A breast is composed of lobules, where milk is produced, and ducts, or pipes, which carry the milk towards the nipple. There is also fat and fibrous tissue between the lobules and ducts. Blood vessels and lymphatic vessels are located in the fat and fibrous tissue. The arteries carry blood into the breast tissue, and the veins carry blood back to the heart. Lymphatic vessels collect the fluid which leaks out of the blood vessels into the tissues of the breast, and carry the fluid back to the heart, passing through lymph nodes on the way. Lymph nodes act as filters to trap any bacteria or viruses or cancer cells. Both men and women have similar breast tissue, even though men's breasts do not usually produce milk.

The most common types of breast cancer are ductal (which arises from the ducts in the breast), and lobular (which arises from the lobules of the breast). 80 out of 100 breast cancers will arise from the ducts. Most of the rest (15 out of 100) will arise from the lobules. Breast cancer is called invasive if it has moved into the rest of the breast tissue, through the walls of the ducts or lobules and into the fat and fibrous tissue.

There is a type of breast cancer which is restricted to growing within the ducts or lobules and has not yet penetrated into the rest of the breast tissue, this is called carcinoma in situ. The most common form of this again arises within the ducts, and may grow along the ducts. If it is not detected it may continue to grow and extend through the walls, becoming an invasive cancer.

Cancers are also subdivided by grade (how aggressive it looks under the microscope), size (how large it is), and what receptors are present on the cancer cells. The common receptors are oestrogen (ER) , progesterone (PR) and the HER-2 receptors. The other important feature is whether the cancer has spread to the lymph nodes (usually under the arm on the same side).

These features will all be used by your doctors to decide what treatment to recommend to you. The final decisions on treatment are always yours to decide.

Anybody can get breast cancer, from very young women in their teens or early twenties, to very old women in their 80s or 90s, as well as men of any age. While younger women with breast cancer get a lot of media attention, the risk of breast cancer increases with age.

Having children and breastfeeding them seems to give some protection against breast cancer. It has been known for many years that nuns who do not have children have a higher risk.

Some families have a higher risk of developing breast cancer. The risk is greater the more family members you have who have had breast cancers, and particularly if those family members are closer to you (for example , sisters rather than cousins). Breast cancer in some families is also linked to ovarian cancer. Any families where a male member has had breast cancer may also be at increased risk. Genetic testing may be useful to help find such families, but not all families which have an increased risk will have a genetic abnormality.

There is no simple answer to this question.

It will depend on many factors - what type of cancer you have, its size, how aggressive it is, how old you are, what receptors are positive, whether any lymph nodes are involved, and whether there is any spread to other parts of the body.

Forms of treatment which may be recommended to you may include surgery (either a lumpectomy or a mastectomy, together with, in most cases, some form of surgery on the lymph nodes); chemotherapy; radiotherapy; and hormonal therapy. There are different combinations of treatment, and the treatment recommendations are made after considering the characteristics of your particular cancer. The final decision is always yours to make, after considering the options. Dr Sardelic will always take the time to make sure you understand your options and will help you to make your decision.

In many (but not all) cases of breast cancer or melanoma, it is necessary to check the lymph  nodes nearby to see if the cancer has spread there, as that may affect what treatment is  recommended. There are two main types of surgery to the lymph nodes in the armpit (axilla), an axillary clearance or a sentinel node biopsy.

Axillary Clearance

Before the introduction of the technique of sentinel node biopsy, an axillary clearance was performed routinely on patients with breast cancer. 

It involves the removal of most of the lymph nodes from under the arm. The main nerves and blood vessels are preserved, but some of the smaller nerves and blood vessels may be tied off.

During the operation, some of the muscles at the front of the armpit need to be pulled out of the way to allow the surgeon access to the deeper structures. The muscles will be sore afterwards, and it may be uncomfortable for patients to raise their arms above their heads. It is important for  patients to maintain their arm movement. Patients having axillary clearances will be shown by the physiotherapists how to do exercises to keep their arms mobile.

Other problems associated with this operation include fluid collection under the wound, numbness on the inside of the arm from the shoulder to the elbow, or lymphoedema. Lymphoedema is a swelling of the entire arm. It may range from mild to severe, although severe cases are uncommon.

Sentinel Node Biopsy

Sentinel node biopsy is a technique which allows limited sampling of the lymph nodes in the  axilla, and therefore is less likely to cause most of the problems associated with axillary  clearances.

A radioactive solution is initially injected into the breast, under the nipple. The injection travels  through the breast tissue to one or more lymph nodes in the axilla. Images are taken of the axilla  which shows which lymph nodes have taken up the injection, and markings are made on the skin.

Once the patient is asleep in theatre, a further injection of blue dye is injected into the breast.  Both the injections travel through very fine lymphatic channels to the axilla. A Geiger counter is  used in theatre to identify the area where the radioactivity is highest. That area is then explored until a “hot” (radioactive) and / or “blue” lymph node is identified. The node (or nodes) is then  removed and sent to the pathologist , to check if there are cancer cells in the node. The fact that  the blue dye or the radioactive injection have travelled to a node does NOT mean the node will  have cancer cells. It is simply the node most likely to show cancer cells, if they have travelled to the axilla.

