Author: Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

Mastodynia / Breast Pain / Mastalgia

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Breast pain (mastalgia) is common in women and occasionally occurs in men
  • Although it is usually mild and self-limited:
    • Approximately 15% of affected women require treatment
  • Evaluation of breast pain is important to determine whether the pain is due to:
    • Normal physiological changes related to hormonal fluctuation or to a pathologic process such as breast cancer
  • Breast pain:
    • Is a rare symptom of breast cancer
  • Women who present with breast pain but who have a normal exam and imaging studies:
    • Can be reasonably assured that their risk of breast cancer is:
      • Similar to that of a woman without breast pain
  • While cyclical breast pain has traditionally been attributed to fibrocystic changes, chronic cystic mastitis, and mammary dysplasia:
    • Breast pain and nodularity are so common that the term fibrocystic “disease”:
      • Has become obsolete:
        • It should no longer be used
  • Epidemiology:

    • Breast pain is common:
      • Up to 70% of women in Western societies:
        • Will experience it sometime during their lives
      • One study of almost 1700 women (mean age 34 years) surveyed by online questionnaire:
        • Found that over one-half (51.5%) had experienced breast pain
    • Pain was more commonly reported among:
      • Older women
      • Those with larger breast sizes
      • Those less fit and / or physically active
    • Among women who reported symptoms:
      • 41% and 35% reported negative impacts from breast pain on their sexual health and sleep, respectively
    • 10% of those symptomatic had reported breast pain as an issue for over half of their lives
  • The prevalence of breast pain appears to depend on the population studied:
    • Breast pain is less common in Asian cultures:
      • Affecting as few as 5% of women
  • Classification and etiology:
    • Breast pain can be classified into three categories:
      • Cyclical
      • Noncyclical
      • Extramammary
    • Clinically it is more important to differentiate between extra mammary and true breast pain than between cyclical and noncyclical pain:
      • This is because management of cyclical and noncyclical breast pain is similar:
        • While extramammary pain may require a different treatment
  • Cyclical breast pain:
    • Affects two-thirds of patients with true mastalgia
    • Cyclical pain is associated with hormonal fluctuations of the menstrual cycle:
      • Usually presenting in the week prior to onset of menses
    • It is frequently bilateral and most severe in the upper outer quadrant of the breasts
    • Minor cyclical breast discomfort is normal:
      • It begins during the late luteal phase and dissipates with the onset of menses
      • This is usually bilateral and diffuse pain
      • Cyclical breast discomfort is caused by normal hormonal changes associated with ovulation:
        • That stimulate the proliferation of normal glandular breast tissue and result in pain
    • The stimulation of ductal elements by estrogen, stimulation of the stroma by progesterone, and / or stimulation of ductal secretion by prolactin:
      • All contribute to cyclical pain during the menstrual cycle
    • Cyclical breast pain can also be associated with pharmacologic hormonal agents:
      • Postmenopausal hormone therapy
      • Oral contraceptive pills
  • Noncyclical breast pain:
    • Affects one-third of women with true mastalgia
    • The pain does not follow the usual menstrual pattern:
      • May be constant or intermittent
      • More likely to be unilateral and variable in its location in the breast
    • Noncyclical breast pain is more likely to be related to:
      • A breast or chest wall lesion
    • Possible etiologies include:
      • Large pendulous breasts:
        • May cause pain due to stretching of Cooper’s ligaments
        • Neck, back, shoulder pain and headache may be present, as well as a rash under the pendulous breast in the inframammary fold
      • Diet, lifestyle:
        • A high-fat diet, smoking, and caffeine intake have been associated with breast pain:
          • It is difficult to conduct randomized trials with appropriate blinding that will negate the placebo effect
        • Hence, there is currently no high-quality evidence to suggest that a low-fat diet, smoking cessation, or caffeine avoidance reduces breast pain
      • Hormone replacement therapy :
        • Up to one-third of menopausal women receiving postmenopausal hormone therapy experience some degree of noncyclical breast pain:
          • Which may spontaneously resolve over time
      • Breast cysts:
        • Solitary cysts:
          • Particularly when the presentation is abrupt, are frequently painful
      • Ductal ectasia:
        • Is characterized by distention of subareolar ducts:
          • Due to inflammation unrelated to infection
          • Ductal ectasia may be associated with fever and acute local pain and tenderness:
            • Caused by penetration of the duct wall by lipid material:
              • Which may resolve to leave a subareolar nodule
          • In one study, the site and degree of duct dilatation correlated with the intensity of noncyclical breast pain
      • Mastitis:
        • Mastitis or breast abscess typically presents as a painful, swollen, and red breast in a febrile woman
        • Mastitis is more prevalent during lactation but can also occur in nonlactating women:
          • Idiopathic granulomatous mastitis [IGM] or smokers
      • Inflammatory breast cancer:
        • Women with de novo inflammatory breast cancer (primary disease) may present with:
          • Pain and a rapidly progressing tender, firm, enlarged breast
        • The skin over the breast is warm and thickened, with a “peau d’orange” (orange skin) appearance, but there is often no fever or leukocytosis
      • Hidradenitis suppurativa:
        • Although primarily confined to the axilla:
          • Can involve the breast and present as breast nodules and pain
      • Other etiologies of breast pain include:
        • Pregnancy
        • Thrombophlebitis (Mondor’s disease)
        • Trauma
        • Macrocysts
        • Prior breast surgery
        • A variety of medications:
          • Hormones as well as some antidepressants, cardiovascular agents, and antibiotics
  • Extramammary pain:
    • Some women who present with breast pain actually have referred pain from sources other than the breasts
    • The breast is innervated by:
      • The anterolateral and anteromedial branches of the intercostal nerves (T3 to T5):
        • Irritation of these nerves anywhere along their course can lead to pain that is felt in the breast or nipple
    • In some studies done in primary care and certain breast clinic settings, it has been found that women presenting with breast pain:
      • More often have extramammary pain rather than true mastalgia
    • Extramammary pain may be from:
      • Musculoskeletal sources such as the chest wall, spinal or paraspinal disorders, trauma, or scarring from prior biopsy
      • It may also be related to medical problems such as biliary, pulmonary, esophageal, or cardiac disease
    • Chest wall pain:
      • Is frequently due to pectoralis major muscle injury, related to repetitive activities such as water skiing, raking, rowing, or shoveling
      • Chest wall pain that presents as bilateral parasternal discomfort can also arise from:
        • Costochondritis:
          • Typically the second through fifth costochondral junctions
        • Tietze syndrome:
          • Typically the second and third costochondral junctions
      • Other etiologies of chest wall pain include:
        • Slipping and clicking ribs and arthritis
    • Spinal and paraspinal disorders:
      • Radicular chest wall pain may be due to:
        • Cervical arthritis:
          • This pain typically occurs in older women in whom vertebral, spinal, and paraspinal problems in the neck and upper thorax accumulate with age
        • Paraspinal muscle spasm and other impingements on the free course of the sensory nerves from the neck and upper thorax:
          • Can cause a radiculopathy leading to pain or hyperesthesia
          • Burning pain, which is typical of nerve root pressure, is a common feature
        • Imaging studies of the neck may reveal the etiology of the pain
    • Trauma:
      • Breast pain can be caused by local trauma, such as seat belt injury, child or pet kicking, or intimate partner violence, to the breasts or anterior chest wall
      • Pain can also be caused by intercostal neuralgia due to a respiratory infection or underlying pleuritic lesions
      • Additionally, gallbladder disease or ischemic heart disease may present as intermittent chest pain attributed to the breast
    • Postthoracotomy syndrome:
      • Is an unusual disorder in which a healing chest wound simulates the effect of a suckling infant
      • It can be associated with:
        • An elevated prolactin concentration
        • Breast pain
        • Milk production
      • A similar effect can be seen with other forms of chest wall irritation, including burns and chafing from clothing overlying the nipple
  • History:
    • It may be helpful to ask women with cyclical pain to record the occurrence and severity of breast pain in a diary and note potential aggravating and ameliorating factors
    • Questions the patient should be asked about her pain include:
      • Where in the breast or axilla does the pain occur?
      • Is the pain bilateral?
      • What does the pain feel like?
      • How severe is the pain?
      • If premenopausal:
        • Is it phasic, with peaks at midcycle and premenstrually?
      • Is it associated with use of oral contraceptive pills or hormone replacement therapy?
