An Image-Rich Educational Review of Breast Pain

Abstract

Breast pain is extremely common, occurring in 70% to 80% of women. Most cases of breast pain are from physiologic or benign causes, and patients should be reassured and offered treatment strategies to alleviate symptoms, often without diagnostic imaging. A complete clinical history and physical examination is key for distinguishing intrinsic breast pain from extramammary pain. Breast pain without other suspicious symptoms and with a negative history and physical examination result is rarely associated with malignancy, although it is a common reason for women to undergo diagnostic imaging. When breast imaging is indicated, guidelines according to the American College of Radiology Appropriateness Criteria should be followed as to whether mammography, US, or both are recommended. This review article summarizes the initial clinical evaluation of breast pain and evidence-based guidelines for imaging. Additionally, the article reviews cyclical and noncyclical breast pain and provides an image-rich discussion of the imaging presentation and management of benign and malignant breast pain etiologies.

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Key Messages.

• Isolated breast pain is most often secondary to physiologic or benign etiologies and is rarely due to malignancy.

• Patients with nonfocal breast pain and a normal physical examination can be cared for with 1) reassurance and symptom control, without the need for diagnostic imaging, and 2) routine screening mammography based on the patient’s age and breast cancer risk status.

• Imaging for patients with clinically significant focal and noncyclical breast pain are based on the American College of Radiology Appropriateness Criteria, which recommends diagnostic mammography and/or US, depending on the patient’s age.

Introduction

Breast pain, also known as mastalgia or mastodynia, is a common clinical scenario that many physicians, including radiologists, encounter in practice. More than 50% of women experience breast pain during their lifetime (1,2). In the primary care setting, mastalgia accounts for 47% of breast-related symptoms (3). Severe breast pain may also be a cause for presentation to the emergency department (4). Breast pain may be the sole presenting symptom or may be associated with other symptoms (palpable mass, nipple discharge, skin changes). Breast pain without other suspicious symptoms is rarely associated with cancer but is a common reason for referral for diagnostic imaging.

Given the prevalence of breast pain, it is important for radiologists to know the appropriate imaging examination for these patients and recognize the imaging appearances for common benign and rare malignant etiologies associated with breast pain. This article summarizes the initial clinical evaluation of breast pain and evidence-based guidelines for imaging for this clinical scenario. Additionally, the article reviews cyclical and noncyclical breast pain and provides an image-rich discussion of the imaging features and management of benign and malignant causes of breast pain.

Clinical examination

The clinical examination of patients presenting with breast pain starts with a complete history and physical examination (5,6). A detailed history should include laterality, location, duration, severity, quality, temporal relationship to menses, and associated inciting or relieving factors. Associated symptoms such as skin changes, nipple discharge, and palpable masses should be evaluated, as well as recent history of pregnancy, trauma/procedures, or strenuous physical activity. Current medications with a focus on hormones, antidepressants, and antihypertensives should be reviewed in addition to personal or family history of breast cancer. Physical examination in the seated and supine positions should include inspection for erythema, dimpling, retraction, or nipple discharge and palpation of the breast and regional lymph node basins, including the axilla, for reproducibility and localization of the pain and for associated masses, nipple discharge, or lymphadenopathy. Additional examination with the patient lying on each side, to allow the breasts to fall away from the chest wall, can be performed to evaluate the underlying muscles and ribs for extramammary causes of pain (6).

Clinical evaluation is key for classifying breast pain as 1) cyclical or noncyclical and 2) focal or diffuse, as well as for 3) excluding the presence of associated breast symptoms. These factors will determine whether further evaluation with breast imaging is indicated or whether the clinical work-up alone is sufficient and the patient can be reassured and treated conservatively without diagnostic imaging.

Imaging evaluation and diagnostic performance

Clinical indications for imaging evaluation of isolated breast pain are provided by the American College of Radiology (ACR) Appropriateness Criteria (Table 1) (7). When pain is associated with other breast symptoms, the imaging evaluation should follow ACR Appropriateness Criteria for the primary concern, such as for palpable masses (8) or nipple discharge (9).

Table 1.

American College of Radiology (ACR) Appropriateness Criteria for Imaging Evaluation of Breast Pain

Classification	Recommendation
Clinically insignificanta	Diagnostic imaging not recommended (all ages). Routine screening mammography per ACR guidelines.
Clinically significantb	For patients <30 years old, diagnostic imaging with US. For patients ≥30 years old, diagnostic imaging with mammography/digital breast tomosynthesis and US.

^aNonfocal, diffuse, cyclical, no other suspicious clinical findings.