The complications of a sentinel node biopsy include blue staining of the skin of the breast (which  may take months to disappear), passing blue-green urine (which lasts for approximately 24-48 hrs), and allergic reactions to the blue dye (very rare).

Fibroadenomas

Fibroadenomas are benign growths (non-cancerous) of fibrous tissue and breast tissue. They can be very small or grow quite large, and can be single or multiple. They are more common in younger women (20 - 40 years old). If a young woman has multiple fibroadenomas, they do not all need to be biopsied, but at the very least regular ultrasounds should be done to ensure none of them develop any concerning features. If there are any lesions with concerning features, a biopsy should be performed.

Breast cysts are collections of fluid within the breast tissue. Often they cannot be felt, and are usually found on ultrasound as an incidental finding. Again, they are common in younger women. If cysts are causing symptoms (eg pain or discomfort) they can be drained to give relief of symptoms. If the cysts have any atypical features they should be biopsied.

Lipomas are benign growths of fat tissue, of variable size. Mostly they are smooth and oval shaped, but occasionally they can be shaped similarly to a bunch of grapes. They can occur anywhere in the body, including the breasts. If a lipoma grows or changes rapidly, it should be removed.

Abscesses

Infections in the breast can lead to abscess formation. If an abscess forms it may need surgical drainage and antibiotics to treat the infection.

Fat Necrosis

Fat necrosis is damage to the fatty , glandular and fibrous tissue of the breast. Sometimes there is a specific injury , but most women diagnosed with fat necrosis have no history of trauma. It can also occur after breast surgery.

It often presents as a firm, painless lump, but it can be painful. Sometimes there can be bruising or redness or even dimpling of the overlying skin.

On imaging, fat necrosis may give a similar appearance to a breast cancer. A biopsy orremoval of the area may be required for a definitive diagnosis.

If the lesion is confirmed as fat necrosis, it can be observed ; often it will resolve without any further action; if it does not resolve, or if it increases in size, it should be removed.

Cyclical Breast Pain

This type of breast pain usually occurs in women in their 20s and 30s, and varies in intensity through the menstrual cycle. It is often descibed as a heaviness or an ache. Usually the pain starts to increase from the middle of the cycle and reaches maximum intensity just before the period starts. The pain settles once the period starts. This sort of pain can also be experienced by older women on hormone replacement therapy (HRT).

Non-cyclical Breast Pain

The main feature of this pain is that it does not fluctuate in severity in association with the menstrual cycle in the same way that cyclical breast pain does.

It can affect women pre or post menopause, but is generally more common amongst older women. It may be persistent (always present) or intermittent. It may vary in its severity. It can affect one or both breasts. Often it is described as a burning , throbbing or stabbing sort of pain.

Sometimes this type of pain can be associated with benign changes in the breasts, but often there is no apparent reason for the pain.

Chest Pain

Pain from the chest can sometimes be experienced as pain in the breast. Chest pain can be due to pain coming from the ribs, the muscles of the chest, or the ligaments or cartilage of the chest wall. Sometimes there may be a history of physical exertion or injury, but not always. This will usually get better over some weeks if it is related to exertion or injury, and can be helped by paracetamol / anti-inflammatory medications / heat packs.

What Can I do about Breast Pain ?

The first thing is to try to work out any pattern to the pain. Keeping a pain chart can be very useful. Each day, make a note of what sort of activities you did, what you had to eat or drink, whether you had your period or not, and how severe the pain was (pick a simple number guide - eg 0 for no pain, 1 for very mild pain, 2 for mild pain, 3 for moderate pain, 4 for marked pain and 5 for severe pain). You should keep a chart for at least a month before making any changes. If you introduce any changes into your diet or start medications, it isimportant to track whether it makes any difference to the pain. It is best to introduce changes one at a time to see what effects they have individually.

Duct Ectasia

This often occurs in women approaching or after the menopause. The ducts behind the nipple become enlarged and can be inflamed, and can accumulate fluid within the enlarged ducts. It often affects both breasts. The discharge can be of various colours, and can even be bloodstained. It will usually settle without specific treatment, but for severe discharge surgery can be performed.

Duct Papilloma

A papilloma is a warty type of growth which can occur within a duct behind the nipple. It may not cause any symptoms, and can be sometimes detected incidentally on breast imaging.

It may cause nipple discharge, which is often affecting one breast only, and sometimes only occurs from a single duct on the nipple. The nipple discharge may persist and can be bloodstained. It can co-exist with duct ectasia. Rarely, it can be difficult to distinguish a papilloma from a cancer, and it may need to be removed surgically.

Nipple Eczema

The nipple can become affected by eczema or dermatitis, which tends to cause an ooze of fluid from the damaged skin of the nipple, and the fluid dries and becomes crusty. This can affect one or both breasts, and can be bloodstained if the eczema is severe. Treatment is usually with steroid based creams.

Breast Cancer

This is an uncommon cause of nipple discharge, and is most often associated with other symptoms such as a lump or inversion (withdrawing) of the nipple into the breast.

Paget’s Disease of the Nipple

Paget’s Disease is a variant of breast cancer which involves the skin of the nipple. The nipple often becomes ulcerated and fragile and bleeds.