compresses or breastfeeding, or with massage. Sometimes redness and pain develop, a condition called mastitis, in which case antibiotics are necessary.
For women in whom the inflammation does not resolve in a few days or seems to get worse under treatment, referral to a breast surgeon should be considered. Although inflammatory breast cancer (see chapter eleven) is rare, it should be considered in cases in which an inflammation does not respond to standard treatment.
Benign breast lumps that occur during lactation are of two basic types: cystic and solid. “Milk cysts” are those most commonly seen in my practice. They are easy to diagnose on ultrasound, and usually they will go away on their own. But if they are painful or of concern to the patient, they can be easily aspirated in the office under local anesthesia.
Solid breast lumps are also common during lactation. Ultrasound is the first step in evaluating new irregularities in nursing mothers. Solid lumps are easily distinguished from cystic lumps. Benign lumps (non-cancerous) are generally easy to distinguish from those that are suspicious.
Benign lumps are typically smooth and round, and for these I simply aspirate the lump with a fine needle and send the cells to the pathologist. If the review confirms that the cells are benign, I can easily monitor the patient’s progress in my office. If, on physical exam or ultrasound, the mass in question is hard and irregular, I typically go straight to a core needle biopsy.
That said, open surgical biopsy should be avoided whenever possible. An open biopsy during lactation is fraught with problems because of dilated milk ducts and increased blood supply to the lactating breasts.
In rare cases, a breast cancer will be diagnosed during lactation. Just as with pregnancy, a team approach is essential for optimal outcomes. A nursing woman on chemo will need to stop breastfeeding, but can safely continue while on radiation as long as she uses only the non-radiated breast.
WHAT I’D TELL MY DAUGHTER
• The combination pill is an excellent choice for most women, but women should be aware of their personal risks and discuss other options with their physician.
• Continue to do monthly self-exam during pregnancy and lactation and report any persistent major changes to your physician.
YES, MEN CAN AND DO have breast problems. As with women, the vast majority are not related to cancer. It has been estimated that a young man has a better chance of winning the lottery than of being diagnosed with breast cancer . . . but surprisingly, it is possible.
The same can’t be said for testicular cancer, the most common malignancy in males between the ages of fourteen and forty. So why mention testicular cancer in a chapter on breast issues in men? The reason is simple: A breast lump can be the first sign of a hidden testicular cancer.
A great deal of progress has been made in treating testicular cancer, but to maximize the potential for cure, it is still important to detect the malignancy at its earliest stage. Also, delays in diagnosis often result in the need for more aggressive treatment, which may include both chemo and radiation therapy.
In addition to the possibility of testicular cancer in young men, there is a chance of breast cancer in older men. As with women, age is a significant predictor of the types of breast problems males are likely to experience. Therefore, in discussing issues on the masculine side, it is logical to divide them into three age categories, recognizing there is a fair amount of overlap between the age groups.
NEWBORNS TO PUBERTY
It is common for newborn babies of both sexes to have enlarged breasts, and some will have lumps below their nipples. This is a self-limiting condition, and no treatment is required. In most cases, the enlargement will go away in a matter of weeks.
In the years between birth and the onset of puberty, breast problems are rare for both sexes. Still, breast lumps and breast infections can occur, and any changes should be reported to a pediatrician.
Puberty is when breast problems become more common in boys. Enlargement on one or both sides is often associated with pain, tenderness, and a distinct mass. A breast lump in this age group is referred to as gynecomastia, which roughly translates as “breasts like those of a woman.”
The term gynecomastia is actually well chosen, because it implies a hormonal origin to the problem, which in fact is the case. The term is reassuring, since it avoids any reference to breast cancer, which is extraordinarily rare in this age group. A careful history and clinical exam of the breast is all it takes to make the diagnosis. In most cases, reassurance and observation are sufficient. Though the risk of missing a breast cancer in this age group is extraordinarily low, I still advise parents to have the child return if there is any progression of symptoms, such as an increase in size or onset of pain or tenderness. When gynecomastia lasts longer than two years, the chances of the breasts returning to normal are greatly reduced. We encourage boys with persistent small lumps to wait them out since, over the next few years, many of these lumps will slowly go away.
Larger lumps are more problematic. Often these protrusions are so obvious they are visible even when the boy is wearing a T-shirt. The embarrassment can be devastating to young boys, who are often already self-conscious about their body image.
With boys who have a large lump or whose entire breast is enlarged because of an excess of fatty tissue, it is more difficult to obtain a satisfactory cosmetic result. In these unusual cases, referral to a plastic surgeon may be indicated.
Although there are reports of gynecomastia cases responding to hormone-blocking medications, I have no personal experience with this approach. If the family has an interest in trying a medical approach, I would recommend consultation with an endocrinologist.
MEN FOURTEEN TO FORTY
When I see a young male with a breast lump in this age group, the first thing that comes to mind is the possibility of an associated testicular cancer. Missing such a cancer in a young man can be just as dangerous as missing the diagnosis of a breast cancer in a young woman.
Thus, every breast lump in this age group needs special attention, even though the chances of it being the first sign of hidden testicular cancer are small. The key to avoiding a delayed diagnosis is for the treating physician to consider testicular cancer as a possibility. Specific questions should be asked about any history of testicular symptoms, such as swelling, tenderness, pain, lumps, or any other oddity the patient can remember. An examination of the testicles should also be done. If there is even the slightest possibility of an abnormal finding on clinical exam, a testicular ultrasound should be ordered.
It is important to keep in mind that the testicular exam can be completely normal and still harbor a “hidden” cancer. These “occult” testicular malignancies are often first detected by blood-test screening in young men with breast enlargement.
I routinely order the following blood tests for young men with breast lumps:
• AFP (alpha-fetoprotein)
• Beta hCG (human chorionic
