The breast illusions

Prof Carol-Ann Benn uncovers the breast illusions that may look like cancer and warns that when it’s not cancer, you need the master magician to spot the trick.

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The great illusionists all had something in common; it was and is difficult to work out the magic trick unless you know a little magic yourself. Here are the secrets to uncovering the breast illusions that may look like cancers, yet are not. After seeing a lady who had a mastectomy for (wait for it) not a cancer, I realised it was time to discuss those great cancer mimics and to teach everyone a little bit of magic. Prior to pulling the rabbit out the hat and saying abracadabra, there are a few rules to ensure breast magic:

• Don’t panic and google your symptoms (easier said than done. I mean when I googled my middle-age fat roll and secrets to get rid of it, I landed up downloading a fake training site). Google is a great corroborator; how you phrase your question about your symptoms usually results in a frightening answer: it could be cancer.
• If you’re worried about anything regarding your breasts or body, ensure that you see a healthcare professional that listens and orders appropriate investigations.
• Take a friend to your consults, ask questions and don’t rush into blind surgical procedures.
• The correct investigations, if you have a breast concern, are to go for a mammogram and/or ultrasound at a reputable breast radiology unit. Find out costs before undergoing breast biopsies (no such thing as you need to have the biopsy as an emergency on that day), and clinical radiology review is always advised. Clinical tricky presentations that are suspicious for cancers require a closer look at the cards hidden up the sleeves.

The first illusion

You have a problem with your nipple. You search itch, rash, red change on nipple; the result tells you Paget’s (a cancer that involves the nipples) and truly this is often.

Missed cancer that can be found in the presence of a normal mammogram, Paget’s starts as a small erosion on the nipple and gradually expands. What else could this be?

The nipple looks cherry red and protruding and feels like there is a mass in it. This alarming-looking mass that affects the nipple is a condition called erosive papillomatosis. The nipple can bleed and looks red and bulbous. How about a nipple adenoma? Sometimes whitish in colour protruding through the nipple. Now for the real weirdo nipple masses.

A syringomatous lesion of the nipple is another unusual mass usually found on the side of the nipple and sometimes looks bluish and fixed on the nipple. Did you know you can get skin cancers on the areolar?

All these unusual conditions are best diagnosed by a trip to the dermatologist (after assessment in a breast unit) and a punch biopsy of the concerning area. Surgical excision will be required so if you find an unusual mass don’t delay as the longer you leave these locally aggressive masses, their continued growth may result in reconstruction of the nipple.

A common sleight of the hand around nipple concerns is eczema which presents with itchy scaly ooze on the nipple but doesn’t require any surgery.

Remember to check the skin of breasts. I found a mole on the top of my breast that I hadn’t noticed before and thought eek! Thank goodness all is fine, but we do see melanomas and even other skin cancers in the décolletage or on the areolar.

The card tricks

How about unusual breast masses that may look or feel like cancers? Did you search red hot breast and inflammation on the breast and inflammatory cancer popped up?

It could be duct ectasia, a complex disorder where there seems to be a sebaceous-like thick breast secretion (like porridge or toothpaste) that blocks the ducts (causing ectasia or dilation of the ducts). It also leaks into the breast stromal fat (periductal mastitis), causing inflammation and this chemical inflammation, followed by a secondary bacterial infection, causes no end of problems.

Smoking is a contributing culprit, aggravated by a combination of environmental factors, hormonal interaction and stress. A range of presentations, from a nipple discharge usually where the nipple is squeezed to nipple retraction or horizontal fissuring of the nipple, may be seen. As well as breast pain which is usually described as a burning or shooting pain due to plasma cell mastitis (inflammation of the breast caused by the thick toothpaste material extruding out of the duct lumen becoming infected with anaerobic bacteria).

But the most important illusionist is when duct ectasia presents as a non-lactating breast abscess (progression from the plasma cell mastitis to bacterial infection and abscess formation). Try avoiding surgeons operating on this condition. Treatment consists of giving antibiotics specific for the bacteria cultured (commonly a staphylococcus aureus). Non-lactating breast abscess may require drainage, but this should be under ultrasound-guided aspiration.

The breast trickster

Another unusual presentation of red hard breast masses are the unusual inflammatory conditions granulomatous or non-granulomatous breast inflammation.

