fibroadenoma, or lipoma (rare), raises more suspicion for malignancy.

Postmenopausal

Cyclic cysts of the breast are less common after menopause and necessitate diagnostic investigation. A postmenopausal woman with unilateral mastalgia (breast pain) has a greater risk for breast cancer. Perimenopausal and postmenopausal women are also at greater statistical risk for breast cancer because of the higher incidence of breast cancer as they age. A new breast lump in a postmenopausal woman warrants a high degree of suspicion for cancer.

Nipple discharge with a lump

The occurrence of nipple discharge with the presence of a lump is worrisome because it can represent a ductal cancer. This condition demands further investigation, such as mammogram, ductogram, or biopsy.

Infection

Any residual masses in the breast after antibiotic therapy are suspicious for malignancy and require biopsy.

Does the person have additional risk factors for breast cancer?

Key questions

Have you ever had breast cancer?

Do you have a family history of breast cancer (i.e., first-degree relative)?

Have you ever had ovarian, endometrial, colon, or thyroid cancer?

Do you have a family history of ovarian, endometrial, colon, or prostate cancer?

Have you ever received radiation to the chest or had a malignancy in childhood?

Risk factors

The presence of risk factors in a woman who has a lump raises the index of suspicion for malignancy. It is important to remember that the absence of such risk factors is not cancer protective. About 70% to 80% of all breast cancer patients have no risk factors for malignancy before their diagnosis. Patients with a personal history of epithelial hyperplasia, ductal carcinoma in situ (DCIS), or lobular carcinoma in situ (LCIS) are usually evaluated every 6 months by a breast specialist because of their increased risk for malignancy. Malignant breast tumors in adolescents are more likely to be metastasis than a primary tumor. Hodgkin lymphoma, rhabdomyosarcoma, or neuroblastoma could be the primary tumor. A history of chest wall irradiation is a risk factor. See Box 5-1 for a summary of characteristics that could increase a woman’s risk for breast cancer.

Box 5-1 Primary Risk Factors for Breast Cancer

Female gender

Age

75% of all cases occur after age 50; no plateau effect with age

Personal history of breast cancer or cancer in situ

DCIS is a precursor of cancer and increases the risk for invasive breast cancer, usually in the same breast

Previous history of breast biopsies for non-malignant breast disease

Biopsy-proved proliferative changes or atypical epithelial hyperplasia; fibrocystic histological findings that indicate increased risk of breast cancer are moderate or severe hyperplasia (1.5-2 times the risk), atypical hyperplasia (5 times the risk), and lobular carcinoma in situ (8-10 times the risk); LCIS is a marker for cancer rather than a precursor; the cancer may occur in either breast

Laboratory evidence of specific genetic mutation

Increases susceptibility to breast cancer (i.e., mutation in BRCA1 or BRCA2 gene)

Personal history of cancer

Ovarian, endometrial, colon, or thyroid cancers

Family history of breast cancer

In first-degree relatives (mother, sister, or daughter) or in two or more close relatives

Is this condition more likely to be benign?

Key questions

How old are you?

Do you have a history of cystic breast changes or lumpy breasts?

Does this lump feel like other lumps you have had?

Do the lumps change with your periods?

Have you ever had a mammogram or ultrasound? Why was it done? What were the results?

Have you ever had a lump drained or biopsied? What was the diagnosis?

Do you have breast implants?

Age

Fibrocystic breast changes occur predominantly between the ages of 20 and 30. Fibroadenomas are more frequent in women ages 15 to 39. Intraductal papilloma and ductal ectasia occur in the age range of 35 to 55 years, whereas breast carcinoma is most prevalent in women age 40 to 70 years. Any woman older than 25 years who has a breast lump should be evaluated by CBE, diagnostic mammography, and/or ultrasound. Magnetic resonance imaging (MRI) sometimes can be used in addition to mammography and ultrasound. Additional evaluation with tissue biopsy may be required.

Timing, consistency, and duration

The most frequent breast complaint is that of a painful, mobile lump that increases in size and tenderness as the menstrual cycle approaches. The lump commonly has discrete borders that allow for measurement of the length, width, and depth of the lesion by the patient (e.g., size of a pea). The lump remains prominent on breast self-examination, is almost always painful to palpate, and frequently causes pain with changes in position of the arm on the affected side. Fibrocystic breast changes exist on a continuum that corresponds with the menstrual cycle. Tenderness and size variations occur throughout the month.

