Common Breast Problems

Miss Rachel Bright-Thomas obtained a first in medical sciences at Cambridge University and then did her clinical training at Oxford University. Rachel spent the next 13 years in surgical training, largely in London teaching hospitals, before moving home to the West Midlands. As part of her training she did a masters degree looking at gene therapy in the prevention and treatment of cancer. On the clinical front she spent her penultimate year in training in 1 of only 9 National Oncoplastic Breast Fellowships, learning how to use plastic surgical techniques to complement and enhance the results of breast cancer surgery.

An overview of the most common conditions that are treated by Rachel Bright-Thomas are detailed below. For information about any additional conditions or treatments not featured within the site, please contact us for more information. Rachel is recognised by all major insurance companies, and holds no financial interests in Spire Healthcare.



Breast Cancer
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Cancer occurs when cells in the body grow and divide in an abnormal way. It is not a single disease, even within breast cancer there are several subtypes but the diagnosis and treatment has common themes with subtle differences that will be outlined below. Additional excellent material on individual types of breast cancer can be found on the breast cancer care website.

What are the symptoms of breast cancer?

There may be no signs or symptoms. A breast screening mammogram may reveal a suspicious mass, which will lead to further testing. A woman may also find a lump or mass during a breast self-exam. The following are possible signs of breast cancer and should immediately be reported to your GP for further evaluation:

• Lump in the breast
• Thickening of the breast skin
• Rash or redness of the breast
• Swelling in one breast
• New pain in one breast
• Dimpling around the nipple or on the breast skin
• Nipple pain or the nipple turning inward
• Nipple discharge
• Lumps in the underarm area
• Changes in the appearance of the nipple or breast that are different from the normal monthly changes a woman experiences

How is breast cancer diagnosed?

At the breast clinic you’ll probably have three different tests, known as triple assessment, to help make a diagnosis. These are:

• a breast examination
• a mammogram (breast x-ray) and/or an ultrasound scan (which uses high-frequency sound waves to produce an image)
• a fine needle aspiration (FNA) or core biopsy

Any investigations will be done by Miss Bright-Thomas or her female colleague in the X-ray department. Any needle test required will be done using local anaesthetic so it won’t be painful but you will be advised to take some paracetamol or similar mild pain killers later in the day when the anaesthetic wears off.

Many women can be assessed, reassured and discharged on the first clinic visit. Even if this is not possible, and a biopsy is required, he results of these tests will be available and communicated to you within a few days after a full multidisciplinary team discussion with the radiologists (Xray doctors) and pathologists. You will be accompanied and supported during this time by our trained breast care nurse specialist.

What is the treatment for breast cancer?

Treatment for breast cancer is determined by the exact type of cancer and staging. Depending on the size and spread of the cancer, most women will undergo a combination of any of the following treatments:

Surgery to the breast
• Local excision if the size of the lump allows (called breast conserving surgery; lumpectomy or wide local excision) or
• Mastectomy if the lump is large relative to your breast size or if there are several abnormal areas within the breast

Surgery to the lymph nodes in the armpit
• Targeted removal of 1 or 2 lymph nodes for full assessment down the microscope (called a sentinel lymph node biopsy) if the initial ultrasound scan of the lymph nodes in your armpit is normal
• Removal of all of the lymph nodes in your armpit (called an axillary clearance) if you are found to have cancer cells within the lymph nodes before treatment begins.

Radiotherapy- Xray treatment - to the breast is used for all women who have breast conserving surgery and is used after a mastectomy where the cancer was large and high grade or with lymph node involvement. Sometimes the radiotherapy also covers the area above the collar bone as well.

Hormonal manipulation (tablets such as tamoxifen in pre-menopausal women or an aromastase inhibitor in women who have gone through the menopause) is used for at least 5 years in all women whose breast cancer cells show the oestrogen receptor on their. This is routinely tested for in the laboratory and these tablets are used in 85% of breast cancers. There is good information about the pros and cons of all the different tablet options on the breast cancer care website.

Chemotherapy is offered to women with breast cancers that are resistant to hormonal manipulation or where the risk of recurrence in the future is thought to be increased. Occasionally it can be useful to give chemotherapy before surgery in order to shrink down the size of a cancer to make breast conserving surgery easier. In some women it is not easy to assess the size of the benefit of chemotherapy. In this case you may be offered an additional test called the “Oncotype DX” test which is performed on the cancer after it has been removed from the body to better assess the size of the benefit to you.

