Breast Pain Differential: Mondor's Disease of the Breast.

Breast pain is a common concern among women in primary care clinics. A rare cause of breast pain is Mondor's disease (MD), which can present as an acute, painful, erythematous, cord-like induration on the breast or anterior chest wall. The disorder is caused by sclerosing superficial thrombophlebitis of the anterolateral thoracoabdominal wall veins. There does not appear to be a racial or ethnic propensity for this condition; however, it is important to understand that it may be more difficult to see in darker skin types (Fitzpatrick skin types IV-VI) and requires close attention on physical exam. The cause of MD is poorly understood but may be related to direct trauma, strenuous exercise, or hormone changes. We review a case of a 54-year-old woman who presented with an anterior chest wall palpable cord, better visualized with adequate lighting and skin traction, ultimately diagnosed as MD based on clinical findings and imaging studies. Mondor's disease often resolves spontaneously with supportive care, as in this patient's case; however, clinicians should be aware of this rare cause of breast pain and its association with hypercoagulable state, vasculitis, and breast cancer.

Efficient management of new patient referrals to a breast service: the safe introduction of an advanced nurse practitioner-led telephone breast pain service.

INTRODUCTION: There has been an almost 100% increase in referrals to breast cancer diagnostic clinics in the past decade. Breaching of the two-week cancer referral target is now commonplace, potentially delaying diagnoses of breast malignancy in many women. Almost one in five of these referrals are women with mastalgia, not a symptom linked to breast cancer. The objective of the study was the safe introduction of an advanced nurse practitioner-led telephone service for women with mastalgia to improve the service for women and create capacity for those with "red flag" breast symptoms. METHODS: Referrals to clinic were triaged, women with mastalgia only were directed to a telephone-based assessment clinic and symptoms evaluated using a multidisciplinary created proforma. RESULTS: Within 23 months, 1,427 women were assessed in the breast pain telephone assessment clinic: 863 (61%) were aged over 40 and 564 (39%) aged under 40. A total of 1,238 underwent telephone assessment. Reassurance and discharge only was needed for 365 (26%). The aetiology of pain was identified as musculoskeletal in 1,104/1,238 (89%) of patients, with only 39/1,238 (3.2%) identified as having true breast pain. Additional symptoms were mentioned by 264 women (18%) during the consultation; all immediately redirected back to a diagnostic clinic. Mammography was undertaken in 609 women (43%). Seven women (0.6%) were diagnosed with a breast malignancy. Patient survey indicated that 93% of patients were satisfied with the care received and 97% said they would recommend the service to a family member or friend. CONCLUSIONS: Although face-to-face assessments for breast pain remain the standard practice in many breast units, data indicating the safety of a telephone assessment clinic, along with high levels of patient satisfaction, question whether services can be delivered differently.

A multicentre review of the direct-access mammography programme in Ireland for women with breast pain.

AIM: To assess the current use of the direct access mammography pathway for breast pain and the rate of breast cancer detection in this patient cohort. MATERIALS AND METHODS: A retrospective review of general practitioner (GP)-referred mammograms performed during a 12-month period from January to December 2022 across four tertiary referral centres. With the use of medical records and GP referrals, patient demographics, presenting symptoms, family history, and clinical outcomes were recorded. RESULTS: The present study comprised 2,046 patients of which 21.6% did not report breast pain at the time of referral. Thirty-five per cent had a positive family history with 40% of these patients having no breast pain. Twelve per cent were recalled with 30% of these patients requiring biopsy. An overall cancer detection rate (CDR) of 7 per 1000 was determined for women with mastalgia. A CDR of 0 per 1,000 was determined for women <50 years with mastalgia alone and no additional risk factors for malignancy. Fisher's exact test showed no statistically significant association between breast pain and breast cancer. CONCLUSION: There was no statistically significant relationship found between breast pain and breast cancer. This review suggests a low cancer detection rate in women <50 years. In women <50 years with mastalgia without additional symptoms or family history, breast imaging is not required.

Post Treatment Mastalgia is a Common Complaint but not an Indication of Recurrence or Second Primary Breast Cancer.

