LECTURE in MAMMOGRAPHY:

BREAST CANCER is the second leading cause of death from cancer in women (lung cancer is first). Each year, approximately 260,000 new cases
of breast cancer and 40,000 deaths from breast cancer are reported in the United States. One of every eight women will develop breast
cancer during her life.

According to WHO in 2020 about 2.3 million women diagnosed with breast cancer and 685,000 deaths globally. Breast cancer is considered as
the worlds most prevalent cancer.

Although it is rare, men can get breast cancer. About 1 out of every 100 breast cancers diagnosed in the United States is found in a man.
Early detection of breast cancer leads to more effective treatment and fewer deaths.

X-ray mammography has proved to be an accurate and simple method of detecting breast cancer, but it is not simple to perform. The
radiographer and support staff must have exceptional knowledge, skill, and caring.

In 1992, the U.S. government mandated regulations in the Mammography Quality Standards Act (MQSA), which set standards for image
quality, patient radiation dose, personnel qualifications, and examination procedures.

MAMMOGRAPHY- is a radiographic examination of the breast which is a prime example of soft tissue radiography wherein only muscle and fat
are imaged.

A Mammographic examination, called a Mammogram or Mammography, is used to aid in the early detection and diagnosis of breast diseases
in women. It has evolved into one of the most critical and demanding x-ray examinations that can be performed.

SOFT TISSUE RADIOGRAPHY

-Radiographic examination of soft tissues requires selected techniques that differ from those used in conventional radiography. These
differences in technique are attributable to substantial differences in the anatomy that is being imaged. In conventional radiography, the
subject contrast is great because of large differences in mass density and atomic number among bone, muscle, fat, and lung tissue.

-In soft tissue radiography, only muscle and fat are imaged. These tissues have similar effective atomic numbers and similar mass densities.
Consequently, soft tissue radiographic techniques are designed to enhance differential absorption in these very similar tissues.

A prime example of soft tissue radiography is mammography.

Mammography was first attempted in the 1920s.
The first initial breast images in the year 1924 was produced by Dr. Stafford Warren.

In the late 1950s the father of mammography, Dr. Robert Egan began teaching about Mammography. He renewed interest in mammography
with his demonstration of a successful technique that used low kilovolt peak (kVp), high milliampere seconds (mAs), and direct film exposure.

In the 1960s, Wolf and Ruzicka showed that xeromammography was superior to direct film exposure at a much lower patient radiation dose.
Spatial resolution and contrast resolution were much improved because of characteristic edge enhancement—the accentuation of the
interface between different tissues. This property is used frequently in the postprocessing of digital images.

Xeromammography was retired by 1990 because single screen-film mammography provided better images at even lower patient radiation
dose.

Mammography has undergone much change and development. It now enjoys widespread application thanks to the efforts of the American
College of Radiology (ACR) volunteer accreditation program and the federally mandated MQSA.

RISK OF BREAST CANCER:

In 2010, approximately 260,000 new cases of breast cancer were reported in the United States, and this number is growing. However, thanks
to early detection, more than 90% of women diagnosed with early-stage disease will survive. Several factors have been identified that
increase a woman’s risk of breast cancer (Box 23-1).
-One of every eight women will develop breast cancer.
-Breast cancer is now a disease that is far from fatal.

In 1995, the National Cancer Institute reported the first reduction in breast cancer mortality in 50 years, and this trend continues. With early
mammographic diagnosis, more than 90% of patients are cured.

-One important consideration in the overall efficacy of mammography is patient radiation dose because radiation can cause breast cancer as
well as detect it.

-However, considerable evidence shows that the mature breast in the screening age group has very low sensitivity to radiation-induced breast
cancer. Radiation carcinogenesis (i.e., the induction of cancer) is discussed in Chapter 36 (Bushong).

2 TYPES OF MAMMOGRAPHIC EXAMINATION:

1. SCREENING MAMMOGRAHY-is performed on asymptomatic women with the use of a two-view protocol, usually Mediolateral Oblique
(MLO) and Craniocaudal (CC),
- to detect an unsuspected cancer.