Any inflammatory response occurring in the breast can lead to induration, pain and a mass becoming palpable. Inflammation in the breast can either arise from local infection or inflammation, or from a systemic disease.

Tuberculosis is the most common cause of granulomatous mastopathy in the breast; and very commonly seen in Africa. But don’t exclude it if you live elsewhere. It can often mimic a breast abscess or a malignant lesion, such as inflammatory breast cancer, and may be extremely difficult to diagnose. In daily practice, it most commonly manifests as a severe breast abscess or ulcer which fails to improve on antibiotics and drainage. I just saw two ladies at the BHF outreach clinic at Tintswalo Hospital with this condition. The common card in this illusion is that despite the size of the abscess you find in the breast, you don’t feel hard malignant lymph nodes that you would feel if the ulcer or abscess was malignant. If pus is aspirated and cultured, bacilli may not be present thus confounding the diagnosis.

There is an association with auto-immune disease, connective tissue disease and in patients with HIV/AIDS but can occur in any individual. The TB bacilli are extremely hardy, and exposure in SA to this pathogen is common. Clinical improvement of the breast on a bacteriostatic antibiotic may indicate the diagnosis, but often empirical treatment without confirming the diagnosis is required. The diagnosis of breast TB is particularly tiresome and can require multiple tests of various types to confirm the diagnosis.

As with other extra-pulmonary disease, nine months of TB treatment is indicated following notification and referral to a TB specialist centre. Regular follow-up ensures a malignant diagnosis isn’t missed.

The great mimicker

Another unusual inflammatory breast condition that is a great mimicker is idiopathic granulomatous mastitis. This is the name given to a mastopathy proven on needle biopsy but with no underlying cause evident. It’s very difficult to diagnose and treat. Interestingly, we see a fair amount in Africa.

Initially, I use a combination of antibiotics and anti-inflammatories. Again, the secret is to not operate. After a prolonged antibiotic course, steroids are prescribed and if still reoccurring referral to a rheumatologist for autoimmune or connective tissue diagnoses and treatment.

Excision should never be done as flare-ups following excision are common. There are a number of mastopathies that can present secondarily to an inflammatory response in the breast caused by diabetes, sarcoidosis and Wegener’s granulomatosis. They should all be diagnosed and treated without surgery.

The above unusual conditions should only be managed in units specialising in breast diseases, as combined approaches by different specialists are often required.

The rabbit in the hat

You felt a big gland (lymph node) in your armpit. Remember feel for lymph nodes with your arms relaxed at your side and not above your head. Lymph nodes that are big and chunky need a focused axillary ultrasound. In fact, every time you go for a breast radiology appointment, insist the doctor does an axillary ultrasound. The secret is serial ultrasounds (insist after six weeks and then three months).

Glands increasing in size or with a thickened cortex or no fatty hilum need a core biopsy. Even with results being benign (not cancerous), if the gland gets bigger, it needs to come out. (Yup, the don’t-rush-into-surgery surgeon now tells you to take it out). Send half for histology and half for microbiology (for weird bugs).

What can cause big glands? Well following silicone prosthetic insertion, either for cosmetic or reconstruction purposes, extracapsular rupture of the prostheses with subsequent leakage of silicon can result in a foreign body initiated inflammatory response and silicone granulomas. In short, rupture can cause silicone to leak and you can get silicone in the glands.

These ruptures were most commonly seen before the use of cohesive gel prosthesis. Concerning causes of large lymph nodes are lymphoma, and unusual infective conditions ranging from viruses (HIV; vaccine reactions), cat scratch disease, TB and others.

The great Houdini escapes

Those mysterious mammogram concerning areas that aren’t cancer. Great cancer mimics on mammogram can be areas of fat necrosis that look like a cancer but are not. Please don’t go for an operation without a radiology review and core needle biopsy (I recently saw a lady who had a mastectomy because it looked like a cancer but was fat necrosis).

Risk lesions in the breast are a bit like the daddy long-legs versus spider analogy. Looks like a cancer (spider) but is not; the secret is good radiology review and a core biopsy if needed.

Remember that to find the illusion requires training in the art of magic. Ensure that you see a master magician, who understands all the secrets behind the illusions that look like cancer.

Header image by Freepik