BACKGROUND: Post-treatment mastalgia is a common complaint in up to 68% of patients after treatment. This symptom is worrisome to patients as many believe it is a sign of recurrence. The current study was performed to evaluate if post-treatment mastalgia is associated with a second breast cancer diagnosis. MATERIALS AND METHODS: Patients included were seen from January 1, 2000 to December 31, 2020. All patients who were treated for breast cancer and then presented with breast pain during follow up were considered to have post-treatment mastalgia. All patients who were diagnosed with a second breast cancer but did not experience post-treatment mastalagia were also evaluated. RESULTS: 1799 patients had a mean age 52.9 years. 36% of patients experienced post-treatment mastalgia. Of patients who complained of post-treatment mastalgia, 19 were diagnosed with a chest wall recurrence (CW), ipsilateral breast tumor recurrence (IBTR), or contralateral breast cancer (CBC). 17 of the 19 patients had breast pain after the second diagnosis and treatment were completed. The average duration between their second diagnosis and initial complaint of breast pain was 6.2 years. The two patients who complained of breast pain prior to their second diagnosis did not have mastalgia at the time of their second diagnosis. Local recurrence or contralateral breast cancer were more common in patients without post treatment mastalgia (10.1% vs 0.3%, p < 0.0001) during follow up. CONCLUSION: Post treatment mastalgia is not associated with recurrence. Interval or repeat imaging does not appear necessary and instead patient education and reassurance are important in its management.

Optimizing Preventive Adjuvant Linac-Based (OPAL) Radiation: A Phase 2 Trial of Daily Partial Breast Irradiation.

PURPOSE: Evidence supports use of partial-breast irradiation (PBI) in the management of early breast cancer, but the optimal dose-fractionation remains unsettled. METHODS AND MATERIALS: We conducted a phase 2 clinical trial (OPAL trial) to evaluate a novel PBI dosing schedule of 35 Gy in 10 daily fractions. Patients with close (<2 mm) margins also received a boost of 9 Gy in 3 fractions. Eligible patients underwent margin-negative lumpectomy for ductal carcinoma in situ or estrogen receptor-positive invasive breast cancer, up to 3 cm, pTis-T2 N0. The primary outcome was any grade ≥2 toxic effect occurring from the start of radiation through 6 months of follow-up. Secondary outcomes included patient-reported cosmesis, breast pain, and functional status, measured using the Breast Cancer Treatment Outcomes Scale, and physician-reported cosmesis, measured using the Radiation Therapy and Oncology Group scale. The Cochran-Armitage trend test and multivariable mixed-effects longitudinal growth curve models compared outcomes for the OPAL study population with those for a control group of similar patients treated with whole-breast irradiation (WBI) plus boost. RESULTS: All 149 patients enrolled on the OPAL trial received the prescribed dose, and 17.4% received boost. The median age was 64 years; 83.2% were White, and 73.8% were overweight or obese. With median follow-up of 2.0 years, 1 patient (0.7%) experienced in-breast recurrence. Prevalence of the primary toxicity outcome was 17.4% (26 of 149 patients) in the OPAL trial compared with 72.7% (128 of 176 patients) in the control WBI-plus-boost cohort (P < .001). In longitudinal multivariable analysis, treatment on the OPAL trial was associated with improved patient-reported cosmesis (P < .001), functional status (P = .004), breast pain (P = .004), and physician-reported cosmesis (P < .001). CONCLUSIONS: Treatment with daily PBI was associated with substantial reduction in early toxicity and improved patient- and physician-reported outcomes compared with WBI plus boost. Daily external-beam partial-breast irradiation with 13 or fewer fractions merits further prospective evaluation.

Management of Mastalgia.

Breast pain is a common symptom in most women during their lifetime, and many times is self-limited. Mastalgia is categorized into 3 main groups: cyclic, noncyclic and extramammary. A good history, examination and targeted imaging can help to delineate the underlying cause of mastalgia and therefore guide treatment options. Diet, medications, stress, hormonal fluctuations, and an ill-fitting bra can be contributing factors for physiologic causes of mastalgia. Breast cancer is rarely a cause but should be excluded. Reassurance, support, dietary changes, nonsteroidal anti-inflammatory drugs and occasionally hormonal medications are options to help with improving breast pain.