-Screening Mammography in patients 50 years or older reduces cancer mortality. Results of clinical trials show that screening of women in the
40- to 49-year age group is also beneficial in reducing mortality. Because younger women have potentially more years of life left, screening in
this group results in more years of life saved.
-Current guidelines recommend screening mammography every year for women, beginning at age 40. Research has shown that annual
mammograms lead to early detection of breast cancers, when they are most curable and breast conservation therapies are available.

The American Cancer Society recommends that women perform monthly breast self-examinations (BSE); a health care professional teaches a
woman to check her breasts regularly for lumps, thickening of the skin, or any changes in size or shape. There is current discussion regarding
breast self-examination because some scientific studies suggest it is not effective. Table 23-1 relates the recommended intervals for breast
self-examination and screening mammography.
*Beginning at age 20 years.
†Beginning at age 35 years.

Baseline Mammogram- first radiographic examination of the breast and is usually obtained before the age of 40. Radiologist use it for
comparison with future mammogram.

2. DIAGNOSTIC MAMMOGRAPHY- is performed in patient with symptoms or evaluated risk factors. It is used to evaluate a patient with
abnormal clinical findings such as breast lump or lumps that have been found by the women or her doctor.
-It may also be done after an abnormal screening mammogram in order to evaluate the area of concern on the screening examination.

-The risk of radiation-induced breast cancer resulting from x-ray mammography has been given a lot of attention. Mammography is considered
very safe and effective.
-The ratio of benefit (lives saved) to risk (deaths caused) is estimated at 1000 to 1.

ANATOMY OF THE BREAST- In the adult female, each of the mammary glands or breasts is a conic or hemispheric eminence that is located on
the anterior and lateral chest walls.

Each breast is made up of 15 to 20 lobes which is covered by adipose tissue and that is further divided into several lobules.

❖NIPPLE – a small projection that contains a collection of between 15 to 20 duct openings from secretory glands within the breast tissue.

❖AREOLA –circular, darker pigmented area surrounding the nipple.

❖MONTGOMERY GLANDS – are small oil glands whose purpose is to keep the nipple lubricated and protected, especially during nursing.

❖INFRAMAMMARY FOLD – junction of the inferior part of the breast with the anterior chest wall.
❖MEDIOLATERAL DIAMETER– is the width of the breast. Inframammary fold Mediolateral diameter

❖CRANIOCAUDAD DIAMETER – the vertical measurement that averages from 12 to 15cm at the chest wall.

❖TAIL OF THE BREAST/ AXILLARY PROLONGATION OF THE BREAST– breast tissue extending into the axilla which is the most common site for
breast cancer occurrence.

❖PECTORALIS MAJOR – a large muscle seen overlying the bony thorax.

❖ALVEOLI – smallest lobules consist of clusters of rounded alveoli. Upon glandular stimulation, peripheral cells of the alveoli form oil globules
in their interior, which, when ejected into the lumen of the alveoli, constitute milk globules.

❖DUCTS – the clusters of alveoli that makes up the lobules are interconnected and drain through individual ducts.

❖AMPULLA- each duct enlarges into a small ampulla that serves as a reservoir for milk just before terminating in a tiny opening on the surface
of the nipple.

❖COOPERS SUSPENSORY LIGAMENTS- are band-like extensions of the fibrous tissue junction to provide support for the mammary glands.

❖TRABECULAE- this term is used by radiologist to describe various small structures seen on the finished radiograph, such as small blood
vessels, fibrous connective tissues, ducts, and other small structures that cannot be differentiated.

The adult female breast consists of 15 to 20 lobes, which are distributed so that more lobes are superior and lateral than inferior and medial.
Each lobe is divided into many lobules----which are the basic structural units of the breast.

The lobules contain the glandular elements, or acini. Each lobule consists of several acini----a number of draining ducts, and the interlobular
stroma or connective tissue. These elements are part of the breast parenchyma and participate in hormonal changes.

By the late teenage years to early 20s, each breast contains several hundred lobules.

The lobules tend to decrease in size with increasing age and particularly after pregnancy-a normal process called involution.