      • Did it begin after a recent birth or pregnancy loss or termination?
      • Is it related to vigorous or repetitive use of the pectoral muscle group?
      • Is there a concurrent neck, back, or shoulder problem?
      • Are there systemic or other local symptoms, such as fever or erythema?
      • Is there a history of recent trauma to the chest?
      • Does the pain affect her ability to perform daily activities?
    • In addition, a complete medical and surgical history and systematic review of systems should be obtained. Breast cancer risk should be assessed
    • Chest wall pain is often lateral and may be burning or knifelike, and localized or diffuse
  • Physical examination:
    • Breast:
      • The breast should be examined for signs of inflammation or infection, which would suggest an etiology of mastitis.
      • Mastitis typically presents as a painful, swollen, and red breast in a febrile woman.
      • Mastitis is more prevalent during lactation but can also occur in nonlactating women
      • The key point in examining a woman with breast pain is to look for signs suggestive of breast malignancy:
        • Such as a mass, skin changes, or bloody nipple discharge
      • The four breast quadrants, subareolar areas, axillae, and supraclavicular and infraclavicular areas should be systematically examined with the woman both lying and sitting with her hands on her hips and then above her head
      • The specific goals of the examination are to:
        • Check for skin changes, noting the symmetry and contour of the breasts, position of the nipples; scars; skin retraction; dimpling; edema or erythema; ulceration or crusting of the nipple; and changes in skin color
        • Check for enlarged or tender axillary, supraclavicular, or infraclavicular lymph nodes
        • Delineate and document breast masses
        • Check for nipple discharge
        • Identify localized areas of tenderness and relate them to areas of pain noted by the woman and to other physical findings
        • Women found to have a palpable breast mass, skin changes, or bloody nipple discharge should be referred to a breast specialist for further evaluation and imaging to treat or exclude breast cancer
    • Chest wall:
      • Physical exam should also aim at differentiating true breast pain from extramammary pain
      • Features of breast pain that suggest an extramammary origin include:
        • Unilateral, and brought on by activity
        • Located very lateral or medial in the breast
        • Reproducible by pressure on a specific area of the chest wall
        • To specifically look for chest wall pain, women may be asked to lie on each side:
          • These positions enable the breast to fall away from the chest wall, which permits palpation of the underlying chest wall muscles and ribs
        • Women with pain in the lower aspect of their breast should have the breast elevated with one hand and the underlying chest wall palpated with the other
      • Chest wall pain due to pectoralis major muscle injury can be reproduced by asking the patient to place her hand flat on the iliac wing and push inward
      • Women found to have chest wall pain can be reassured that there is no serious underlying cause for the pain, and they can be treated according to the symptoms
  • Imaging:
    • For most women who present with breast pain, a thorough history and physical examination must be performed, and clinical judgment must be used in deciding upon any diagnostic imaging studies
    • Suspicious physical findings present:
      • Women of any age who have suspicious physical findings such as a mass, skin changes, or bloody nipple discharge should undergo:
        • Mammography with or without ultrasound
    • Suspicious physical findings absent:
      • Assuming they are up to date with breast cancer screening, women who have breast pain but no other suspicious findings on physical exam:
        • May undergo breast imaging selectively based on their presentation and age
          • Breast imaging, even with a negative result, has been credited with alleviating patient anxiety
          • Seeking reassurance is often cited as the main reason for imaging in patients with breast pain
          • Many women do not seek further medical attention after assurance that their pain is not due to breast cancer
      • The imaging modalities most commonly used in these clinical scenarios are breast ultrasound and mammography
      • There are no data to suggest the use of breast magnetic resonance imaging (MRI) for this patient population
      • In a case-control study, there was no difference in breast cancer incidence in women undergoing mammography for a painful breast (0.5%) compared with the contralateral nonpainful breast (0.5%) and compared with women without breast pain (0.7%)
    • Three studies of ultrasound for focal breast pain without a palpable mass detected cancer in 0%, 1.2%, and 4.6% of patients
    • The American College of Radiology Appropriateness Criteria guidelines recommend the following approach to selecting an imaging modality:
      • Women with cyclical or bilateral nonfocal breast pain:
        • Usually do not require imaging:
          • The yield of finding a specific cause with imaging is low
      • Women with noncyclical, unilateral, or focal breast pain that is not extramammary (eg, chest wall pain), as determined by physical exam:
        • Should undergo breast imaging to elucidate the underlying etiology and exclude breast cancer
      • The choice of imaging modality is based on age:
        • Women under 30 years of age:
          • Should undergo ultrasound because it is more accurate than mammography for that age group
          • Mammography is added if abnormality is found on the ultrasound and/or if a patient’s history or risk status justifies the radiation exposure
        • Women between 30 and 39 years of age:
          • Should also undergo ultrasound
          • Unilateral or bilateral mammography should also be performed because in this age group some small cancers are found on mammography but not ultrasound
        • Women age 40 and older:
          • Should undergo both mammography and ultrasound
      • For women who have breast pain but no abnormality on physical examination or imaging studies:
        • The risk for breast cancer is low at approximately 0.5%
  • Treatment:
    • After obtaining normal findings on clinical and imaging studies, reassurance is often all that is required:
      • A simple assurance that the patient does not have breast cancer provides adequate relief for 78% to 85% of women
      • Such patients would also benefit from a follow-up visit in two to three months to exclude or treat recurrent/persistent pain
    • For some women, however, breast pain can cause problems with their activities of daily living:
      • As an example, in a study of 1171 healthy premenopausal women:
        • 11% reported moderate-to-severe pain that interfered with sexual activity (48%), physical activity (37%), social activity (12%), and school activity (8%):
          • Consequently, these women required treatment for their breast pain
    • Approximately 15% of women seen in the breast clinic for breast pain:
      • Require treatment beyond simple reassurance
    • Breast pain is treated:
      • Medically
    • Breast surgery is not indicated to treat pain:
      • In the absence of any breast pathology
    • First-line therapy:
      • First-line therapy for breast pain is conservative and typically includes:
        • Reassurance that this is not a malignancy
        • Physical support
        • Over-the-counter analgesics
        • Manipulation of hormone-based medications for those who take them
    • I prefer to treat with first-line therapy for six months before moving onto one of the second-line therapies:
      • Which may be more effective but also have more side effects
    • Some practitioners also endorse therapies such as caffeine abstinence or evening primrose oil (EPO):
      • Although such therapies have not been proven effective by vigorous placebo controlled trials:
        • They are generally harmless and may provide relief for some patients
    • Physical support:
      • Support garments:
        • A well-fitting brassiere to better support the breast is widely advocate
        • The use of a support bra with steel underwire tends to reduce mastalgia in women with pendulous breasts
        • In addition, use of a “sports bra” during exercise has been shown to reduce pain related to breast movement
        • Wearing a soft, supportive bra at night stops the breast pulling down on the chest wall, supports tender breast tissues, and helps many women sleep
        • Women with asymmetric breasts may benefit from specialized fitting to place extra padding on one side, which permits appropriate support of that side without overcompressing the contralateral side
      • Compresses:
        • Some women obtain relief from application of warm compresses or ice packs or gentle massage
        • For those who breast feed:
          • Ice packs are recommended during the obstructive (prebacterial) phase of puerperal mastitis:
            • To decrease milk production regionally and thereby relieve ductal intraluminal pressure and subsequent pain
    • Acetaminophen or NSAID:
      • Can be used to relieve breast pain
      • Topical NSAIDs may also be useful:
        • While the weaker types of topical NSAID (eg, ibuprofen gel) may not be effective in relieving breast pain
        • Data from randomized trials demonstrated significant improvement in those treated with diclofenac gel with minimal side effects
        • In the United States (US), two types of topical NSAIDs are available:
          • Salicylate, the active ingredient in aspirin, is found in Aspercreme and Nuprin