Previous mammograms or biopsies

History or documentation of cyclic changes in lumps or the presence of glandular breast tissue on a mammogram or ultrasound supports a clinical diagnosis of benign disease. More convincing evidence of benign disease occurs when there is a clear fluid aspirate from the cyst with no residual or recurring breast lump, with the caveat that benign disease and malignant disease can occur simultaneously.

Breast implants

With a ruptured implant, augmented breast tissue is pushed away from the chest wall by the implant.

Could this lump be mastitis related to lactation?

Key questions

Have you recently had a baby?

Are you currently breastfeeding or breast suckling?

Are your nipples sore or cracked?

Have you had pierced nipples?

Is your breast painful or hot? Are there any areas of redness?

Have you had a fever?

Childbirth

Engorgement or congestive mastitis begins on day 2 or 3 after delivery and affects both breasts. A breast mass in a lactating woman is usually associated with mastitis, an inflammation of breast tissue, and a blocked duct. It occurs most often in primiparous nursing mothers and is usually caused by coagulase-positive Staphylococcus aureus. It can also occur during periods of weaning when the flow of milk is disrupted. Inflammatory breast cancer in lactating women is rare but must be considered.

Sore, cracked, or pierced nipples

Cracked or pierced nipples can be a site for the introduction of infection.

Painful or hot breast

Mastitis is characterized by a breast that is painful, hot, and red. In lactating women, the most frequent symptom is a painful erythematous lobule in an outer quadrant of the breast. Although mastitis is most common in lactating women, it can also occur in nonlactating women, usually as the result of a generalized dermatitis occurring from insect bites, sunburn, or allergic reactions. However, the most common cause of an inflamed breast in nonlactating women is inflammatory breast cancer. In inflammatory breast cancer, the entire breast is swollen, heavy, and edematous.

Fever

Fever is a sign of infectious mastitis and occurs most often in association with lactation and breastfeeding. High fever does not occur because of simple breast engorgement in the postpartum period. Also, fever does not usually occur in inflammatory breast cancer and is rare in dermatitis reactions.

Diagnostic reasoning: focused history for nipple discharge

A focused history can help sort out the causes of the most frequently presenting cases of nipple discharge. Questioning should address normal lactation, high circulating levels of prolactin, and malignancy.

Is this normal lactation?

Key questions

When was your last normal menstrual period? How frequent are your cycles?

Is it possible that you are pregnant? What are you using for birth control?

When was your last delivery or miscarriage? How long were you pregnant?

Did you breastfeed? For how long? When did you stop?

Is the nipple discharge clear or milky?

How long have you had the nipple discharge?

Menstrual cycle

Frequently, fibrocystic breast changes are most marked just before menses and manifest as a spontaneous multiple duct discharge that can be either unilateral or bilateral.

Pregnancy and lactation

Pregnancy is the most common cause of breast tenderness and clear or milky nipple discharge (galactorrhea). A bloody nipple discharge during pregnancy is usually the result of vascular engorgement and clears within weeks. Recent pregnancy and/or breastfeeding (within 8 weeks) can account for a prolonged clear or milky discharge that is successfully suppressed by decreased breast stimulation or by the administration of dopamine agonist therapy (bromocriptine or pergolide). If the patient has had prolonged lactation, there can be milk formation even though prolactin levels are normal.

Color of discharge

Normal lactation produces a discharge that is milky and nonpurulent. Mastitis associated with breastfeeding can produce purulent discharge. A subareolar abscess can also produce a purulent discharge. Mastitis and abscesses that produce purulent nipple discharge must be distinguished from inflammatory breast cancer by biopsy or by evoking remission with antibiotic therapy.

Oral contraceptives can cause a clear, serous, or milky discharge from single or multiple ducts. Ductal ectasia and papillomatosis can produce a greenish or brownish nipple discharge. A serous or serosanguineous discharge from a single duct is usually indicative of an intraductal papilloma, but can be from an intraductal cancer. A bloody nipple discharge can occur with benign or cancerous conditions.

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