-The openings of each acinus join to form lactiferous ductules that drain the lobules, which in turn join to form 15 to 20 lactiferous ducts, one
for each lobe. Several lactiferous ducts may combine before emptying directly into the nipple. As a result, there are usually fewer duct
openings on the nipple than there are breast ducts and lobes. The individual lobes are incompletely separated from each other by the Cooper's
ligaments. The space between the lobes also contains fatty tissue and additional connective tissue. A layer of fatty tissue surrounds the gland,
except in the area immediately under the areola and nipple.
LYMPHATIC DRAINAGE:

-The lymphatic drainage of the breast is very important, especially from the aspect of pathology. This is because breast carcinomas tend to
spread by travelling through the lymphatic vessels, creating metastatic deposits in distant parts of the body.

-Lymph from the breast lobules, nipple and areola areas collect into the subareolar lymphatic plexus. From here, around 75% of lymph (mostly
from the lateral quadrants of the breast) drains into the pectoral lymph nodes, and then into the axillary lymph nodes. While the remainder
drains into the parasternal lymph nodes or internal mammary lymph nodes. This is why axillary lymph nodes are the first to be surgically
removed in certain stages of breast cancer. The axillary lymph nodes drain into the subclavian lymphatic trunks, which also drain the upper
limbs. The parasternal nodes drain into the bronchomediastinal trunks, which also drain the thoracic organs. Besides the axillary and
parasternal nodes, some drainage of the breast can occur via the intercostal lymph nodes which are located around the heads and necks of the
ribs. The intercostal lymph nodes drain either into the thoracic lymph duct or the bronchomediastinal lymph trunks.

BLOOD SUPPLY: Breast blood supply comes from three sources:

• Branches of the axillary artery supply the lateral part of the breast. These are the superior thoracic, thoracoacromial, lateral thoracic and
subscapular arteries.
• Branches of the internal thoracic artery, supply the medial part of the breast as the medial mammary arteries.
• Perforating branches of second, third and fourth intercostal arteries contribute to the supply of the entire breast. Breast veins follow the
mentioned arteries. They drain into the axillary, internal thoracic and second to fourth intercostal veins.

One of the major challenges associated with imaging the breast radiographically is that the various tissues have low inherent subject contrast
or breast tissue makeup. These differences accounts for the contrast differences that are apparent on the final image and therefore provide
the basis for the radiographic image of the breast.

3 main types of breast tissue:

❖Glandular tissue
❖Fibrous or Connective tissues
❖Adipose or Fatty tissue

 The breast tissue most sensitive to cancer by radiation is glandular tissue.

Young breasts are dense and are more difficult to image because of glandular tissue. Older breasts are more fatty and easier to image.

In a premenopausal woman, the fibrous and glandular tissues are structured into various ducts, glands, and connective tissues. These are
surrounded by a thin layer of fat. The screen-film radiographic appearance of glandular and connective tissue is one of high optical density
(OD).

Postmenopausal breasts are characterized by a degeneration of this fibroglandular tissue and an increase in adipose tissue. Adipose tissue
appears dark on film with higher OD and requires less radiation exposure.

If a malignancy is present, it appears as a distortion of normal ductal and connective tissue patterns. Approximately 80% of breast cancer is
ductal and may have associated deposits of microcalcifications that appear as small grains of varying size. In terms of detecting breast cancer,
microcalcifications smaller than approximately 500 μm are of interest.

2 methods are commonly used to subdivide the breast into smaller areas for localization purposes.

❖QUADRANT SYSTEM - Is the easiest to use for general lesion localization.

❖CLOCK SYSTEM- compares the surface of the breast with the face of a clock.
- provide a more accurate description of a lesion.

Approximate incidence of breast cancer by location within the breast:

Because the mass density and atomic number of soft tissue components of the breast are so similar, conventional radiographic technique is
useless.

- In the 70- to 100-kVp range, Compton scattering predominates with soft tissue; thus, differential absorption within soft tissues is minimal.

-Low kVp must be used to maximize the photoelectric effect and thereby enhance differential absorption and improve contrast resolution.

Recall that x-ray absorption in tissue occurs principally by photoelectric effect and Compton scattering. The degree of absorption is determined
by the tissue mass density and the effective atomic number. Absorption caused by differences in mass density is simply proportional to the
mass density for both photoelectric effect and Compton scattering.

Absorption caused by differences in atomic number, however, is directly proportional for Compton scattering and proportional to the cube of
the atomic number for photoelectric effect.