          • Diclofenac, which has the same active ingredient as the oral NSAID, is available as a patch, gel, or topical solution
    • Second-line therapy:
      • Treatment with one of the second-line therapies may be required in patients who still have debilitating breast pain despite first-line therapy for six months
      • Some physicians prefer to use tamoxifen first because it has fewer side effect than danazol
      • Treatment with tamoxifen or danazol for one to three months, until either pain subsides or side effects increase
      • Tamoxifen:
        • For patients with more severe mastalgia refractory to other treatments, tamoxifen can provide breast pain relief
        • A meta-analysis of three randomized trials found tamoxifen to be more effective in relieving breast pain than placebo (relative risk 1.92, 95% CI 1.42-2.58)
        • Tamoxifen is effective at both doses of 20 mg daily and 10 mg daily:
          • The side effects are significantly reduced at the lower dose
          • Thus, when used off-label to treat severe mastalgia, tamoxifen is usually given at 10 mg once daily for three months
        • However, tamoxifen is associated with menopause-like symptoms such as:
          • Hot flashes:
          • Vaginal dryness
          • Joint pain
          • Leg cramps
        • It can also increase the risk of:
          • Blood clots
          • Strokes
          • Uterine cancer
          • Cataracts
        • Thus, tamoxifen is infrequently used to treat mastalgia
        • Restricting tamoxifen to the luteal phase of the menstrual cycle has also been suggested to reduce side effects
      • Danazol:
        • Is an androgen, and for severe mastalgia, it is usually given at 200 mg once daily
        • It should be noted that since 2018, the US Food and Drug Administration (FDA) no longer approves the use of danazol for the indication of fibrocystic breast disease
        • Danazol is effective in relieving breast pain and tenderness:
          • According to a meta-analysis of four randomized trials against placebo, it resulted in a 20 point mean reduction in pain score on a visual analogue scale (VAS) of 0 to 100
        • However, the use of danazol is limited by its androgenic effects
        • At the recommended dose of 200 mg daily, significant proportions of patients reported side effects such as:
          • Weight gain (30%)
          • Menstrual irregularity (50%)
          • Deepening of the voice (10%)
          • Hot flashes (10%)
        • Restricting the use of danazol to the luteal phase of the menstrual cycle reduces the side effects without compromising its effectiveness
    • Women on hormone-based medications:
      • Postmenopausal hormone therapy that causes breast pain should be decreased or discontinued if at all possible:
        • This should only be done if breast pain is intolerable and after discussing with the patient the risks and benefits or curtailing hormone replacement therapy
      • It is not clear whether oral contraceptives cause or relieve cyclical mastalgia:
        • Decreasing the dose of estrogen in an oral contraceptive regimen can be effective in controlling breast pain
      • In other studies, oral contraceptives can reduce breast pain severity and duration in some women with cyclical symptoms:
        • The impact of oral contraceptive pills on breast pain may largely depend on their compositions; alternatively, they may have different effects on different women
      • Progestogens also improve breast pain symptoms in some women:
        • While oral and topical (applied to the breast) progesterone did not show benefit in randomized trials:
          • A vaginal cream of micronized progesterone (4 g of vaginal cream containing 2.5% natural progesterone used from the 19th to the 25th day of the cycle for six cycles) reduced breast pain in 65% of women compared with 22% of controls in a trial
    • Therapies not proven by randomized trial data:
      • The role of diet and lifestyle in relieving cyclical breast pain is unclear, with a strong likelihood of a placebo response for many interventions
      • However, some practitioners feel that some of these treatments (eg, caffeine abstinence and evening primrose oil [EPO]) are worth trying because they are generally harmless and may offer some women pain relief
      • A low-fat (15% of calories), high complex carbohydrate diet has been effective in some observational studies and small randomized trials:
        • However, the trials could not be blinded, which may invite a placebo effect
        • Additionally, such low-fat diets are difficult to maintain beyond a few weeks
      • Elimination of caffeine has not been effective in controlled trials, although it seems to be helpful in some women
      • EPO or its active ingredient gamma linoleic acid (GLA) has been studied in multiple randomized trials of breast pain:
        • Despite early enthusiasm, neither has been shown to be effective beyond the placebo effect
      • Vitamin E has been shown in multiple randomized trials to be no better than placebo in the treatment of benign breast disease:
        • Thus, vitamin E should not be prescribed to treat mastalgia
      • Bromocriptine is a dopamine agonist that inhibits prolactin release:
        • Although bromocriptine is effective in relieving pain compared with placebo, it is less effective than danazol, and up to 80% of women develop side effects such as headaches and dizziness
        • Therefore, it is no longer used to treat breast pain
      • Several other drugs that affect estrogen or prolactin secretion (including bromocriptine and other gonadotropin-releasing hormone [GnRH] agonists) have been studied but are not advocated for use in patients with severe mastalgia, because of unfavorable side effect profiles
  • Investigational therapies:
    • Because of the unfavorable side effect profiles of the medications currently used to treat mastalgia (eg, danazol, tamoxifen), there is great interest in developing natural (herbal) products that could relieve breast pain:
      • However, the benefits of most of these products remain unproven due to a lack of vigorous testing in randomized trials
    • Phytoestrogens, such as genistein, isoflavones, and soy milk, have been investigated as treatments for breast pain:
      • Soy milk has been tested against cow milk in a controlled trial, and although an improvement of symptoms was noted in 56% of test subjects versus 10% of controls, the trial was criticized for noncompliance due to the unpalatable taste of the soy milk
    • Agnus castus, a fruit extract, has significantly lowered visual analogue pain scores against placebo in controlled trials and is well tolerated
    • Matricaria chamomilla (chamomile) extract has also improved cyclical breast pain on a visual analogue scale compared with placebo in a controlled trial
    • Chest wall pain:
      • For women diagnosed with chest wall pain, local heat and analgesics such as acetaminophen or NSAIDs may relieve pain, but most women do not require therapy beyond reassurance that the source of pain is muscle strain or articular
      • Patients should reduce or cease activities that brought on or aggravated their pain until the pain improves
      • In severe cases in which the pain is localized but not relieved by over-the-counter pain medications, a trigger point injection with a mixture of a local anesthetic and corticosteroid may bring relief for the patient and can be repeated as necessary
  • Prognosis:
    • In general, mastalgia has a natural history of remission and relapse, evidenced by the fact that improvement is seen in as many as 40% of women receiving placebo in randomized trials
    • The prognosis of women who have breast pain is variable and influenced by the age of onset of pain and whether pain is cyclical or noncyclical:
      • In one series, cyclical breast pain spontaneously resolved within three months of onset in 20% to 30% of women, but transient relapses were common
      • In another series, noncyclical breast pain spontaneously resolved in 50% of patients
    • Relief may be spontaneous or related to a hormonally mediated event:
      • Such as pregnancy or menopause
  • Associated conditions:
    • Breast pain is usually a symptom, not a diagnosis
    • Although most women who have breast pain will not have any associated conditions, some will, in which case their pain should be treated as a component of the associated condition
    • Premenstrual syndrome:
      • Is characterized by the presence of both physical and behavioral (including affective) symptoms that occur repetitively in the second half of the menstrual cycle and interfere with some aspects of the woman’s life
      • Breast tenderness is one of the common symptoms of PMS
      • A meta-analysis of 10 randomized trials of selective serotonin reuptake inhibitors (SSRIs) used in women with premenstrual symptoms showed SSRIs to be more effective than placebo at relieving breast pain
        • Thus, women who have breast pain or tenderness as a component of PMS may benefit from SSRIs
    • Breast cancer:
      • The presence of a breast cancer in a patient who presents with only pain is extremely low, ranging from 0.5% to 33.%
      • Breast pain may occur at the time of presentation of a breast cancer, although the pain is typically associated with adjacent benign, cystic breast tissue rather than the cancer
      • One caveat in retrospective studies is that recall of breast pain might be increased after the diagnosis of breast cancer
      • In addition, pain may also occur following the imaging and core biopsy of the cancer rather than being associated with the cancer itself.
    • Prior breast surgery:
      • Pain that develops after breast surgery is of a different etiology and treated differently from de novo breast pain