The Impact of Chemotherapy on Toxic Effects and Cosmetic Outcome in Patients Receiving Whole Breast Irradiation: An Analysis Within a Statewide Quality Consortium.

PURPOSE: We investigated whether the use of chemotherapy before whole breast irradiation (WBI) using either conventional fractionation (CWBI) or hypofractionation (HWBI) is associated with increased toxic effects or worse cosmetic outcome compared with WBI alone. METHODS AND MATERIALS: We identified 6754 patients who received WBI alone (without a third field covering the superior axillary and supraclavicular nodal regions) with data prospectively collected in a statewide consortium. We reported rates of 4 toxic effects: physician-reported acute moist desquamation, patient-reported acute moderate/severe breast pain, a composite acute toxic effect measure (including moist desquamation and either patient- or physician-reported moderate/significant breast pain), and physician-reported impaired cosmetic outcome at 1 year after WBI. Successive multivariable models were constructed to estimate the effect of chemotherapy on these outcomes. RESULTS: Rates of moist desquamation, patient-reported pain, composite acute toxic effects, and impaired cosmetic outcome were 23%, 34%, 42%, and 10% for 2859 patients receiving CWBI and 13%, 28%, 31%, and 11% for 3895 patients receiving HWBI. Receipt of chemotherapy before CWBI was not associated with higher rates of patient-reported pain, composite acute toxic effects, or impaired cosmetic outcome compared with CWBI without chemotherapy but was associated with more moist desquamation (odds ratio, 1.32 [1.07-1.63]; P = .01). Receipt of chemotherapy before HWBI was not associated with higher rates of any of the 4 toxic effects compared with HWBI alone. CONCLUSIONS: In this cohort, use of chemotherapy before WBI was generally well tolerated. CWBI with chemotherapy but not HWBI with chemotherapy was associated with higher rates of moist desquamation. Rates of acute breast pain and impaired cosmetic outcome at 1 year were comparable in patients receiving chemotherapy before either CWBI or HWBI. These data support the use of HWBI after chemotherapy.

[Mastalgia : management and state of the art]. / Mastodynies : prise en charge et connaissances actuelles.

This article tries to facilitate the management of mastalgia. During their lifetime most women will experience breast pain. Many of them will visit a physician for this purpose, often led by the fear of cancer. However, in the absence of other clinical signs such as a lump or nipple discharge, the risk of malignancy remains low. In addition to the patient's medical history and physical examination, an imaging may be necessary. The absence of clinical or radiological abnormalities suffices to reassure patients in most cases. The management of mastalgia is based mainly on diet and life-style changes, the use of a well-suited bra and topical anti-inflammatory medication. In the case of mastalgia not responding to first line treatments, the patient should be referred to a breast-care unit.

Cet article cherche à faciliter la prise en charge des mastodynies. Au cours de leur vie, la majorité des femmes présenteront des mastodynies. Nombreuses sont celles qui consulteront leur médecin à cet égard, souvent par crainte d'un cancer. Cependant, en l'absence d'autres signes cliniques comme une masse ou un écoulement mamelonnaire, le risque de malignité reste faible. Outre l'anamnèse et l'examen clinique, une imagerie peut s'avérer nécessaire. L'absence d'anomalies cliniques ou radiologiques permet de rassurer les patientes dans la majorité des cas. Le traitement reposera essentiellement sur des mesures hygiéno-diététiques, le port d'un soutien-gorge adapté et l'utilisation d'anti-inflammatoires topiques. En cas de mastodynies invalidantes et réfractaires aux anti-inflammatoires, la patiente devra être adressée pour un suivi spécialisé.

A Five-step Systematic Therapy for Treating Plugged Ducts and Mastitis in Breastfeeding Women: A Case-Control Study.