^bFocal, noncyclical.

The main indication for breast imaging in patients with isolated breast pain is based on whether the pain is “clinically insignificant” or “clinically significant” (7). “Clinically insignificant” breast pain is defined as nonfocal (>1 quadrant), diffuse, or cyclical with no other suspicious clinical findings. For this scenario, imaging is not indicated beyond routine screening recommendations based on age and breast cancer risk status (10,11). “Clinically significant” breast pain is defined as focal and noncyclical, and the imaging recommendations are based on patient age. For women with clinically significant breast pain who are younger than 30 years old, targeted US at the area of focal pain is appropriate. For women with clinically significant breast pain who are 30 years and older, diagnostic mammography, including digital breast tomosynthesis, and US are appropriate. For diagnostic mammography, a skin marker is typically placed at the site of focal pain, and full craniocaudal and mediolateral oblique views are obtained. Other projections may include a full mediolateral and/or spot compression views at the site of focal pain, and protocols are varied across practices. When mammography is performed as the initial examination and has negative results, US may not be necessary, particularly for patients with nondense breasts (12–15). Breast MRI and molecular breast imaging are “usually not appropriate” for women with clinically insignificant or clinically significant breast pain given the lack of relevant literature (7).

The ACR Appropriateness Criteria also provide guidance on the use of diagnostic mammography and US for pregnant and lactating women with focal breast pain (16). Although most cases of pregnancy-associated breast cancer present as a palpable mass, focal pain is a less common presenting symptom (16,17). The criteria emphasize that mammography is not contraindicated during pregnancy or lactation and can be safely performed when warranted by clinical symptoms and for further evaluation of negative or suspicious sonographic findings (16).

Mammography and US have been found to perform well for excluding cancer in women with focal breast pain because of a high negative predictive value (NPV). Several studies have reported the NPV of mammography and US at 99.8% to 100% (13–15,18,19).

Most imaging examinations performed for isolated breast pain have negative results, with no correlate to explain the patient’s symptoms (Figure 1). Prior studies have reported negative imaging results (Breast Imaging Reporting and Data System [BI-RADS] 1) in 77.3% to 95% of isolated breast pain cases (13,18,20–24). Occasionally, a benign correlate will be identified at the site of focal pain. Prior studies have reported benign imaging findings (BI-RADS 2), most commonly cysts, in 2.5% to 20% of cases (21,22,25). Specific benign findings may be reassuring to the patient and offer an opportunity for intervention, such as cyst or abscess aspiration, for symptomatic relief. Rarely, malignant findings will be associated with the site of focal pain. The reported malignancy rates range from 0% to 2.3% (13,15,18,19,21,22,25–28). Several studies observed malignancy rates (0.2% to 0.4%) similar to the cancer detection rate in asymptomatic screening mammography population (5/1000 screens; 0.5%) (12,14,21,25–27). In the prospective observational follow-up study by Duijm et al, the prevalence of breast cancer was similar in the symptomatic cohort of women with isolated breast pain (0.4% in the painful breast; 0.8% total including asymptomatic contralateral malignancy) and in control women referred for screening mammography (0.7%) (21).

Figure 1.

Forty-eight-year-old woman with constant focal left breast pain. A: Spot mediolateral oblique view from a diagnostic mammographic examination with digital breast tomosynthesis shows no suspicious finding at the area of pain indicated by a BB skin marker. B: Targeted US of the area of focal pain shows no suspicious findings. Clinical follow-up and symptomatic management were recommended.

Imaging should be used judiciously for isolated focal breast pain according to evidence-based guidelines. Given the low likelihood of malignancy associated with focal breast pain without an associated palpable mass and the high NPV of mammography and US, it has been suggested that imaging may have greater impact on patient reassurance than for cancer detection (22,29). US has been shown to reduce anxiety and pain in a questionnaire study of 51 patients with breast pain and a normal physical examination result (20). However, initial imaging for isolated breast pain in 1 study (30) was shown to increase subsequent use of health care resources and also can have the drawback of unnecessary biopsy or follow-up imaging recommendations because of false positive findings on US (15). A cost-analysis study of 799 patients with breast pain at 3 community breast imaging centers concluded that imaging for breast pain without associated suspicious symptoms is an overuse of health care resources (23). The authors propose new recommendations for focal breast pain evaluation: an annual screening mammogram for women 40 years and older and reassurance for women younger than 40 (23). Likewise, a study by Mohallem Fonseca et al of 953 patients found that the cancer detection rate in patients with isolated breast pain was comparable with the cancer detection rate in asymptomatic women and suggested that diagnostic imaging evaluation for isolated breast pain may not be necessary and can lead to overuse of health care resources (28). Other investigators have suggested a shared decision-making approach in the primary care setting regarding initial imaging evaluation of localized persistent noncyclical breast pain in women over 35 years old based on a systematic review of the literature (31). An update of the ACR Appropriateness Criteria for breast pain is anticipated to be released soon.