What is these Lesion in the Breast?

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • In a postmenopausal woman who is not taking hormone therapy:
    • The new development of a cyst would be uncommon
Diagnostic ultrasound images of nodular density
  • The lesion contains diffuse internal echoes:
    • So it is sonographically compatible with a complicated cyst
  • Low-grade carcinomas, especially ER+ tumors:
    • Grow slowly enough that one would not expect a mammogram 2 years earlier in such a patient to be completely normal
    • In addition, a low-grade carcinoma grows slowly enough to allow desmoplasia to occur:
      • Creating spicules
    • Low-grade carcinomas are less cellular than high-grade tumors, and have more collagen and less water:
      • These factors contribute to posterior shadowing:
        • Especially in lesions 1.5 cm or larger
    • A high-grade carcinoma:
      • Grows so rapidly that desmoplasia does not have time to develop
      • They are more cellular, evoke an inflammatory rather than fibroelastotic response, have more water content, and frequently have cystic or hemorrhagic necrosis:
        • All of these factors contribute to posterior enhancement rather than shadowing
  • Triple-negative breast cancer:
    • Can frequently be confused with a benign lesion on both mammogram and ultrasound due to its unique biological characteristics
    • Being a highly metabolically active cancer:
      • Its shape is usually round, oval and/ or lobulated, not spiculated like lower grade breast malignancies, and it often lacks an echogenic rim
    • As in other high-grade cancers, posterior acoustical enhancement rather than shadowing is seen
    • Astute sonographers will be able to demonstrate its low elasticity using specialized features on their ultrasound machine or by increasing transducer probe pressure
  • References
    • Dogan BE, Tumbull LW. Imaging of triple-negative breast cancer. Ann Oncol. 2012;23(Suppl 6):vi23-vi29
    • Kojima Y, Tsunoda H. Mammography and ultrasound features of triple-negative breast cancer. Breast Cancer. 2011;18(3):146-151.
    • Stavros AT. Ultrasound of solid breast nodules: distinguishing benign for malignant. In: Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004:445-527.
    • Wojcinski S, Soliman AA, Schmidt J, Makowski L, Degenhardt F, Hillemanns P. Sonographic features of triple-negative and non-triple-negative breast cancer. J Ultrasound Med. 2012;31(10):1531-1541.