PURPOSE: This study aimed to describe the clinical response to five-step systematic therapy (FSST) in the management of plugged ducts and mastitis. FSST was a comprehensive milk stasis dredging treatment, which contained five steps to make the milk out of the plugged duct. METHODS: This retrospective study included 922 breastfeeding women, 714 with plugged ducts, and 208 with mastitis who received FSST from June to September 2017. The breast pain score, swelling degree, and range of breast induration were recorded pre-FSST and post-FSST. RESULTS: After a single FSST, pain score and swelling degree were significantly improved (both p < .001) in all cases. After FSST, the mean breast pain relief score was 1.69 ± 0.70, whereas the mean swelling fade away degree was 1.61 ± 0.62. In the subgroup analysis, pain score and swelling degree were significantly improved (both p < .001) in the plugged ducts group and the mastitis group. The score of pain relief in the plugged ducts group was less than that in the mastitis group (1.63 ± 0.68 vs. 1.91 ± 0.70, t = 5.30; p < .001), whereas improvement of swelling fade away was greater in the plugged ducts group than the mastitis group (1.65 ± 0.64 vs. 1.48 ± 0.56, t = 3.49; p = .001). The composition ratio of changes in induration range between the two groups was statistically different (Pearson χ2 = 137.87, p < .001), of which more obvious improvement in the plugged ducts group than the mastitis group (χ2 = 25.65, p < .001). CONCLUSION: FSST can relieve pain, reduce breast swelling and range of induration, and for plugged ducts or mastitis varied degree differently.

Acute toxicity of normofractionated intensity modulated radiotherapy with simultaneous integrated boost compared to three-dimensional conformal radiotherapy with sequential boost in the adjuvant treatment of breast cancer.

BACKGROUND: Intensity-modulated radiotherapy (IMRT) improves dose homogeneity and late toxicity compared to simple tangential techniques in adjuvant whole-breast radiotherapy for patients with breast cancer. Simultaneous-integrated boost (SIB) radiotherapy shortens the overall treatment time and improves dose homogeneity. However, prospective randomized trials regarding IMRT with SIB for adjuvant radiotherapy in breast cancer are lacking. METHODS: The IMRT-MC2 (MINT) trial is a phase III prospective randomized controlled trial comparing IMRT with SIB (Arm A: whole breast 28 × 1.8 Gy, Boost 28 × 2.3 Gy) to 3D-conformal radiotherapy with a sequential boost (Arm B: whole breast 28 × 1.8 Gy, boost 8 × 2 Gy) in patients with breast cancer after BCS. Indication for boost radiotherapy was defined as age < 70 years or age > 70 years with presence of additional risk factors. This is a retrospective analysis of acute toxicity at one of two trial sites. RESULTS: Five hundred two patients were randomized, of which 446 patients were eligible for this analysis. There was no statistically significant difference in terms of any grade radiation dermatitis between the two treatment arms at the end of treatment (p = 0.26). However, radiation dermatitis grade 2/3 (29.1% vs. 20.1 and 3.5% vs. 2.3%) occurred significantly more often in Arm A (p = 0.02). Breast/chest wall pain at the first follow-up visit was significantly more common in patients treated on Arm B (p = 0.02). CONCLUSIONS: Treatment on both arms was well tolerated, however there were some differences regarding radiodermatitis and breast pain. Further analyses are ongoing. TRIAL REGISTRATION: clinicaltrials.gov , NCT01322854 , registered 24th March 2011.

Clinical Factors Affecting the Therapeutic Efficacy of Evening Primrose Oil on Mastalgia.