Therefore, x-ray mammography requires a low-kVp technique. As kVp is reduced, however, the penetrability of the x-ray beam is reduced,
which in turn requires an increase in mAs.
If the kVp is too low, an inordinately high mAs value may be required, which could be unacceptable because of the increased patient radiation
dose. Technique factors of approximately 23 to 28 kVp are used as an effective compromise between the increasing dose at low kVp and
reduced image quality at high kVp.

Tissue Variations of the Breast- The glandular and connective tissues of the breasts are often tissue-density structures. The ability to
demonstrate radiographic detail within the breast depends on the fat within and between the breast lobules and the fat surrounding the
breasts.

Young breasts are dense and are more difficult to image because of glandular tissue. Older breasts are more fatty and easier to image.

Breast can be classified into three broad categories:

1. FIBRO-GLANDULAR BREAST - Post puberty

- 15 – 30 years of age
- Childless females over the age of 30
- Pregnant or lactating females

The postpubertal adolescent breast contains primarily dense connective tissue and casts a relatively homogeneous radiographic image with
little tissue differentiation. The development of glandular tissue decreases radiographic contrast. During pregnancy, significant hypertrophy of
glands and ducts occurs within the breast. This change causes the breasts to become extremely dense and opaque.

Fig. 24-5 Craniocaudal projection of normal breast in a 19-year old woman who has never been pregnant. Note the dense glandular tissues
with small amounts of fat. In women who do not become pregnant, the breasts may remain dense for many years.

2. FIBRO-FATTY BREAST - 30 – 50 years of age

- Young women with 3 or more pregnancies

After the end of lactation, considerable involution of glandular and parenchymal tissues usually occurs, and these tissues are replaced with
increased amounts of fatty tissue. Fat accumulation varies markedly among individuals. This normal fat accumulation significantly increases the
natural radiographic contrast within the breasts.

3. FATTY BREAST - Postmenopausal

- 50 years old and above
- Breast of children and male

The glandular and connective tissue elements of the breast can regenerate as needed for subsequent pregnancies. After menopause, the
glandular and stromal elements undergo gradual atrophy.

External factors such as surgical menopause and ingestion of hormones may inhibit this normal process. From puberty through menopause,
mammotrophic hormones influence cyclic changes in the breasts. Thus, the glandular and connective tissues are in a state of constant change.

Diagrammatic profile drawings of breast. illustrating the most likely variation and distribution of radiographic density (shaded areas) related to
the normal life cycle from adolescence to senescence. This normal sequence may be altered by external factors such as pregnancy. hormone
medications. surgical menopause. and fibrocystic breast condition.

Congenital abnormalities of the nipple:

1.Accessory nipples or polythelia

Also known as a supernumerary nipple, is the presence of one or more extra nipples on the body. Accessory nipples are seen in 1–5% of the general
population with the same incidence in male and females.

Accessory nipples commonly appear along the “milk line”. This refers to the area on the front of your body that starts in your armpit and goes down
through and past your nipples to your genital area. More than 90% are seen in the inframammary region. These nipples can be unilateral or bilateral and
are quite well developed with surrounding areola in some. They are prone to the same diseases as normal nipples. Supernumerary nipples can also lactate
in both men and women, especially if they’re more fully d

eveloped.

Supernumerary nipples usually aren’t a health risk. Most require no treatment unless the nipple causes irritation or is excised for cosmetic reasons. A quick
surgery can remove them.
2. Congenital nipple inversion

Sir Ashley Cooper first described congenital inverted nipples in 1840. It is seen in 2% of the general population, with a family history of such a condition in
50% of patients. The cause for this abnormality is thought to be tethering and shortening of breast ducts and development of fibrous bands behind the
nipples during intrauterine life.

It can cause mechanical problems with breast feeding; however, many can breast feed without any difficulty, probably because of changes that occur in the
breast during pregnancy.

There are a variety of procedures described for the surgical correction (e.g., tightening of the areolar edge circumferentially and use of adjacent dermal
flaps to augment nipple); however, loss of sensation and inability to breast feed are major concerns with surgical procedures.

Most of the procedures involve short circumareolar incision or an incision at the base of the nipple. The tight bands are stretched, but it is often required to
divide the ducts. A stitch can be placed at the base of nipple when it is everted, but this is not recommended.

