A diagnosis based on imaging alone is acceptable, providing the patient is young (≤21 years old), and the lesion measures <3 cm. Otherwise, a histological diagnosis should be established by core needle biopsy. In patients with multiple fibroadenomas, two or more lesions should be sampled, and the remainder should be imaged and monitored. Any fibroadenoma over 4 cm requires full assessment by core biopsy. Multiple core biopsy passes (ideally 5–6 cores) should be performed in order to ensure that the lesion is adequately sampled and minimising potential sampling error.

Following a core biopsy pathologic diagnosis of a simple fibroadenoma, simple reassurance that the lesion is benign, with no malignant potential, is all that is required, and no further follow-up is necessary. However, excision is often performed at the request of the patient who despite this knowledge wishes the lesion to be removed. Larger lesions are usually excised first because they are often visible and symptomatic, but if they have been adequately sampled, they can be safely observed. Lesions over 5 cm are usually excised even if they are fibroadenomas on core biopsy because they are usually symptomatic, causing pain and/or discomfort. It is important to be certain that they are simple fibroadenomas and not phyllodes tumours.

A cosmetic approach is recommended if a fibroadenoma is to be excised. Lesions in the lower half of the breast can be approached through an incision in the inframammary fold. Lesions in the upper half can be excised through a circumareolar incision or if near the axilla through an axillary skin crease incision.

If an inframammary incision is used, then the incision is taken down to the rectus abdominus muscle and pectoral major muscle. The breast is elevated from the pectoral fascia without disturbing the fascia, and the fibroadenoma is approached from behind the breast. Fibroadenomas can be enucleated, and the best way to perform this is to open the capsule with blunt dissection using a pair of Metzenbaum scissors through the posterior aspect of the breast. The scissors are aimed at the fibroadenoma and opened, and this results in opening of the breast tissue down to the capsule of the fibroadenoma. Once the capsule is reached, the scissors are pushed into the capsule and opened, and this splits the capsule. A finger can then be inserted and the fibroadenoma enucleated. It usually remains attached at the point where the blood supply enters, and at this site the fibroadenoma is adherent to the capsule. Once the fibroadenoma is fairly mobile within the capsule, it is usually possible to deliver it through the wound and divide any residual attachment to the capsule under direct vision with diathermy. The defect in the back of the breast is closed with absorbable interrupted sutures. Bleeding is rarely a problem but careful inspection of the capsule is performed, and any bleeding is stopped with diathermy. The inframammary wound is then closed carefully in layers.

If the fibroadenoma is being approached through a circumareolar incision, then having deepened the incision the plane between the subcutaneous fat and the breast fat is entered. This may be facilitated by hydrodissection using normal saline or a 1 in 500,000 adrenaline in normal saline solution. Once the breast tissue over the fibroadenoma is reached, then the tissue is opened down to the fibroadenoma using scissors pointed at the fibroadenoma with the scissors being opened to divide the overlying breast tissue, and then the capsule around the fibroadenoma is also split with scissors. Enucleation is performed with a finger, and the lesion is delivered through the tunnel into the wound and the blood supply of the fibroadenoma divided under direct vision. No sutures in the breast tissue are needed. The skin is closed in layers with absorbable sutures. Small fibroadenomas can be removed using vacuum-assisted core biopsy devices [10].

Most phyllodes tumours are benign and require total removal but do not require to be widely excised. When removing a benign phyllodes tumour, the lesion together with the capsule is excised with the aim of achieving clear margins clear (≥1 mm) of the phyllodes tumour. If following excision of an apparently simple fibroadenoma a phyllodes tumour is diagnosed and the surgeon is confident that the lesion has been excised completely, then careful follow-up, rather than re-excision, is appropriate. Borderline and malignant phyllodes may require a wider excision.

It is important to differentiate between pain arising from the chest wall and true breast pain. Features suggesting that the breast pain is referred pain from the chest wall include:

Careful clinical examination is essential. A patient complaining of breast pain should have an examination lying on her side allowing the breast to fall away from the breast wall, and the underlying ribs and muscles should then be palpated. The patient should be asked to indicate if there is any localised tenderness on the palpation of the chest wall and whether the pain elicited is similar to that they normally suffer. If the patient has pain in the lower part of the breast, then the underlying chest can be checked by lifting the breast upwards with one hand while palpating the underlying chest wall with the other hand.

The mainstay of treating breast pain is reassurance that there is no serious underlying problem [12]. Lifestyle issues are important and it is not uncommon for women who spend many hours at a desk, sitting in front of a computer, to have chest wall pain. If, on examination, the pain is very localised to one specific spot on the chest wall, then infiltration of the site of the pain with a combination of prednisone (40 mg in depot form) combined with a long-acting local anaesthetic such as bupivacaine can produce long-lasting pain relief.

Pain in bed at night is a problem for many women. Wearing a soft supportive bra stops the breast pulling down on the chest wall, and this helps many women to sleep. There have been numerous studies looking at the role of caffeine, essential fatty acids, and diet as a contributing factor for breast pain. There is little evidence that activities such as cutting out caffeine, taking evening primrose oil, or transferring to a low-fat diet are beneficial [13–16].