BACKGROUND: Saturated fatty acid esters may cause mastalgia via hypersensitivity of breast epithelium to circulating hormones. Evening primrose oil (EPO) may restore the saturated/unsaturated fatty acid balance and decrease sensitivity to steroidal hormones or prolactin. Conflicting results exist regarding EPO treatment for mastalgia. The aim of this study was to determine the effectiveness of EPO and factors affecting its efficacy in treatment of mastalgia. METHODS: The study included 1015 patients, ages 14-82 (mean age 42.21 ± 10.8), admitted to Acibadem Breast Clinic between January 2015 and March 2018. The patients were divided into group I (n = 581) treated with EPO (1300 mg, twice a day) and group II (n = 434) treated with paracetamol (500 mg, twice a day). The visual analog scale was used to assess EPO's therapeutic efficacy, compared with paracetamol, measured at admittance, 2 weeks, and 6 weeks. Clinical factors affecting the efficacy of EPO were analyzed. RESULTS: The therapeutic efficacy of EPO on mastalgia was significantly higher than with paracetamol (p < 0.001). Factors significantly affecting the efficacy of EPO treatment were hormone replacement therapy (HRT), IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis (p < 0.01). Replacement of iron or thyroid hormone efficiently treated mastalgia in patients that did not respond to EPO treatment. Side effects (allergy, anxiety, blurred vision, constipation, and nausea) were rare and not statistically significant (p = 0.88). CONCLUSION: EPO can be used in the treatment of mastalgia without significant side effects. HRT, IUD-with-levonorgestrel, iron deficiency, overt hypothyroidism, and Hashimoto thyroiditis significantly affect the efficacy of EPO on mastalgia.

Breast pain affects the performance of elite female athletes.

Although breast pain is problematic for many active women, no published research has investigated breast pain experienced by elite female athletes. This study aimed to examine the extent that mastalgia and exercise-induced breast pain affected the sporting performance of elite female athletes during training and competition. A custom-designed online survey with questions related to sport participation, as well as the frequency, severity and perceived performance effects of mastalgia and exercise-induced breast pain, was distributed to sporting organisations, coaches, medical staff and teams/clubs throughout Australia. Five hundred and forty female athletes competing nationally or internationally across 49 different sports participated in the survey. Sixty-three percent of respondents reported experiencing breast pain associated with their menstrual cycle and 33% reported that this pain worsened during activity. Forty-four percent of athletes reported experiencing exercise-induced breast pain during training or competition. Both types of breast pain were also reported to negatively affect sporting performance (20% and 32%, respectively). Mastalgia associated with the menstrual cycle and exercise-induced breast pain should be acknowledged as potential problems affecting the sporting performance of elite female athletes. Awareness around the impact of breast pain and the development and implementation of breast pain management strategies are essential for this population.

How best to address breast pain in nonbreastfeeding women.

This guide-with accompanying algorithms-will help you to streamline your approach to breast pain in a patient who isn't breastfeeding.

[Breast pain and fever in a 46-year-old immunosuppressed patient with breast implants]. / Schmerzen im Bereich der Mamma und Fieber bei einer 46­Jährigen mit Immunsuppression und Mammaaugmentation.

A 46-year-old immunosuppressed patient presented with a breast implant-associated infection 10 years after breast augmentation in Southeast Asia. No pathogen was identified in the initial conventional microbiological workup. Subsequently, infection with Mycobacterium abscessus-a nontuberculous mycobacteria-was diagnosed using a special culture technique. Increased rates of such infections are reported after cosmetic surgery in foreign countries, presumably due to inoculation with these ubiquitous pathogens. This case highlights the fact that the differential diagnosis and thus the microbiological workup should be extended in cases without initial pathogen detection.

Breast pain and cancer: should we continue to work-up isolated breast pain?

PURPOSE: To assess the cancer detection rate (CDR) in patients presenting with isolated breast pain. METHODS: A retrospective review was performed of consecutive patients presenting to a large tertiary care academic center or an affiliated hospital with isolated breast pain from October 1, 2013 to September 30, 2015. Medical records were reviewed for patient demographics, pain characteristics, imaging findings, and outcome. RESULTS: The study cohort was comprised of 971 exams in 953 patients, with a median age of 50 years. A total of 62.5% (607/971) of the cases were assessed by mammography and ultrasound, 24.4% (237/971) by ultrasound only, and 13.1% (127/971) by mammography only. Including the abnormalities detected in the asymptomatic breast, 88.7% (861/971) of the cases were negative or had benign findings (BI-RADS 1 and 2), 6.8% (66/971) were probably benign (BI-RADS 3), 3.9% (38/971) were suspicious (BI-RADS 4), and 0.6% (6/971) were highly suggestive of malignancy (BI-RADS 5). CDR on initial work-up was 0.8% (8/953), of which 0.6% (4/690) was in average-risk patients while 1.5% (4/263) was in higher-than-average risk patients. CONCLUSIONS: CDR in patients presenting with isolated breast pain overall was low, comparable to the expected incidence of breast cancer in asymptomatic women. Work-up for isolated breast pain may therefore be unnecessary and lead to overutilization of healthcare resources. Routine screening mammography should be encouraged and higher-than-average risk patients may benefit from additional tests.

