Clinical Review

Evaluating patients with breast concerns: Lump, pain, and mastitis

OBG Manag. 2023 April;35(4):16-24 | doi:10.12788/obgm.0272

References

Eberl MM, Phillips RL Jr, Lamberts H, et al. Characterizing breast symptoms in family practice. Ann Fam Med. 2008;6:528-533.
Malherbe F, Nel D, Molabe H, et al. Palpable breast lumps: an age-based approach to evaluation and diagnosis. S Afr Fam Pract (2022). 2022;64:e1-e5.
Expert Panel on Breast Imaging; Klein KA, Kocher M, Lourenco AP, et al. American College of Radiology ACR appropriateness criteria: palpable breast masses. Accessed February 15, 2023. https://acsearch.acr.org/docs/69495/Narrative/
Stachs A, Stubert J, Reimer T, et al. Benign breast disease in women. Dtsch Arztebl Int. 2019;116:565574.
Hines N, Slanetz PJ, Eisenberg RL. Cystic masses of the breast. AJR Am J Roentgenol. 2010;194:W122133.
Berg WA. Reducing unnecessary biopsy and follow-up of benign cystic breast lesions. Radiology. 2020;295:52-53.
Duman L, Gezer NS, Balcı P, et al. Differentiation between phyllodes tumors and fibroadenomas based on mammographic sonographic and MRI features. Breast Care. 2016;11:123-127.
Lerwill MF, Lee AHS, Tan PH. Fibroepithelial tumours of the breast—a review. Virchows Arch. 2022;480:45-63.
Vasei N, Shishegar A, Ghalkhani F, et al. Fat necrosis in the breast: a systematic review of clinical. Lipids Health Dis. 2019;18:139.
Kerridge WD, Kryvenko ON, Thompson A, et al. Fat necrosis of the breast: a pictorial review of the mammographic, ultrasound, CT, and MRI findings with histopathologic correlation. Radiol Res Pract. 2015;2015:613139.
Taboada JL, Stephens TW, Krishnamurthy S, et al. The many faces of fat necrosis in the breast. AJR Am J Roentgenol. 2009;192:815-825.
Tan PH, Lai LM, Carrington EV, et al. Fat necrosis of the breast—a review. Breast. 2006;15:313-318.
Holbrook AI. Breast pain, a common grievance: guidance to radiologists. AJR Am J Roentgenol. 2020;214:259-264.
Expert Panel on Breast Imaging; Moy L, Heller SL, Bailey L, et al. ACR appropriateness criteria: palpable breast masses. J Am Coll Radiol. 2017;14:S203-S224.
Chetlen AL, Kapoor MM, Watts MR. Mastalgia: imaging workup appropriateness. Acad Radiol. 2017;24:345-349.
Arslan M, Kucukerdem HS, Can H, et al. Retrospective analysis of women with only mastalgia. J Breast Health. 2016;12:151-154.
Fariselli G, Lepera P, Viganotti G, et al. Localized mastalgia as presenting symptom in breast cancer. Eur J Surg Oncol. 1988;14:213-215.
Leddy R, Irshad A, Zerwas E, et al. Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump. Breast J. 2013;19:582-589.
Leung JW, Kornguth PJ, Gotway MB. Utility of targeted sonography in the evaluation of focal breast pain. J Ultrasound Med. 2002;21:521-526.
Goyal A. Breast pain. BMJ Clin Evid. 2011; 2011:0812.
Kasales CJ, Han B, Smith Jr JS, et al. Nonpuerperal mastitis and subareolar abscess of the breast. AJR Am J Roentgenol. 2014;202:W133-W139.
Mahoney MC, Ingram AD. Breast emergencies: types, imaging features, and management. AJR Am J Roentgenol. 2014;202:W390-W399.
Snider HC. Management of mastitis, abscess, and fistula. Surg Clin North Am. 2022;102:1103-1116.
Oztekin PS, Durhan G, Kosar PN, et al. Imaging findings in patients with granulomatous mastitis. Iran J Radiol. 2016;13:e33900.
Pluguez-Turull CW, Nanyes JE, Quintero CJ, et al. Idiopathic granulomatous mastitis: manifestations at multimodality imaging and pitfalls. Radiographics. 2018;38:330-356.
Hovanessian-Larsen LJ, Peyvandi B, Klipfel N, et al. Granulomatous lobular mastitis: imaging, diagnosis, and treatment. AJR Am J Roentgenol. 2009;193:574-581.

CASE 7 Patient with breast pain and swelling

A 39-year-old woman presents with left breast swelling and pain of 1 month’s duration. On examination, there is a 6-cm area of edema, induration, and erythema.

Granulomatous mastitis

A diagnostic mammogram and ultrasound demonstrated an ill-defined hypoechoic mass (FIGURE 7a). Ultrasound-guided biopsy was performed, which showed granulomatous mastitis, negative for fungus and acid-fast bacilli. The patient was treated with prednisone and gradually improved (FIGURE 7b).