Biologic therapies- such as Herceptin are used where the breast cancer cells express certain surface markers (such as the Her 2 receptor). Again further information on this is available on the breast cancer care website.

What is the prognosis (outlook) after breast cancer?

The outlook for breast cancer now is generally very good because of the combination of better pre-treatment assessment, great surgical techniques, targeted use of hormonal treatments, chemotherapy and biologic agents and the management of patients with a multidisciplinary approach. Miss Bright-Thomas is a core member of the Worcestershire Breast Multidisciplinary Team and has previously been it’s chairperson. She will ensure you have access to all the best treatment options available, including a full range of surgical and chemotherapy NHS trials should you be interested in this.

Types of breast Cancer

Invasive Ductal Carcinoma (IDC)

Also known as infiltrating ductal carcinoma, this cancer originates in the breast ducts and has invaded the fatty tissue of the breast outside of the duct. It is the most common form of breast cancer, representing 80 percent of all breast cancer diagnoses

Invasive Lobular Carcinoma (ILC)

Also known as infiltrating lobular carcinoma, this is the second most common form of breast cancer (10-15 %). ILC may present at a slightly older age than IDC and more commonly occurs in women with a family history of breast cancer. This type of cancer is more difficult to see on imaging because of the way it grows with spreading branches. Ladies with ILC will usually be offered an MRI scan of the breast before treatment to get as accurate an assessment of size as possible. The outlook of treatment for ILC is no worse than for any other type of breast cancer.

There are other breast cancer subtypes such as medullary carcinoma, mucinous carcinoma, tubular carcinoma and papillary carcinoma which may require minor modifications in treatment and Miss Bright-Thomas has experience in treating all of these subtypes.

Lobular Neoplasia or Lobular Carcinoma in situ (LCIS)

While lobular carcinoma in situ (LCIS) sounds like a type of breast cancer, it is really a risk factor or marker for an increased risk of developing breast cancer. It is often identified by chance in women in their 40s or 50s, following a biopsy for something else within the breast. It cannot normally be seen on a mammogram or felt on examination.

What can I do if I have LCIS in my breast?

First, there is no need to panic. LCIS simply means that we have identified that you may be at higher risk for developing breast cancer (approximately 7% at 10 years). The most important thing to do now is to contact Miss Bright-Thomas where your breast health can be closely monitored.

When lobular neoplasia is identified through breast screening women will generally be advised to have a small operation called an excision biopsy. This is surgery to remove more breast tissue, which will be examined under a microscope to be sure it is just LCIS and there is not a small associated infiltrating lobular carcinoma (seen in less than 1/3 of cases).

This operation is carried out under a short general anaesthetic. Miss Bright-Thomas will generally use dissolvable stitches placed under the skin which won’t need to be removed. However, if non-dissolvable stitches are used, they’ll need to be taken out a few days after surgery. You’ll be given information about this and about looking after the wound before you leave the hospital. The operation will leave a scar but this will fade over time.

You will be seen to check the wound and get the results of your laboratory analysis about a week after surgery. If there is only LCIS you are likely to be offered increased surveillance mammography, maybe annually to age 50 or 60, entry into a clinical trial to monitor you in the future or possibly the use of a tablet such as tamoxifen on a daily basis for 5 years in an attempt to reduce your risk of breast cancer in the future.
Breast cyst
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What is a breast cyst?

Breast cysts are a common cause of a breast lump. They are benign (non-cancerous ) lumps. They are spaces filled with fluid that occur in the breast. They are most common in women in their forties and fifties, approaching the menopause, or in women who use HRT after the menopause. Breast cysts can feel soft or hard and can be any size. They can develop quickly and can feel uncomfortable and even painful. However, many women have breast cysts and are completely unaware of them. Most importantly having a breast cyst does NOT increase your risk of subsequent breast cancer.

How are breast cysts diagnosed?

In the breast clinic you’ll probably have three different tests, known as triple assessment, to help make a diagnosis. These are:

• a breast examination
• a mammogram (breast x-ray) if you are aged 40 or over
• an ultrasound scan (which uses high-frequency sound waves to produce an image)

The diagnosis can be made immediately and you will be seen with and supported by an experienced breast care nurse on the day. She will also be a point of contact should you have any questions later on.