A device called a “Niplette” is available from pharmacies. This is a suction device that, when used regularly, is successful in a few women at everting the
nipple.

3. Athelia

Complete absence of nipple and areola is termed as athelia. This condition can be familial (autosomal dominant), and may be unilateral or bilateral, and is
seen in association with amastia or rare syndromes such as scalp-ear-nipple or SEN syndrome (scalp nodules and ear malformation), AARR syndrome (Al-
Awadi/Raas-Rothschild syndrome) and Poland’s syndrome.

A thorough investigation to rule out any other associated ectodermal abnormalities is required. Nipple and areola reconstruction can be carried out using
small tissue flaps along with tattooing of a new areola in the absence of any other deformity. Skin grafts could also be used to create areola.

4. Accessory breast tissue or supernumerary breasts: Polymastia

Accessory breast tissue or supernumerary breasts are seen in approximately 1–2% of the general population but figures as high as 6% have been reported.
There is a female preponderance with some reported as hereditary cases. In approximately a third of patients, accessory breasts are found in more than
one site; the most common site is the axilla. Axillary accessory breast tissue can have its own nipple–areola complex.

Polymastia is usually diagnosed at puberty or during pregnancy when the accessory breast tissue develops along with the normal breasts. These are mostly
asymptomatic, but can cause discomfort, and in some are seen as cosmetically unacceptable. Accessory breast tissue is susceptible to all the normal
changes and disease spectrum seen in the normal breast. Breast cancer cases have been reported in accessory breast tissue.

The best policy is to try and avoid surgery, as it may cause unsightly scars, restriction of movement, cause pain and is not without complications. Any
surgery needs an experienced surgeon and careful preoperative marking. Scar placement for any surgery is vital; it should not extend beyond the edge of
the pectoralis major.

Liposuction is useful for the fatty element of accessory breasts, and in some cases, it is the only treatment required. Liposuction is also valuable in helping
to define the planes between accessory breast tissue and the underlying axilla.

5. Asymmetry (aplasia & hypoplasia) of the breast

One breast can be hypoplastic or absent (aplasia) and this can occur in isolation or in association with a defect in (one or both) pectoral muscles. Some
degree of breast asymmetry is common, but it is more pronounced in cases of hypoplasia.

This ‘true asymmetry’ can be treated with various treatment options, including augmentation of the smaller breast with implant, reduction and mastopexy
of the larger breast, or a combination of both these options. Where there is asymmetry in the skin, the use of expanders prior to permanent implant
replacement can improve symmetry. To get true symmetry, there is usually a need to operate on both breasts. The best age to perform surgery is when the
breasts have fully developed – usually approximately at age 17 or 18 years. More than one operation may be required. Some hypoplastic breasts can also
have a tubular element.

Lipofilling is useful to provide implant cover and improve contour to obtain a high degree of symmetry

6. Amastia

The total absence of breast tissue and nipple– areola complex is called amastia. Whereas absence of breast tissue only is called amasia. Can be unilateral
or bilateral.

In amastia, the mammary ridge disappears completely or fails to develop. There is often evidence of associated ectodermal defects such as cleft palate,
isolated pectoral muscle and upper limb deformities, urological abnormalities, and even Poland’s syndrome. Familial cases have been reported with an
autosomal dominant trait. New breasts can be reconstructed using expanders and implants or using myocutaneous flaps such as the latissimus dorsi
myocutaneous flap.

Abnormalities of the shape of the breast:

1.Tubular breasts
Tubular breasts are characterized by normal function/physiology of the breast tissue, but abnormal anatomical shape. It can be unilateral or bilateral, and
the classical features include some or all of: lack of breast skin; breast hypoplasia and asymmetry; conical breasts; herniated nipple–areolar complex; large
areola and a constricted breast base.

Standard treatment includes placement of expanders through an inframammary fold incision following radial scoring and later replacement with implants.
These procedures do not correct the ‘herniated nipple and areola complex’, and a second procedure is often required to correct this deformity, such as
reducing the size by circular periareolar round block mastopexy (this could also be performed at the time of primary surgery in select cases).

Lipofilling in the periphery of the breast (not recommended within the breast) helps to achieve a final better contour and adds volume along with the
expander.

The long-term outcome from surgery is not always satisfactory with loss of sensation, scar issues and asymmetry being common complications.