Simple Breast Cyst

Rodrigo Arrangoiz MS, MD, FACS, FSSO

  • Although most of these lesions are benign:
    • The presence of a mass can cause significant anxiety because of the concern that the mass represents a cancer
  • A mass can be solid or cystic and is not always seen on a mammogram
  • An ultrasound of the breast:
    • Can determine whether a breast mass is cystic or solid
  • Cysts are most frequently seen in women who are 40 to 49 years old:
    • But they may be present at any age
  • Cysts are most often hormonally regulated and may occur in the perimenopausal period
  • Cysts on ultrasound:
    • Can be either simple or complex
  • Ultrasound is 90% to 100% accurate for characterization of benign cysts when strict criteria are used
  • Simple cysts:
    • Have a negligible risk of cancer, and current evidence indicates that a simple cyst does not need to aspirated:
      • Unless it is symptomatic, and no other work-up is necessary
  • Simple cysts on ultrasound are:
    • Anechoic, well circumscribed, with smooth walls and posterior enhancement, as depicted in the image
  • Complex cysts:
    • Have a very low malignancy rate (0.3%) and a 6-month follow-up ultrasound is reasonable
    • However, a complex cystic lesion with a significant solid component:
      • May have an associated cancer risk of up to 23%
    • Therefore, if the mass has a solid component:
      • A biopsy is indicated to rule out an associated malignancy
  • References:
    • Berg WA, Campassi CI, Ioffe OB. Cystic lesions of the breast: sonographic-pathologic correlation. Radiology. 2003;227:183-191.
    • Morrow M, Wong S, Vetna L. The evaluation of breast masses in women younger than forty years of age. Surgery. 1998;124:643-640.
    • Osborne MP, Boolbol S, Asad J. Benign conditions of the breast. In Kuerer H (ed.): Breast Surgical Oncology. New York, NY: McGraw-Hill; 2010:165-179.
    • Venta LA, Kim JP, Pelloski CE, et al. Management of complex breast cysts. Am J Roentgenol. 1999;173:1331-1336.
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Axillary Ultrasound in the Evaluation of Breast Cancer Patients