What is the treatment for breast cysts?

Most cysts don’t require any treatment or follow-up, and they often go away by themselves, although they can recur. If the cyst is particularly large or uncomfortable, this can be sometimes be helped by drawing off the fluid using a fine needle and syringe. This is generally well tolerated and only takes a few seconds to do.
Breast pain (or mastalgia)
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Breast pain provokes anxiety for many women but it is a common breast problem. It can often affect just 1 breast or 1 part of 1 breast, and often radiates into the armpit or even down the arm. It is rarely a sign of breast cancer. In fact, very few breast cancers are accompanied by pain. Breast pain and tenderness can be a very normal part of a woman’s life, particularly when she:
• Is lactating (producing milk to feed her baby)
• Just before a period
• Is premenopausal
• Is pregnant
• Is going on or off of hormone replacement therapy or birth control pill

Breast pain is generally split into cyclical and non-cyclical pain

a) Cyclical breast pain (70% of cases) tends to start about 1 week before your period is due and ease off after the period. There are theories that this is associated with deficient progesterone levels in this part of the monthly cycle, raised prolactin levels or differential breast responses to normal fluctuating hormone levels. It can often be helped with good bra fitting, use of ibuprofen or voltarol gel rubbed into the tender area or prescription medication in extreme cases. There is some suggestion that VERY Low fat diets may help but only 2 trials suggest this and these diets are often difficult to tolerate.
Some women find high dose evening primrose oil (3000mg daily for 3 months) helpful but the evidence supporting this is not strong and there is a possibility that some of the effect is a placebo effect.

b) Non-cyclical breast pain (30% 0f cases). This is more common in larger breasts and more common in those who exercise (>1/3 of women running the London Marathon). It often has a poor response to medical treatment but often resolves spontaneously after a variable period of time) – it can be due to:
1 Breast problems- breast cysts; periductal mastitis; fat necrosis; mondors syndrome; diabetic mastopathy or related to a simple lack of support for the suspensory ligaments of the breast
2 Problems in the underlying chest wall - such as minor muscle trauma; chostochondritiis (viral inflammation where the bony part of the ribs meet the rib cartilages near to the breast bone (sternum) ; rib fracture; arthritis in the back with nerve root irritation; nipple irritation from surfing or running.
3 Problems within the chest (in the underlying lung; heart problems; indigestion; acid reflux)
4 Medication- statins; theophylline; HRT in post-menopausal women
5 Post surgical breast pain- increasingly recognised in breast cancer survivors both in ladies who have had a mastectomy or a clearance of the lymph nodes in the armpit or after radiotherapy to the breast or chest wall.

Rachel and her team can help you to understand the cause of your breast pain and ensure that any underlying breast problems are dealt with. This may just require a clinical examination but some ladies may also be recommended to have a mammogram if over 40 years of age or a breast ultrasound scan. Our breast care nurse can also advise you on proper bra fitting and we can discuss various means of alleviating your breast pain.

70% of women wear the wrong bra—too tight or too loose—and this can create breast pain, as the breast tissue is unsupported throughout the day. It is important to be properly fitted for a bra so you wear the right size.
Diabetic Mastopathy
Diabetic mastopathy is an uncommon condition, presenting with hard, painless lumps in the breast. It is usually seen in pre-menopausal women (and occasionally men) with long standing Type 1 diabetes. It may be due to chronic damage to the breast tissue from persistently high blood glucose levels.

The diagnosis is made by triple assessment

What is the treatment?
Once the diagnosis is confirmed no specific treatment is required. Surgery is rarely recommended.
DCIS (Ductal carcinoma in situ)
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What is ductal carcinoma in situ (DCIS)?

DCIS is a VERY early form of breast cancer, where the cancer cells have developed within the milk ducts but remain there (so called ‘in situ’ ) as the cells don't have the ability to spread outside the ducts into the surround- ing breast tissue or to other parts of the body. So it is usually described as a pre-invasive, intraductal or non- invasive cancer. Both men and women can develop DCIS, however it is very rare in men. As a result of being confined to the breast ducts, a diagnosis of DCIS has a very good outlook.

What are the symptoms of DCIS?

DCIS often has no accompanying symptoms and it is usually identified on a mammogram. The image of the breast appears as though it has irregular calcium deposits (microcalcifications). However, some people may notice a change in the breast such as a lump, discharge from the nipple or more rarely, a type of rash involving the nipple (called Paget’s disease).

