In general, routine imaging is not indicated for women with noncyclic diffuse breast pain, although diagnostic mammography or DBT may be considered in women ≥ 40 years of age 14 (see “Less common diagnoses with breast pain”4,5,17-21).
SIDEBAR
Less common diagnoses with breast pain
Many women presenting with breast pain are concerned about malignancy. Breast cancer is an uncommon cause of breast pain; only 0.5% of patients presenting with mastalgia without other clinical findings have a malignancy.4 Mastalgia is not a risk factor for breast cancer.
When mastalgia is associated with breast cancer, it is more likely to be unilateral, intense, noncyclic, and progressive.5 Concerning features that warrant further evaluation include new onset focal pain with or without an abnormal exam. If symptoms cannot be explained by an obvious cause (such as trauma, costochondritis, radicular back or intercostal pain, herpes zoster, or superficial thrombophlebitis that does not resolve), diagnostic breast imaging is indicated.
Inflammatory breast cancer (IBC) is an aggressive form of breast cancer that initially presents with breast pain and rapidly enlarging diffuse erythema of the breast in the absence of a discrete breast lump. The initial presentation is similar to that seen with benign inflammatory etiologies of the breast tissue like cellulitis or abscess, duct ectasia, mastitis, phlebitis of the thoracoepigastric vein (Mondor’s disease), or fat necrosis.17 Benign breast conditions due to these causes will generally resolve with appropriate treatment for those conditions within 7 days and will generally not present with the warning signs of IBC, which include a personal history of breast cancer, nonlactational status, and palpable axillary adenopathy. Although uncommon (accounting for 1%-6% of all breast cancer diagnoses), IBC spreads rapidly over a few weeks; thus, urgent imaging is warranted.17
Mastitis is inflammation of the breast tissue that may or may not be associated with a bacterial infection and uncommonly occurs in nonbreastfeeding women. Periductal mastitis is characterized by inflammation of the subareolar ducts and can present with pain, periareolar inflammation, and purulent nipple discharge.18 The condition is typically chronic, and the inflamed ducts may become secondarily infected leading to duct damage and abscess formation. Treatment generally includes antibiotics along with incision and drainage of any associated abscesses or duct excision.18,19
Idiopathic granulomatous mastitis (IGM) is a rare inflammatory breast disease that typically affects young parous women. The presentation can vary from a single peripheral breast mass to multiple areas of infection with abscesses and skin ulceration. The etiology is unknown. Diagnosis requires a core needle biopsy to rule out malignancy or other causes of granulomatous disease. IGM is a benign condition and typically resolves without treatment over the course of several months, although antibiotics and/or drainage may be required for secondary infections.20,21
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