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Normal Axillary Lymph Node
  • A normal axillary lymph node (Image):
    • Is elliptical in shape (or bean shaped), and has a narrow, symmetrical, hypoechoic cortex surrounding an isoechoic to hyperechoic fatty hilum (mediastinum)
    • The cortex of a normal node is composed largely of lymphatic tissue and fluid-filled cortical sinuses:
      • Thus the hypoechoic echogenicity
    • The hilum contains alternating medullary cords and sinusoids that have innumerable acoustic interfaces:
      • Thus the higher degree of echogenicity
Metastatic Axillary Lymph Node. Another presentation of a metastatic node is an asymmetric cortex where the tumor can be seen invading the hilum with convex indentations that look like “rat bites”
Lymph node completely replaced with metastatic carcinoma obliterating the fatty hilum. Doppler shows more than a single blood vessel supplying the node.
  • When a lymph node is completely replaced with metastatic cancer:
    • It will be rounded, hypoechoic, and the hilum will be completely obliterated (Image)
    • Before the node reaches the stage of complete replacement:
      • It can have an asymmetric, thickened cortex, with an eccentric hilum (Image)
  • Another presentation of a metastatic node:
    • Is an asymmetric cortex where the tumor can be seen invading the hilum with convex indentations that look like “rat bites” (First Image)
  • A metastatic node can also have severe compression of a central hilum resulting in a slit-like central hyperechoic band (Image)
Severe compression of the hilum by metastatic carcinoma resulting in a “slit-like” central hilum
Lymph nodes with eccentric hila and asymmetric, thickened cortices.
  • Reactive nodes can be difficult to distinguish from metastatic nodes (Image)
Reactive node.
  • In general, benign causes of nodal enlargement:
    • Tend to thicken the cortex diffusely
  • In addition, it is not uncommon to have a metastatic node adjacent to a normal node:
  • But all nodes in a region tend to be reactive when the cause is benign
  • Finally, a reactive node has blood supply on Doppler examination through a single hilum, whereas metastatic nodes tend to have multiple transcapsular vessels
  • References
  • Rahbar H, Partridge SC, Javid SH, Lehman CD. Imaging axillary lymph nodes in patients with newly diagnosed breast cancer. Curr Probl Diagn Radiol. 2012;41(5):149-158.
  • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

Ultrasound Evaluation of a Solid Breast Nodule

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Stavros has proposed the following BIRADS categories for breast ultrasound (see Table 1)
Proposed BIRADS categories for breast ultrasound
  • The American College of Radiology classification subdivides category 4 into:
    • BIRADS 4a:
      • Which has a 2% to 10 % risk of malignancy
    • BIRADS 4b:
      • Which has a 10% to 50 % risk
    • BIRADS 4c:
      • Which has a 50% to 95% risk
  • BIRADS 5 has 95% or greater chance of malignancy
  • In evaluating a solid sonographic nodule:
    • One should first look for any of the 10 signs of malignancy:
      • If even one of them is present:
        • The lesion cannot be considered BIRADS 3
    • The 10 signs of malignancy include:
      • Shadowing
      • Hypoechoic echotexture
      • Spiculation
      • Angular margins
      • Thick echogenic halo
      • Microlobulation
      • Taller than wide
      • Duct extension
      • Branching pattern
      • Calcifications
  • Note that Stavros compares the echogenicity of lesions to that of breast fat, not breast parenchyma:
    • Therefore, a lesion with hypoechoic echotexture would be very hypoechoic if breast parenchyma is used as the reference
  • The hypoechoic lesion in the image does not have smooth margins but appears microlobulated
  • Regardless of whether the classification of Stavros or the American College of Radiology is used:
    • The risk of the lesion in this patient is not low enough to be considered BIRADS 3 nor high enough risk to warrant BIRADS 5:
      • Thus, it falls somewhere in the BIRADS 4 range:
        • Biopsy is required
  • References
    • D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. 5th ed. Reston, VA: American College of Radiology; 2013
    • Jales RM, Sarian LO, Torresan R, Marussi EF, Alvares BR, Derchain S. Simple rules for ultrasonographic subcategorization of BI-RADS®-US 4 breast masses. Eur J Radiol. 2013;82(8):1231-1235.
    • Stavros AT. Breast Ultrasound. Philadelphia, PA: Lippincott Williams & Wilkins; 2004.