How is DCIS diagnosed?

If the radiologist (X-ray doctor) who read your mammogram suspects you have DCIS, he or she will arrange for you to have a mammographically guided (stereotactic) biopsy. The biopsy can often be done the same day, you will be given an idea of the most likely diagnoses and the biopsy report will follow within a few days.

What is the treatment for DCIS?

Local excision  with radiation therapy. Most patients have great success rates having a wide local excision (lumpectomy or breast conserving treatment ) and subsequent X-ray treatment to the breast. Rachel has great experience treating women diagnosed with DCIS through the breast screening programme (> 40 cases/year) with a variety of “oncoplastic” operations aimed to minimise any change in breast shape or size whilst giving first class cancer treatment.
Mastectomy. Some women have more extensive DCIS where a mastectomy may be the more appropriate surgical treatment instead of a lumpectomy. This would generally be accompanied with a lymph node biopsy from the armpit at the same time and is unlikely to require any additional radiotherapy afterwards. Mastectomy can often be accompanied by immediate breast reconstruction should this be required. Rachel can offer a range of immediate or delayed breast recon- struction techniques and works closely with several plastic surgeons if additional input is required.
Chemotherapy. Chemotherapy is not needed for DCIS, since the disease is noninvasive.
Hormonal Therapy. Hormonal therapy is only occasionally  recommended as part of a clinical trial if the DCIS expresses the oestrogen receptor on the surface of the cells.

What is the prognosis for DCIS?

Women with DCIS have an excellent prognosis. By treating DCIS in a specialist centre you ensure your health is in the best possible hands.

Following treatment for DCIS most women are offered annual screening mammograms for 5 years or to age 50 to monitor the opposite healthy breast. By definition, there is no risk of distant recurrence since the cancer is noninvasive.
Duct ectasia
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Duct ectasia is a benign (not cancer) breast condition. It’s caused by normal breast changes that happen with age, and it’s nothing to worry about. It normally presents with a change in shape of the nipple (nipple inversion) or nipple discharge.

Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), which are surrounded by fibrous and fatty tissue. As women get nearer to the menopause and the breasts age (from 35 years onwards) the ducts behind the nipple shorten and widen. This is called duct ectasia. Sometimes a secretion is produced and can collect in the widened ducts. This can cause nipple inversion. Some people also experience pain, although this is not common.

There can also be a discharge of these secretions through the nipple, which is usually thick but can also be watery. It can vary in colour, and can occasionally be bloodstained.

How is it diagnosed?

After your GP has examined your breasts you’re likely to be referred to a breast clinic and you will have a clinical examination, a mammogram if you are over 40 years of age, an ultrasound scan of the area behind the nipple and you are also likely to have a few drops of any nipple discharge put onto a slide to be looked at down the microscope. This is to rule out any other more worrying cause for the symptoms that you have.

Treatment

Most cases of duct ectasia don’t need any treatment as it’s a normal part of ageing and any symptoms will usually clear up by themselves. Try not to squeeze the nipple as this may encourage further discharge. In the meantime, if you have any pain you may want to take pain relief such as paracetamol.

If you continue to have discharge from the nipple (without squeezing) which doesn’t settle, or if the analysis of the nipple fluid shows any worrying features, you may be offered an operation to remove the affected duct or ducts, (a microdochectomy) or removal of all the major ducts (a total duct excision). The operation is usually done under a general anaesthetic, and you’ll be in hospital for the day, but sometimes you might have to stay overnight. You’ll have a small wound near the areola (darker area of skin around the nipple) with a stitch or stitches in it, and Rachel and your breast care nurse will tell you how to care for it afterwards.

You’ll be advised about which pain relief to take after the operation as your breast may be slightly sore and bruised. The operation will leave a small scar but this will fade in time. After the operation your nipple may be less sensitive than before, and for a few people it may become flattened or inverted. The operation should solve the problem but, as finding all the ducts can sometimes be difficult, your symptoms may return and you may need further surgery to remove more ducts. It’s important to go back to your GP if you have any new symptoms.

What is the prognosis for Duct Ectasia? Having duct ectasia doesn’t increase your risk of developing breast cancer in the future.