Focal breast pain: imaging evaluation and outcomes.

OBJECTIVES: To determine the number and characteristics of cancers detected and the optimal imaging evaluation in women presenting with focal breast pain (FBP). MATERIALS AND METHODS: We performed a retrospective review of 4720 women who underwent imaging for FBP from 2001 to 2013. Women 18 and over with one or two foci of breast pain and no concurrent breast symptoms were included. 944 patients met criteria. We recorded the imaging work-up, presence and type of finding at the site of pain, BI-RADS® assessment, and pathological outcomes. Subsequent imaging and clinical follow up was recorded. RESULTS: Imaging evaluation consisted of sonogram alone in 286 women, mammogram alone in 231 women, and both in 427 women. 113 women had an imaging finding at the site of pain; 103 were designated benign or probably benign. 12 biopsies of corresponding findings were performed: 9 benign, 1 invasive lobular carcinoma, 1 invasive ductal carcinoma, 1 ductal carcinoma in situ. All three malignancies were seen mammographically; 2 had an ultrasound correlate. At initial evaluation, 4 incidental breast cancers were diagnosed remote from the site of FBP. All were seen on mammogram and 2 of 4 had an ultrasound correlate. On follow up evaluation, 9 cancers were diagnosed at the site of pain and 13 incidental cancers were diagnosed. CONCLUSION: FBP is rarely associated with malignancy. Targeted ultrasound may be deferred in women 40 and older with FBP, no other clinical findings, and a negative mammogram.

Persistent breast pain in post-surgery breast cancer survivors and women with no history of breast surgery or cancer: associations with pain catastrophizing, perceived breast cancer risk, breast cancer worry, and emotional distress.

Background: Persistent breast pain (PBP) is prevalent among breast cancer survivors and has powerful negative psychological consequences. The present study provided a first test of the hypothesis that: (a) pain catastrophizing, (b) heightened perceived risk of cancer, and (c) worry that pain indicates cancer may be independent mediating links between breast cancer survivors' experiences of PBP and heightened emotional distress. Methodology: We assessed levels of PBP and psychological factors in breast cancer survivors (Survivor Group: n = 417; Stages I-IIIA; White = 88.7%; Age M = 59.4 years) at their first surveillance mammogram post-surgery (6-15 months). A comparison group of women without histories of breast surgery or cancer (Non-cancer Group: n = 587; White = 78.7%; Age M = 57.4 years) was similarly assessed at the time of a routine screening mammogram. All women completed measures of breast pain, pain catastrophizing, perceived breast cancer risk, and worry that breast pain indicates cancer, as well as measures of emotional distress (symptoms of anxiety, symptoms of depression, and mammography-specific distress). Analyses included race, age, BMI, education, and menopausal status as covariates, with significance set at 0.05. Results: As expected, PBP prevalence was significantly higher in the Survivor Group than in the Non-cancer Group (50.6% vs. 17.5%). PBP+ survivors also had significantly higher levels of emotional distress, pain catastrophizing, mammography-specific distress, and worry that breast pain indicates cancer, compared to PBP- survivors. Structural equation modeling results were significant for all hypothesized mediational pathways. Interestingly, comparisons of PBP+ to PBP- women in the Non-cancer Group showed similar results. Conclusion: These findings suggest the importance of (a) pain catastrophizing, (b) perceived breast cancer risk and, (c) worry that breast pain may indicate cancer, as potential targets for interventions aimed at reducing the negative psychological impact of PBP in post-surgery breast cancer survivors, as well as in unaffected women with PBP due to unknown reasons.