Congenital chest wall deformity

1.Poland’s syndrome

Unilateral chest wall hypoplasia with ipsilateral upper limb deformity is called Poland’s syndrome. A patient with some of these features was first described
by Alfred Poland from Guys Hospital London in 1841. It was later named Poland’s syndrome by Clarkson in 1962, who, when also working at Guy’s Hospital
London (London, UK), reported three patients with breast and hand deformities and noted Poland had described a similar case earlier.

Poland’s syndrome consists of some or all of: absence or hypoplasia of the breast; absence of pectoralis major or minor; absence of nipple; absence of
adjacent muscles and sometimes costal cartilage; rib abnormalities; and upper limb deformities (e.g., syndactyly, micromelia or brachydactyly). Familial
cases have been reported. Poland’s syndrome is three-times more common in males, with an incidence of one in 7000 to one in 1,000,000 in the general
population. Pectus excavatum and Poland’s syndrome, that include defects of the chest wall are the commonest forms of congenital chest wall defects.
These defects can be corrected surgically.

Clinical breast changes

Many normal changes occur in a woman’s breast as she becomes older. Most of these are included in the concept of ANDI (aberrations of normal
development and involution).

ANDI includes all the benign changes that take place in the breasts with age. For example, lumps may develop within the breast tissue. It is very important
to remember that there is always a cause for a breast lump and that the diagnosis must fit the age of the patient.

breast lump

➢A lump is a local area of firm tissue that can be felt in a breast.

➢The lump is firmer than the surrounding breast.

➢Usually, a woman is concerned about a lump because she has not noticed it before.

➢They may be malignant (a cancer). Fortunately, most breast lump are benign

What does benign mean?

Benign means that the condition (e.g. a breast lump) is not malignant, i.e. not cancerous. A benign lump may increase in size but does not spread into the
surrounding tissue to elsewhere in the body.

A benign lump may get bigger but does not spread.

The two commonest causes of benign conditions associated with a breast lump are:

• A fibroadenoma

• A cyst

However, it is always possible that the lump may be malignant.

What are common causes of a benign lump in the breast?

1.Breast fibroadenomas

The woman may have one fibroadenoma or many fibroadenomas (fibroadenomata). A fibroadenoma consists of both fibrous and glandular tissue.

They tend to grow to a size of 1 to 3 cm and most stay at that size. However some will increase in size and may get to be 6 cm or larger. Over decades, they
will tend to get smaller. It is common to have more than one fibroadenoma.

➢Fibroadenomas in young patients (less than 20 years) do not need any specific investigations.

➢Ultrasound scan: shows a round, dark mass with sharp edges. The normal breast tissue tends to ‘flow’ over the lump.

➢Mammography if the woman is older than 40: fibroadenomas look round on a mammogram and are generally white.
➢Cytology: A fine needle aspiration and cytology is very helpful as the cytology is usually typical. However, fibroadenomas can be difficult to diagnose as
sometimes they do not show the typical changes, especially in pregnancy.

A fibroadenoma cannot be definitely diagnosed using ultrasound scanning and cytology alone. If a core (Tru-cut) biopsy is not going to be performed then
all 3 tests (clinical, ultrasound and cytology) must suggest that the lump is a fibroadenoma.

The best test to confirm the diagnosis of a fibroadenoma is a core biopsy.

The majority of women who develop a fibroadenoma are under the age of 35. Therefore, most new breast lumps in young women are fibroadenomas. After
the age of 40, breast cancer becomes a commoner cause of a lump in the breast.

They are round and movable. They feel rubbery and tend to move under the fingers when the breast is examined.

Core (Tru-cut) biopsy

This is a small sample of tissue taken with a special core (Tru-cut) biopsy needle. The tissue is then examined under a microscope (histology). The advantage
of this method is that it causes minimal trauma and does not require the whole lump to be removed. However, if there is any doubt about the result of the
core biopsy it is best to remove the lump.

A core biopsy will give a tissue diagnosis and will also sample some of the surrounding tissue. A core biopsy showing typical changes would give a definite
diagnosis.

There is a slightly higher risk of developing breast cancer. Anyone who is older than 35 and develops a new fibroadenoma should have mammograms once
a year after the age of 40.