However, it’s still important to be breast aware and go back to your GP if you notice any other changes in your breasts, regardless of how soon these occur after your diagnosis of duct ectasia.
Fat necrosis
Fat necrosis is a benign (not cancer) condition and does not increase your risk of developing breast cancer. It presents with a firm lump in the fatty tissue of the breast which can be painful or painless and is sometimes associated with an overlying bruise. It often arises following minor trauma to the breast, following a needle biopsy, breast surgery (including breast reconstruction), or even radiotherapy. It is diagnosed with triple assessment of the breast.

Once the diagnosis is confirmed, there is rarely a need for any treatment. The lump may stay the same size but generally reduces or even disappears with time.
Fibroadenoma
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Fibroadenomas are solid benign (not cancerous) breast lumps that are common in young women (often in their late teens and twenties), although they can occur in women of any age. They are usually smooth, painless mobile rubbery lumps, but sometimes they can be tender, particularly just before a period. There can be more than one within the breast and they can increase in size during pregnancy and breastfeeding.

How are fibroadenomas diagnosed?

Miss Bright-Thomas and her team of specialists are incredibly sensitive to the anxiety a breast lump creates for her patients. Therefore, we follow strict triple assessment guidelines for evaluation. All women will have a clinical examination and ultrasound scan of the lump. Women over 40 will also be offered a mammogram.

All ladies over the age of 24 with a solid lump will have a needle biopsy to confirm the diagnosis. You will be contacted with the results of the biopsy within a week after a formal multidisciplinary team discussion.

What is the treatment for fibroadenomas?

If fibroadenomas are large or are causing the patient concern, they may require surgical removal, but this is rare. Many fibroadenomas stop growing or shrink over time.

When required, Rachel Bright-Thomas will aim to remove fibroadenomas with small incisions around the edge of the areola or at the outer or lower edge of the breast to minimise scarring. The surgery is done as a day case procedure with dissolvable stitches and minimal dressings.
Intraductal papilloma
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An intraductal papilloma is a benign (not cancer) breast condition. Intraductal papillomas are most common in women over 40 and usually develop naturally as the breast ages and changes.

Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), which are surrounded by glandular, fibrous and fatty tissue. Sometimes a wart-like lump develops (the papilloma) in one or more of the ducts. It’s usually close to the nipple, but can sometimes be found elsewhere in the breast.

You may feel a small lump or notice a discharge of clear or bloodstained fluid from the nipple. Generally intra- ductal papillomas aren’t painful but some women can have discomfort or pain around the area. They can also be identified with no symptoms through your routine screening mammogram.

Intraductal papillomas can occur in both breasts at the same time. Intraductal papillomas generally don’t increase the risk of developing breast cancer. However, when an intraductal papilloma contains atypical cells (which are abnormal but not cancer), this has been shown to slightly increase the risk of developing breast cancer in the future. Some people who have multiple intraductal papillomas may also have a slightly higher risk of developing breast cancer.

How are they found and treated?

Intraductal papillomas can be found by chance following routine breast screening (a mammogram or breast x-ray), after breast surgery or if you go to your GP (local doctor) with symptoms. You will then be referred to a breast clinic where you’ll be seen by a specialist, such as Miss Bright-Thomas, who will examine you and use additional simple investigations such as a mammogram and breast ultrasound scan as described in the “triple assessment” section.

Excision biopsy

If your investigations show a papilloma, Miss Bright-Thomas may want you to have an operation called an excision biopsy. This is surgery to remove more breast tissue, which will be examined under a microscope to exclude the small chance of any associated cancerous or pre-cancerous change and to stop any symptoms you may be having.

An excision biopsy is usually carried out under a general anaesthetic. Miss Bright-Thomas will use dissolvable stitches placed under the skin which won’t need to be removed. However, if non-dissolvable stitches are used, they’ll need to be taken out a few days after surgery. You’ll be given information about this and about looking after the wound before you leave the hospital. The operation will leave a scar but this will fade over time.

Follow-up

You will be seen to check the wound and get the results of your laboratory analysis about a week after surgery.

What this means for you

For most people, having an intraductal papilloma doesn’t increase their risk of breast cancer.

Even though your intraductal papilloma has been removed, it’s still important to be breast aware and go back to your GP if you notice any other changes in your breasts.
Mondor's disease
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What is Mondor’s disease

Mondor’s disease is a rare, benign (not cancer) breast condition. It can occur in women or men.