Breast Density on Imaging Studies

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Women over age 40 with heterogeneously dense breasts or extremely dense breasts:
    • At average risk for developing breast cancer:
      • 12% to 13% lifetime risk:
        • Require only annual mammography
  • The decision to pursue additional imaging in patients with elevated risk should supplement but never entirely replace mammography
  • Use of screening ultrasound or MRI of the breast are appropriate for women at increased risk:
    • But the benefit remains to be determined in women of average risk for breast cancer
  • Breast fibroglandular composition:
    • Is defined by one of the following four descriptions:
      • Almost entirely fatty
      • Scattered areas of fibroglandular density
      • Heterogeneously dense
      • Extremely dense
  • The U.S. population distribution of breast density is as follows:
    • 10% almost entirely fatty
    • 40% scattered areas of fibroglandular density
    • 40% heterogeneously dense
    • 10% extremely dense
  • Women with heterogeneously dense or extremely dense breasts:
    • Are considered to have dense breasts:
      • Sensitivity of mammography decreases as breast density increases
      • Increased breast density not only has a masking effect, which may obscure masses:
        • But also serves as an independent risk factor for breast cancer
        • It has been reported that the increased risk:
        • May be as much as 4 to 6-fold
          • Estimates this high are obtained when comparing women with dense breasts to those with fatty replaced breasts
          • Since only 10% of women have fatty replaced breasts:
            • It makes more sense to make the comparison with women of average breast density
          • The relative risk for cancer in women with heterogeneously dense breasts compared with the average woman is approximately 1.2, and the relative risk for cancer in women with extremely dense breasts compared with the average woman is approximately 2.1
  • In general, breast density decreases with increasing age and increasing body mass index:
    • So it is not the absolute density that is a risk factor:
      • But the difference in the observed and expected density
  • Several states have passed legislation requiring women with dense breasts to be specifically informed of their breast density:
    • Such women are informed of the limitations of mammography in dense breasts and are instructed to discuss further management with their physicians
    • An informed decision regarding potential use of supplemental screening options, in addition to mammography, should be discussed, factoring in elements such as overall breast cancer risk as well as the positives and negatives of additional screening, including likelihood of additional benign biopsies
    • Guidelines for enhanced screening have been developed using lifetime risk calculations as calculated by models stressing family history, such as the Tyrer Cuzick Model, and not purely using breast density
  • References
    • 1. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA. ACR BI-RADS® Atlas: Breast Imaging Reporting and Data System, 5th ed. Reston, VA: American College of Radiology; 2013. 2. 3. Freer PE. Mammographic breast density: impact on breast cancer risk and implications for screening. Radiographics. 2015;35(2):302-315.
    • Brentnall AR, Harkness EF, Astley SM, Donnelly LS, Stavrinos P, Sampson S, et al. Mammographic density adds accuracy to both the Tyrer-Cuzick and Gail breast cancer risk models in a prospective UK screening cohort. Breast Cancer Res. 2015;17(1):147.
    • American College of Radiology. ACR statement on reporting breast density in mammography reports and patient summaries. https://www.acr.org/Advocacy-and-Economics/ACR-Position-Statements/Reporting-Breast-Density. November 26, 2017. Accessed July 16, 2020.
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Galactoceles

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Galactoceles:
    • Are milk retention cysts:
      • That result from a blocked milk duct
  • They present as cystic, sometimes very large masses:
    • During pregnancy, lactation, and after weaning
  • They are often painless unless they become infected
  • Initially, they contain milky fluid:
    • But over time, contents become thicker and more creamy or oily as the fluid is reabsorbed
  • Ultrasound is the primary diagnostic method
    • Typical findings include a:
      • Well-defined lesion with thin echogenic walls
      • The internal appearance consists of either homogeneous contents or heterogeneous contents with fluid clefts and anechoic rims
  • Management consists of:
    • Needle aspiration demonstrating milky contents:
      • Which both confirms the diagnosis and excludes malignancy
  • Surgical resection is reserved for:
    • Cases refractory to conservative management
  • References
    • Sawhney S. Petkovska L, Ramadan S, Al-Muhtaseb S, Jain R, Sheikh M.Sonographic appearance of galactoceles. J Clin Ultrasound. 2002;30(1):18-22.
    • Sabate JM, Clotet M, Torrubia S, Gomez A, Guerrero R, de las Heras P. Radiologic evaluation of breast disorders related to pregnancy and lactation. Radiographics.2007;27(Suppl 1):S101-S124.

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Less Frequent Mammography for Breast Cancer Survivors Has No Impact on Survival

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Certain breast cancer survivors can safely reduce the frequency with which they undergo surveillance mammography 3 years after surgery, according to findings presented at the 2023 San Antonio Breast Cancer Symposium
  • The results are important, because currently in the US, breast cancer survivors are told to undergo an annual mammogram every year for an indefinite period of time after their surgery:
    • In the UK, survivors routinely undergo an annual mammogram for the first 5 years after surgery then de-escalate to once every 3 years afterward for those aged 50 and older
  • These findings presented at SABCS suggest that survivors can get screened less frequently than current guidelines allow.
  • In the phase 3 Mammo-50 trial:
    • Researchers randomly assigned women who underwent curative surgery for breast cancer to one of two groups.
    • One was assigned to undergo a mammogram every year, and another received mammograms less frequently: once every 2 years for those who had breast-conservation surgery and once every 3 years for those who had mastectomies
    • After a 5-year follow-up period, the groups had similar rates of both overall survival (OS) and breast-cancer specific survival
    • The annual group had a breast-cancer specific survival rate of 98.1% and an OS of 94.7%, whereas the less-frequent group had a breast-cancer specific survival rate of 98.3% and an OS of 94.5%
    • The two groups also had similar recurrence rates:
      • 5.9% for the annual group and 5.5% for those assigned to less frequent screening
    • Although the researchers acknowledged that the de-escalation arm had a lower compliance rate than the annual arm:
      • At 69% compared with 83%, they added that a sensitivity analysis revealed this difference in adherence did not impact their final results
  • In a concurrent substudy evaluating the participants’ quality of life using four different validated questionnaires, researchers reported no differences between the two groups in the domains of distress, mental well-being, and other areas
  • Researchers acknowledged that the study was limited by the fact that it focused only on women older than 50 who were already cancer-free for at least 3 years
  • De-escalation of mammographic surveillance reduces the burden on the health care system, decreases the inconvenience for women having to undergo these mammograms, and reduces the associated stress of waiting for results:
    • The trial demonstrated that the outcomes from undergoing less frequent mammograms were no worse than undergoing annual mammograms for this group of women