A breast cancer may feel like a fibroadenoma.

Are fibroadenomas associated with an increased risk of breast cancer?

Breast cysts

❑Cysts are benign (non-cancerous) lumps in the breast that are filled with fluid. The fluid may be yellow, green or very dark.

❑There may be microcysts (very small cysts) or macrocysts (larger cysts). Macrocysts are larger than 1 cm and may be felt as a lump. Usually, small cysts
can only be seen on a mammogram and ultrasound scan.

❑The cysts may not be distended with fluid in which case they are soft. A cyst is like a balloon. The more it is filled up, the more it is palpable. If it is only
partially filled, it may not be palpable as it is soft. Therefore, it is possible to have large cysts that cannot be felt.

➢Cysts are associated with shrinkage of the lobes of the breast (involution). This occurs with age so cysts commonly occur in women in their 40s. One in
ten women will get cysts that can be felt at some point in their lives. Even more will have cysts on a mammogram or ultrasound scan.

➢Cysts cause anxiety because the woman may fear she has cancer. The cyst may also be tender.

➢If they are untreated, they tend to disappear after menopause. Women who are on HRT (hormone replacement therapy) may continue to get cysts.

➢As they generally occur in women over 40 years of age, they should have a mammogram to make sure they are simple cysts. It must not be assumed on
clinical examination alone that a breast cyst is benign.

➢The most important thing is to make a diagnosis and make sure it is not a cancer. Some cysts should be aspirated.

➢Not all cysts need to be aspirated. However, a cyst should be aspirated if:
• It is palpable.

• It looks unusual on the ultrasound scan or mammogram.

• It is hard and tender. Draining the cyst provides relief to the patient.

➢A 23G needle can be put into a cyst to drain it. This is called fine needle aspiration (FNA). It will provide relief for the woman if it is a painful cyst and will
also give an instant diagnosis. If the fluid is not blood stained, it does not need to be sent off for cytology. Blood from a cyst indicates that the cyst may be
malignant. All bloody fluid must be sent for histology.

Painful breasts

➢Mastalgia means tender or painful breasts.

➢Over 70% women will get mastalgia at some time in their lives. It is nearly always associated with normal breasts. It is commonest in adolescence and in
women in their 40s.

➢If women are not taking HRT and are over 40 years of age, they may not have mastalgia but may have musculoskeletal pain (pain in the muscles or joints).

➢The pain is commonly in the upper outer quadrant of the breast as that is where most of the breast tissue is. The classic history is that pain increases
before the menstrual period and gets better afterwards. This is so-called cyclical mastalgia.

➢Women over 40 should have a mammogram. Although cancer is very rarely associated with mastalgia, many women will not feel better until they know
they have not got cancer.

➢Breast cancer is not a cause of mastalgia except in obvious and advanced cases. Painful breasts
➢Most women with mastalgia are concerned that they have breast cancer. Thoughtful and appropriate reassurance of this concern is the key treatment for
mastalgia. Mastalgia is not a disease that requires medical intervention and medication.

➢Beside reassurance, the best common-sense advice is for the woman to get a new bra! Nearly half of all women wear the wrong sized bra. Bras are
expensive but they are cheaper than doctors. Most women will be relieved if they know they have not got cancer.

➢If there is no improvement, lots of remedies have been tried. The only drugs that have been shown to work are non-steroidal anti-inflammatory agents
e.g. Brufen and Voltaren. They should ideally be given as a skin cream to rub onto the painful area so there are no side effects. Antibiotics and diuretics
have no role.

Non-cancerous changes of the nippleareola complex

➢Changes under the nipple and areola (nipple-areola complex) include:

❑Duct ectasia and periductal mastitis

❑Nipple problems

❑Nipple discharge

Duct ectasia

➢Duct ectasia is the dilatation of the ducts under the nipple-areola complex. It is part of the normal ageing process of the breast. Normally the ducts are
about 1 mm in diameter. However, with age, they become wider and blocked.

➢Although it is generally seen in older women, it may present at a younger age.

➢These changes are normal with ageing and usually do not cause problems.

➢Periductal mastitis (PDM) is an inflammatory condition of the nipple and retroareolar region. This commonly results in localised sepsis with small
abscesses, scarring and purulent drainage from the nipple. The nipple may be pulled in which can cause an inverted nipple. The problem with periductal
mastitis is making the diagnosis.