^{Art Credit: Images courtesy of Leigh Neumayer, MD, MS, MBA}

Granulomatous mastitis (GM) is a rare benign inflammatory process, with etiologies that include fungal infections, tuberculosis, Wegener granulomatosis, sarcoidosis, and idiopathic causes. Imaging can be nonspecific and show variable features. Mammograms can appear normal or show asymmetry or mass and skin thickening. Ultrasound can show heterogeneous parenchyma, ill-defined hypoechoic collection, or a mass with margins that can be circumscribed or indistinct or with tubular extensions, with or without overlying skin thickening, fistulas, and reactive lymph nodes.²⁴

In this clinical setting, the differential diagnosis includes infectious mastitis, inflammatory breast cancer, foreign body injection granulomas, and diabetic mastopathy. Treatment involves drainage and fluid culture if there is a collection on imaging. A core biopsy is performed if imaging demonstrates a solid mass or fluid culture is negative and symptoms persist or recur. Oral steroids represent the mainstay of treatment if a core biopsy shows GM. However, immunosuppressants, including methotrexate, and surgery are options if initial treatment is not helpful.^25,26

Conclusion

Breast symptoms are common reasons for patient visits to obstetricians and gynecologists. With a good understanding of the various symptomatic breast diseases and conditions, and by having a close collaboration with radiologists and breast surgeons, clinicians can provide excellent care to these patients and thereby improve patient outcomes and satisfaction. ●

References

Eberl MM, Phillips RL Jr, Lamberts H, et al. Characterizing breast symptoms in family practice. Ann Fam Med. 2008;6:528-533.
Malherbe F, Nel D, Molabe H, et al. Palpable breast lumps: an age-based approach to evaluation and diagnosis. S Afr Fam Pract (2022). 2022;64:e1-e5.
Expert Panel on Breast Imaging; Klein KA, Kocher M, Lourenco AP, et al. American College of Radiology ACR appropriateness criteria: palpable breast masses. Accessed February 15, 2023. https://acsearch.acr.org/docs/69495/Narrative/
Stachs A, Stubert J, Reimer T, et al. Benign breast disease in women. Dtsch Arztebl Int. 2019;116:565574.
Hines N, Slanetz PJ, Eisenberg RL. Cystic masses of the breast. AJR Am J Roentgenol. 2010;194:W122133.
Berg WA. Reducing unnecessary biopsy and follow-up of benign cystic breast lesions. Radiology. 2020;295:52-53.
Duman L, Gezer NS, Balcı P, et al. Differentiation between phyllodes tumors and fibroadenomas based on mammographic sonographic and MRI features. Breast Care. 2016;11:123-127.
Lerwill MF, Lee AHS, Tan PH. Fibroepithelial tumours of the breast—a review. Virchows Arch. 2022;480:45-63.
Vasei N, Shishegar A, Ghalkhani F, et al. Fat necrosis in the breast: a systematic review of clinical. Lipids Health Dis. 2019;18:139.
Kerridge WD, Kryvenko ON, Thompson A, et al. Fat necrosis of the breast: a pictorial review of the mammographic, ultrasound, CT, and MRI findings with histopathologic correlation. Radiol Res Pract. 2015;2015:613139.
Taboada JL, Stephens TW, Krishnamurthy S, et al. The many faces of fat necrosis in the breast. AJR Am J Roentgenol. 2009;192:815-825.
Tan PH, Lai LM, Carrington EV, et al. Fat necrosis of the breast—a review. Breast. 2006;15:313-318.
Holbrook AI. Breast pain, a common grievance: guidance to radiologists. AJR Am J Roentgenol. 2020;214:259-264.
Expert Panel on Breast Imaging; Moy L, Heller SL, Bailey L, et al. ACR appropriateness criteria: palpable breast masses. J Am Coll Radiol. 2017;14:S203-S224.
Chetlen AL, Kapoor MM, Watts MR. Mastalgia: imaging workup appropriateness. Acad Radiol. 2017;24:345-349.
Arslan M, Kucukerdem HS, Can H, et al. Retrospective analysis of women with only mastalgia. J Breast Health. 2016;12:151-154.
Fariselli G, Lepera P, Viganotti G, et al. Localized mastalgia as presenting symptom in breast cancer. Eur J Surg Oncol. 1988;14:213-215.
Leddy R, Irshad A, Zerwas E, et al. Role of breast ultrasound and mammography in evaluating patients presenting with focal breast pain in the absence of a palpable lump. Breast J. 2013;19:582-589.
Leung JW, Kornguth PJ, Gotway MB. Utility of targeted sonography in the evaluation of focal breast pain. J Ultrasound Med. 2002;21:521-526.
Goyal A. Breast pain. BMJ Clin Evid. 2011; 2011:0812.
Kasales CJ, Han B, Smith Jr JS, et al. Nonpuerperal mastitis and subareolar abscess of the breast. AJR Am J Roentgenol. 2014;202:W133-W139.
Mahoney MC, Ingram AD. Breast emergencies: types, imaging features, and management. AJR Am J Roentgenol. 2014;202:W390-W399.
Snider HC. Management of mastitis, abscess, and fistula. Surg Clin North Am. 2022;102:1103-1116.
Oztekin PS, Durhan G, Kosar PN, et al. Imaging findings in patients with granulomatous mastitis. Iran J Radiol. 2016;13:e33900.
Pluguez-Turull CW, Nanyes JE, Quintero CJ, et al. Idiopathic granulomatous mastitis: manifestations at multimodality imaging and pitfalls. Radiographics. 2018;38:330-356.
Hovanessian-Larsen LJ, Peyvandi B, Klipfel N, et al. Granulomatous lobular mastitis: imaging, diagnosis, and treatment. AJR Am J Roentgenol. 2009;193:574-581.

Evaluating patients with breast concerns: Lump, pain, and mastitis

References

CASE 7 Patient with breast pain and swelling

Granulomatous mastitis

Conclusion

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