Breast pain classification and differential diagnoses

Mastalgia is typically classified as cyclical, noncyclical, or extramammary (5). The cause of breast pain is often idiopathic, physiologic, or secondary to a benign etiology, with malignancy occurring only rarely (Table 2). Factors such as diet, medications, stress, hormonal fluctuations, and an improperly fitted bra may contribute to physiologic mastalgia (6,32).

Table 2.

Classification and Differential Diagnoses for Breast Pain

Classification	Benign	Malignant
Cyclical	• Normal/physiologic • Fibrocystic change • Hormonal-based medications	-
Noncyclical	• Cyst • Fibroadenoma • Duct ectasia • Pseudoangiomatous stromal hyperplasia • Infection (mastitis, abscess) • Inflammation (idiopathic granulomatous mastitis, lupus mastitis, diabetic mastopathy) • Mondor’s disease (superficial thrombophlebitis) • Trauma • Postsurgical • Sebaceous or epidermal inclusion cyst • Dercum’s disease (adiposis dolorosa) • Medications, hormone replacement therapy • Pregnancy • Large pendulous breasts (Cooper ligament strain) • Gynecomastia (males)	• Inflammatory breast cancer • Invasive carcinoma with perineural invasion
Extramammary (referred pain)	• Costocondritis, Tietze syndrome • Rib fracture, chest wall trauma • Radiculopathy • Shoulder bursitis • Shingles • Pneumonia • Myocardial ischemia • Esophageal spasm • Biliary disease	-

Cyclical breast pain

Cyclical mastalgia is the most common type of breast pain and is characterized by a temporal association with the menstrual cycle (5,6). Pain typically occurs in the luteal phase, related to physiologic hormonal stimulation of the breast tissue, and is most intense during the week before menstruation. Cyclical mastalgia occurs in up to two-thirds of people with breast pain, most often in their mid-20s to 30s. It typically presents as diffuse bilateral pain but can localize to the upper outer quadrant in some patients because most of the fibroglandular tissue is usually located in that quadrant. Patients may describe the pain as dull, shooting, stabbing, heaviness, aching, or throbbing (6). Cyclical breast pain may also be associated with the use of hormonal medications, such as oral contraceptives and hormonal replacement therapy.

Imaging is not recommended in the examination of patients with cyclical mastalgia and a normal physical examination result because this type of breast pain is not associated with malignancy and has no specific imaging correlate (7,25). Reassurance is the primary treatment approach for patients with cyclical mastalgia, which typically resolves spontaneously in most patients over several months (5,6). Improvement typically occurs after menopause but can flare in the perimenopausal period (5,6).

Fibrocystic change frequently presents with cyclical breast tenderness, in response to hormonal fluctuation, and is a spectrum of benign histopathologic changes including cysts commonly seen in premenopausal women. These findings may also present as a painful area of concern (13,21,27). Fibrocystic change usually has a characteristically benign appearance on imaging (Figure 2). Mammographic findings include often bilateral, partially circumscribed, partially obscured oval or round equal density masses. Calcifications may be diffuse punctate or grouped layering milk-of-calcium in microcysts. US typically demonstrates a spectrum of multiple simple cysts, complicated cysts with debris, or clustered microcysts. On MRI, oval or round T2 hyperintense masses without enhancement or with thin peripheral pericystic enhancement are usually observed. Fibrocystic change may warrant aspiration or biopsy if the imaging appearance is not classically benign. Treatment is the same as for physiologic cyclical breast pain.

Figure 2.

Multimodality imaging appearance pattern of the benign histologic diagnosis of fibrocystic change in 3 different premenopausal patients. A: Craniocaudal mammogram of the left breast demonstrates heterogeneous dense breast tissue with numerous bilateral (right breast not shown) partially circumscribed and partially obscured masses (circle) and a dominant mass in the upper outer quadrant (arrow), which was a benign cyst on US (not shown). B: Transverse (left) and longitudinal (right) US images demonstrate multiple small cysts (arrows) and normal-appearing fibroglandular tissue in the upper outer right breast corresponding to a painful palpable area of concern. C: T2-weighted (left) and postcontrast T1-weighted axial fat-saturated images (right) from breast MRI demonstrate multiple oval and round T2 hyperintense, nonenhancing masses (arrows) with circumscribed margins with marked background parenchymal enhancement.