It is due to an inflammation of a vein (thrombophlebitis) just under the skin of the breast or chest wall and it looks and feels like a cord or string under the skin. This can be painless or tender. If the arm on the affected side is raised, it sometimes causes the skin overlying the inflamed vein to look pulled in or dimpled.

The cause of Mondor’s disease is often unclear, but it can occur as a result of vigorous exercise, an injury to the breast, following surgery or sometimes after a core biopsy. It may be more common in women on the oral contraceptive pill.

How is it diagnosed?

Your GP will examine your breast and is likely to refer you to a breast clinic where you’ll be seen by a specialist doctor or nurse, such as Miss Bright-Thomas. She may be able to confirm you have Mondor’s disease simply by examining you, but you are likely to be offered a mammogram and or a breast ultrasound scan to ensure that there is no other underlying breast problem.

Treatment

You won’t usually need treatment for Mondor’s disease as it will get better by itself and most importantly it DOES NOT increase your risk of breast cancer in the future. Any pain associated with it will usually only last for a couple of weeks, but the cord can remain for several weeks or months before it goes away altogether. It may be helped by using anti-inflammatory tablets or gel (ie ibuprofen).
Nipple discharge
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What is nipple discharge?

Nipple discharge may be common for premenopausal women who have had children or breast fed - especially milky discharge. This is usually due to normal hormonal changes within a woman’s body. It often occurs in both breasts.

There are some specific types of nipple discharge that warrant closer evaluation:

Bloody nipple discharge – If the discharge is bloody, a papilloma is suspected. This wart-like growth inside the duct can bleed. However, this can also be a symptom of breast cancer, so proper evaluation is recommended.
Clear nipple discharge – Clear watery or bloody discharge can be a sign of abnormal cells (including cancer cells) within the breast. Full evaluation in a breast clinic is recommended.

How will I be evaluated for nipple discharge?

After your GP has examined your breasts you’re likely to be referred to a breast clinic and you will have a clinical examination, a mammogram if you are over 40 years of age, an ultrasound scan of the area behind the nipple and you are also likely to have a few drops of any nipple discharge put onto a slide to be looked at down the microscope. This is to rule out any worrying cause for the symptoms that you have and to see if any underlying papilloma can be identified.

How will my nipple discharge be treated

Most of the time no treatment is required.

However, if the analysis of the nipple fluid shows any worrying features, you may be offered an operation to remove the affected duct or ducts causing the discharge and to be certain that there is no underlying papilloma or small cancer behind the nipple. The operation is usually done under a general anaesthetic, as a day case. You’ll have a small wound near the areola (darker area of skin around the nipple) with a stitch or stitches in it, and Rachel and your breast care nurse will tell you how to care for it afterwards.

You’ll be advised about which pain relief to take after the operation as your breast may be slightly sore and bruised. The operation will leave a small scar but this will fade in time. After the operation your nipple may be less sensitive than before and you will not be able to breast feed on that side. For a small percentage of people the nipple may also become flattened after the operation

The laboratory analysis of the tissue removed will usually be available within a week and the procedure is normally enough to stop the discharge. Obviously further treatment may be required if any cause for concern is found within the tissue that is removed.
Paget’s disease
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Paget’s disease is a rare type of breast cancer that occurs in the ducts adjacent to the nipple and areola and spreads to the skin of the nipple and the areola. Accounting for only one percent of breast cancers, it is a rare presentation.

About half of people presenting with Paget's disease of the nipple will have a separate associated area of DCIS or an underlying breast cancer elsewhere in the breast.

What are the symptoms of Paget’s disease?

• Redness and irritation of the nipple and/or areola
• Crusting and scaling of the nipple area
• Bleeding from the nipple/areola
• Oozing from the nipple/areola
• Burning and/or itching of the nipple/areola

How is Paget’s disease diagnosed?

As with all breast problems, triple assessment (using a clinical examination, mammogram, ultrasound and a biopsy of any abnormal looking tissue) is the key to making an accurate diagnosis. There is often a delay in diagnosing Paget's disease if women are wrongly treated for eczema of the nipple, so if you are concerned please seek advice from an expert like Miss Bright-Thomas who is used to dealing with problems like this. The results of a nipple biopsy should be available within a few days after the case has been discussed in a full multidisciplinary meeting (where Miss Bright-Thomas, the X-ray doctor and the laboratory specialist (pathologist) are all present.