➢Ductal ectasia and periductal mastitis are important, as many of the features caused by these conditions are similar to the changes found with cancer.
Ductal ectasia may result in periductal mastitis.

Who gets ductal ectasia and periductal mastitis?

➢Generally, women in their 60s but much younger women may get the same changes.

➢A lump under the areola. These may be fluid filled and tend to disappear.

➢An abscess next to the areola.

➢An inverted nipple.

problems can be caused by ductal ectasia and periductal mastitis

What should be done?

➢All women over 40 should have a mammogram and the fluid from the discharge should be sent off for cytology.

➢Most women will need to be sent to a breast unit for a diagnosis to be made as ductal ectasia and periductal mastitis may mimic breast cancer.

Is nipple inversion always abnormal?

➢Nipple inversion (turned or pulled inwards) is usually normal. It is only abnormal if a nipple used to be everted (sticking out) and becomes inverted.

Nipple problems

Common nipple problems:

❑Cracked nipples

❑Keratin pearl

❑Eczema of the nipple

❑Nipple pain

❑Nipple polyps

1.cracked nipples
➢This is very common in breastfeeding mothers. It may cause pain with breastfeeding and can result in mastitis or an abscess. A little breast milk should be
left on the nipple at the end of each feed. The nipple must be kept dry between feeds. If it becomes a problem, antibiotic cream can be applied.

2.keratin pearl

➢A keratin pearl is a small yellow bead which appears on the nipple. This is very common and requires no treatment.

3.nipple pain

➢This is particularly common in breastfeeding women or women around the time of menopause. In breastfeeding women, it may be caused by a cracked
nipple or an infection. The commonest organisms causing infection are Candida or Staphylococcus. They should be treated with an antifungal or an
antibacterial cream.

➢The cause of nipple pain around the time of menopause is not known and women should be reassured after they have had a normal mammogram. It is
important to examine all women with nipple pain.

Nipple discharge

➢One in five women can squeeze a small amount of fluid from the nipple. The discharge is usually either greenish in color or thick (like toothpaste). This is
normal and does not need to be investigated.

➢However, a discharge that occurs on its own without squeezing the nipple may not be normal especially if there are large amounts of discharge.

➢Four types of fluid are commonly discharged from the nipple:

❑Milky fluid. This is normal around the time of breastfeeding. It may continue for a long time after breastfeeding has finished and is commonly from both
breasts. If it is completely unrelated to pregnancy, a serum prolactin level should be done.

❑Greenish or brownish fluid. Commonly causes by ductal ectasia. This is generally thin and is from more than one duct. It is abnormal if it leaks out of the
nipple spontaneously and the woman has to wear a breast pad.

❑Bloody fluid. There is always a pathological cause for bloody discharge from the breast. Often, the cause is not cancerous but all women with a bloody
discharge need a mammogram and, if possible, an ultrasound scan.

❑Watery colorless fluid. This should be treated the same as bloody fluid.

Nipple discharge

➢Greenish fluid that appears after squeezing the breast needs no investigation. Milky fluid also does not need testing.

➢Bloody fluid or watery fluid should be put on a slide and sent for cytology.

➢All women with bloody or watery fluid need a mammogram and an ultrasound scan.

➢If no lumps are found on mammogram or ultrasound scan, all women with a watery or bloody discharge should have a duct exploration.

What should be done nipple discharge?

➢10% of women with a bloody or watery discharge will have a cancer causing the discharge. This percentage is much higher if there is also a breast lump.

➢The commonest cause of a bloody discharge is an intraductal papilloma. The discharge is usually from one duct only.

Intraductal papilloma

➢An intraductal papilloma is a growth in a duct. The closer the growth is to the nipple, the more likely it is to be non-cancerous. The further away from the
nipple, the more likely it is to be a papillary cancer. All intraductal papillomas need a histological (tissue) diagnosis. This usually means removal of the
papilloma.

➢An intraductal papilloma generally presents with bleeding from a single duct. Infections of the breast

➢They may be caused by any of the following:

❑An associated condition or abnormality in the breast

❑An abnormality in the immune system

❑A particular pathogen (organism causing the infection)