The treatment that has been shown to have greatest efficacy in true breast pain is tamoxifen [17]. Although most commonly given for cyclical pain, it can help true noncyclical breast pain. It is best tolerated in a dosage of 10 mg a day [18]. Compared with other treatments, such as danazol, there are fewer adverse events with tamoxifen [18]. It is possible to restrict the use of tamoxifen to the luteal phase of the cycle, and this can relieve pain in up to 85 % of women [19, 20].

A variety of nonhormonal agents have been tried for breast pain. Although some studies have reported an improvement with soya milk, there is general non-compliance in studies published to date [21]. Agnus castus, a fruit extract, has been shown in one trial to improve breast pain [22]. Selective serotonin reuptake inhibitors have also been shown to improve breast pain [23].

Following aspiration, the majority of patients require no clinical follow-up. It is only those patients who have multiple bilateral cysts who merit any further clinical follow-up. The only reason for seeing these women is that they tend to continue to develop multiple bilateral cysts and return at regular intervals to breast clinics. Regular assessment by clinical assessment and ultrasound allows them to be reassured without the need for regular re-referral. During follow-up only symptomatic cysts should be aspirated. Studies show a small but not a significant increased risk of breast cancer in women with palpable breast cysts [25].

They are normally identified on imaging with only a few palpable on clinical examination. A core needle biopsy should be performed. There is some concern that a standard 14-gauge core biopsy might miss a small area of DCIS in association with a radial scar or a complex sclerosing lesion. For this reason larger, vacuum-assisted core biopsy or a needle localisation excision biopsy is required to make a definitive diagnosis [26]. Debate continues as to whether all radial scars should be excised because of their association with invasive and in situ breast cancer [27].

Imaging can usually diagnose duct ectasia, and for patients with nipple inversion who have no suspicious features clinically or radiologically, surgery is not required. Surgery is only indicated in multiduct discharge, if it is troublesome or there is an inverted nipple and the patient wants the nipple to be everted. Duct ectasia (Fig. 3.6) should not be confused with periductal mastitis which is a separate condition [28–30]. Once cancer has been excluded, patients with duct ectasia can be reassured and do not require follow-up.

Options include observation if there is no evidence of atypia or excision (Fig. 3.7). Papillomas can be removed with vacuum-assisted core biopsy. They are often excised to exclude malignancy, but given their frequency and low rate of malignancy, there needs to be greater consideration as to whether all such lesions need to be removed [31].

Physical examination should include application of firm pressure around the areola as the presence of a dilated duct will result in the production of discharge through the nipple (Fig. 3.11). The nipple should also be squeezed with firm digital pressure, and if fluid is expressed, then the site and character of the discharge recorded. Age is an important predictor of malignancy, and in one study 3 % of patients younger than 40, 10 % of patients between the ages of 40 and 60 and 32 % of women older than 60 years of age who had nipple discharge as their only symptom were found to have cancer [35]. Mammography has a low sensitivity of only approximately two thirds in women with nipple discharge [36, 37]. Ultrasound can identify visible lesions within the breast ducts including papillomas [38]. Imaging the ductal tree by ductography or galactography can identify intraductal lesions, but this investigation has a sensitivity of only 60 % for malignancy [33, 39]. Nipple cytology, ductoscopy and ductal lavage have a role in routine assessment of nipple discharge [40–44]. Of these techniques, ductoscopy is the most accurate but takes longer than 6 months to learn and the equipment is costly [45].

If clinical examination demonstrates a mass lesion visible on mammography or ultrasonography, then image-guided core biopsy of this lesion should be performed and the patient managed appropriately [38]. Otherwise, if no abnormalities are found on clinical examination, surgery is indicated for spontaneous discharge from a single duct that has one or more of the following characteristics:

Discharge from multiple ducts normally only requires surgery when it causes distressing symptoms.

Options for surgery for single-duct discharge include microdochectomy or total duct excision. Current evidence suggests that total duct excision is more effective than microdochectomy at establishing a specific diagnosis and has a lower chance of missing any malignancy that is present [46]. For this reason, many units perform total duct excision in women over the age of 45 and only perform microdochectomy in younger women [47].

In drug-related gynecomastia, withdrawal of the drug or change to an alterative treatment should be considered. Gynecomastia is seen in bodybuilders who take anabolic steroids, and some of these have learned that by taking tamoxifen, they can counteract these symptoms. Bodybuilders should be encouraged to reduce or stop steroids. In young men, gynecomastia is seen in both heavy beer and lager drinkers and in young men who smoke cannabis. There are phytoestrogens in beer and lager; cannabis is also estrogenic in its action.

In patients with symptomatic gynecomastia, both tamoxifen and danazol improve symptoms, but recurrence when the drug stops can be a problem [53, 54]. Tamoxifen at a dose of 10 mg is effective and produces less side effects than 20 mg. Surgery for gynecomastia is not straightforward and should normally be performed by experienced breast surgeons or plastic surgeons. It often involves a combination of excision of breast tissue and liposuction occasionally with removal of overlying skin [55–57] (Fig. 3.14).