What is the treatment for Paget’s disease?

If the breast cancer is limited to Paget’s disease, treatment includes the surgical removal of the nipple and areola, as well as a margin of healthy tissue around the areola. The nipple can often be reconstructed at the same time or later on. If there is any associated underlying breast cancer the treatment will need to be adjusted to take account of this.

What is the prognosis for Paget’s disease?

If the breast cancer is limited to Paget's disease, The prognosis is generally very good. If there is an associated second area of cancer within the breast the outlook will depend upon the details of this condition.
Periductal mastitis
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What is periductal mastitis?

Periductal mastitis occurs when the ducts under the nipple become inflamed and sometimes infected. It’s a benign condition (not cancer), which can affect women of all ages but is more common in younger women.

Symptoms include:

• the breast becoming tender and hot to the touch
• the skin may appear reddened
• discharge from the nipple, which can be bloody or non-bloody
• a lump near the nipple.
• a pulled-in (inverted) nipple.

Occasionally, an abscess (collection of pus) or fistula (a tract that develops between a duct and the skin) may develop.

People who smoke have an increased risk of being affected by periductal mastitis, because substances in cigarette smoke can damage the ducts behind the nipple. Nipple rings (piercings) can increase the chances of infection and make periductal mastitis more difficult to treat.

How is it diagnosed?

Your GP will refer you to Miss Bright-Thomas who can make a definite diagnosis. To do this you will probably have a breast examination, mammogram and/or ultrasound scan.

If you have discharge from the nipple a sample may be looked at under a microscope, especially if it’s bloody, to help confirm the diagnosis.

Treatment

Some people may not need any treatment for periductal mastitis as it can clear up by itself. However go back to your GP if your symptoms return or if you have any new symptoms. Smoking can slow down the healing process, so if you smoke it’s a good idea to try to cut down or to stop.

If you need treatment, this will usually be with antibiotics. You may also want to take pain relief, such as paracetamol, if your breast is painful.

If you have developed an abscess and/or a fistula, Miss Bright-Thomas will decide the best way to treat it. This may involve using a fine needle and syringe to draw off (aspirate) the pus, or sometimes an opening is made in the skin to allow the pus to be drained. This can be done under either local or general anaesthetic.

If periductal mastitis doesn’t get better after taking antibiotics or if it comes back, you may need to have an operation to remove the affected duct or ducts. However, we try to avoid surgery as there is at least a 50% chance of the problem recurring after surgery and the nipple can loose sensation, so the best option is normally to stop smoking first.

What is the prognosis for periductal mastitis?

Having periductal mastitis does not increase your risk of breast cancer. However, it’s still important to be breast aware and go back to your GP if you notice any further changes in your breasts regardless how soon these occur after having periductal mastitis.
Phyllodes tumor
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Phyllodes tumours are rapidly growing breast lumps that arise from an overgrowth of the connective tissue of the breast, rather than from the breast ducts. Most Phyllodes tumours are benign (non cancerous) , but a small percentage (<10%) are malignant (cancerous). These rare malignant phyllodes act more like a sarcoma than a standard breast cancer. They rarely spread elsewhere in the body.

What are the symptoms of Phyllodes tumours?

These tumours will usually present as a smooth, rapidly growing painless lump in the breast of pre-menopausal women, although they can occur at any age. Occasionally the skin can be red or discoloured over the lump but this is not common.

How are Phyllodes tumours diagnosed?

The standard approach of triple assessment (using a breast examination, a mammogram and/or an ultrasound scan of your breast and a needle core biopsy should make the diagnosis. More detailed information on this is given in the section on triple assessment.

What is the treatment for Phyllodes tumours?

While the tumours are most often benign, it is still critical to remove the entire tumour. Even if one cell is left behind, it can grow back. Treatment involves excision of both the tumour and a small margin of healthy tissue surrounding the tumour. You will not need any surgery to the armpit for a phyllodes tumour and it is unlikely that you will require any other treatment.

What is the prognosis (outlook) for Phyllodes tumours?

The prognosis is generally excellent. However, because phyllodes tumours can sometimes return within the breast, Miss Bright-Thomas may want to follow you up for a year or 2, usually once a year, with a clinical examination and a mammogram or ultrasound scan. If your tumour comes back, you’ll need to have further surgery.






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