Younger Postmenopausal Patients May Skip Adjuvant Radiotherapy After Early Breast Cancer Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Younger postmenopausal patients with low-risk, stage I HR-positive breast cancer and certain genetic markers may be able to safely forgo adjuvant radiotherapy:
    • According to study findings presented at the 2023 San Antonio Breast Cancer Symposium in Texas
  • In the IDEA (Individualized Decisions for Endocrine therapy Alone) trial:
    • 200 postmenopausal patients with stage I HR-positive, HER2-negative breast cancer:
      • All of whom had scores of 18 or less on the Oncotype DX recurrence assay:
        • Elected to skip adjuvant radiotherapy:
          • Provided they were willing to continue with endocrine therapy for 5 years
    • All participants were aged between 50 and 69 years and required to have a margin of 2 mm or more after breast-conserving surgery
    • The primary outcome:
      • Was the rate of disease recurrence at 5 years after surgery
    • Patients had a mean recurrence score of 11.2
    • Eighty-five patients had grade 1 tumors, whereas 109 had grade 2 tumors and 6 had grade 3 tumors
    • The tumors were a mean of 10 mm
    • The median follow-up was 5.21 years
    • Both the overall survival rate and breast-cancer survival rate were 100% at 5 years:
      • The researchers reported, with a 5-year freedom-from-recurrence rate of 99% (95% CI, 96-100):
        • However, 2 patients died after the 5-year follow-up period had expired
    • There were two breast cancer related events during the follow-up period:
      • One event, which occurred at the 21-month mark:
        • Was an isolated axillary recurrence:
          • This was treated with axillary dissection and breast irradiation as well as local irradiation
      • The other was an ipsilateral breast event:
        • Which occurred at 49 months and was treated with another breast-conserving surgery
    • Another 6 patients experienced recurrence after the 5-year follow-up period, the researchers reported:
      • Five of these were ipsilateral breast events, and one was an ipsilateral breast event with regional occurrence
    • For the entire follow-up period:
      • The crude rate of ipsilateral breast events was:
        • 3.3% (n = 2 of 60) for patients who were 50 to 59 years old
        • 3.6% (n = 5 of 140) for those who were 60 to 69 years old
      • The crude overall relapse rates in these age groups were 5% (n = 3) and 3.6%, respectively
  • These findings indicate that younger postmenopausal patients with stage I breast cancer who skip radiotherapy after breast-conserving surgery:
    • Have a very low risk of disease recurrence within 5 years:
      • However, 5 years is an early time point for this population, and longer-term follow-up of this study and others will be essential to determine whether this option can be safely offered to women in this age group
  • Reference:
    • Jagsi, R. Five-year outcomes of the IDEA trial of endocrine therapy without radiotherapy after breast-conserving surgery for postmenopausal patients age 50-69 with genomically-selected favorable stage I breast cancer. Abstract GS02-08. SABCS 2023.
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Radiation Changes in the Breast Seen on Mammogram

Rodrigo Arrangoiz MS, MD, FACS, FSSO
Right craniocaudad image.
Right mediolateral oblique image.
  • The mammogram:
    • Shows trabecular thickening and an increased thickness of the skin
  • Trabecular thickening:
    • Is an increased prominence of linear structures in the breast:
      • Primarily corresponding to Cooper’s ligaments
    • It is almost always seen in conjunction with skin thickening:
      • It indicates significant breast edema
    • It has a number of different causes, including:
      • Congestive heart failure
      • Renal failure
      • Venous or lymphatic obstruction
      • Diffusely infiltrating carcinoma
      • Radiation
    • When the cause is lymphatic obstruction:
      • The obstruction can be the result of surgery, radiation, or lymphatic invasion by cancer
  • Unilateral breast edema with increased trabecular and skin thickening:
    • Sometimes occurs with congestive heart failure
  • The pedal edema that develops during the daytime:
    • Decreases at night and the fluid accumulates in the dependent breast in patients who sleep on their side
  • References
    • Berg, WA, Birdwell RL, Kennedy A. Diagnostic Imaging: Breast. Salt Lake City, UT: Amirsys; 2006.
    • Verbelen H, Gebruers N, Beyers T, De Monie AC, Tjalma W. Breast edema in breast cancer patients following breast-conserving surgery and radiotherapy: a systematic review. Breast Cancer Res Treat. 2014;147(3):463-471.
    • Wratten CR, O’Brien PC, Hamilton CS, Bill D, Kilmurray J, Denham JW. Breast edema in patients undergoing breast-conserving treatment for breast cancer: assessment via high frequency ultrasound. Breast J. 2007;13(3):266-273.
    • Menta A, Fouad TM, Lucci A, Le-Petross H, Stauder MC, Woodward WA, et al. Inflammatory breast cancer: what to know about this unique, aggressive breast cancer. Surg Clin North Am. 2018;98(4):787-800.
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