Noncyclical breast pain

Noncyclical mastalgia is not related to the menstrual cycle and accounts for approximately one-third of patients presenting with breast pain, most often women in their 40s and 50s (5,6). It typically presents as unilateral, constant or intermittent burning pain localized to 1 quadrant (6). Diagnostic imaging examination of patients with noncyclical breast pain is appropriate to exclude the rare likelihood of malignancy and to determine whether there is a benign, treatable etiology (7). There are many causes of noncyclical breast pain, as described in this section. However, frequently the cause is not identified (idiopathic). Noncyclical mastalgia spontaneously resolves in 50% of women (5).

Breast cysts are a common cause for focal noncyclic pain (13–15,18,19,21–23,27,29,33), particularly if inflamed or ruptured (complicated cysts) (28,29). Figure 3 demonstrates the classic imaging appearances of simple cysts. On US, simple cysts are oval, anechoic masses with circumscribed margins and posterior acoustic enhancement and without internal vascularity. Inflamed cysts may have a mildly thickened wall and internal layering or mobile debris. Simple cysts may undergo fine-needle aspiration (18) for symptomatic relief, whereas complicated cysts may require interval follow-up imaging in addition to aspiration (27,28) and potentially biopsy, depending on the imaging appearance.

Figure 3.

Multimodality imaging appearance of benign cysts. A: Premenopausal female patient with a tender palpable area of concern in the upper outer right breast. Craniocaudal (left) and mediolateral oblique (right) views from a diagnostic mammogram of the right breast demonstrate an oval, equal density mass with obscured margins (circles) at the area of concern indicated by a BB skin marker. B: Longitudinal US image of the area of concern demonstrates an oval anechoic mass (arrow) with circumscribed margins and posterior acoustic enhancement, which corresponds to the mass on mammography and is a classic US appearance of a simple cyst. C: Appearance of a simple cyst on axial chest CT (right) is a low attenuating oval nonenhancing circumscribed mass (arrows) with no associated uptake of FDG on PET/CT (left). D: On breast MRI, simple cysts appear as a hyperintense oval mass (arrows) with circumscribed margins on T2-weighted images (left) and with no internal enhancement on postcontrast T1-weighted fat-saturated images (right).

Duct ectasia is frequently asymptomatic but has been reported in patients with mastalgia (14,19,26,27,29,34). This benign process reflects duct widening from glandular atrophy and secretory stasis and may be associated with periductal inflammation and fibrosis. Figure 4 demonstrates the classic imaging appearance of duct ectasia. Mammographic features include subareolar tubular or branching ducts, usually bilateral. US findings include dilated (>2 mm) retroareolar ducts that are anechoic fluid-filled or with mobile debris. Biopsy may be necessary if a hypoechoic potential intraductal mass is identified. High-intensity signal within dilated retroareolar ducts can be observed on the T2-weighted and precontrast T1-weighted image on MRI. Duct ectasia without associated suspicious findings are treated with reassurance and supportive measures. Microductectomy may be warranted if associated with bloody nipple discharge.

Figure 4.

A: US appearance of benign duct ectasia on transverse US is multiple elongated anechoic tubular structures (arrow). B: Ducts should be carefully evaluated for the presence of a hypoechoic intraductal mass (arrow), which could represent intraductal papilloma or ductal carcinoma in situ and should be recommended for US-guided biopsy (BI-RADS 4).

Benign solid masses, such as fibroadenomas and papillomas, are usually not painful but have been reported in patients presenting with focal breast pain (13,14,18,21,22,26,29,33). Fibroadenomas are hormonally sensitive and may be tender before menses. Pain may also be associated with fibroadenomas with rapid growth or infarction, in rare cases (35). Phyllodes tumors can also present with a painful palpable mass that appears indistinguishable from a fibroadenoma by imaging (36). Reactive lymph nodes may also be painful (13,14,26). Dercum’s disease (adiposis dolorosa) is a rare cause of noncyclical mastalgia characterized by multiple painful lipomas (37).

Pseudoangiomatous stromal hyperplasia (PASH) is an uncommon benign proliferation of myofibroblasts likely due to hormonal stimuli (38). Pseudoangiomatous stromal hyperplasia has a wide range of clinical presentations, ranging from incidental findings on screening mammography to large palpable masses. Up to one-third of patients with PASH may present with breast pain (13,39). The imaging appearance of PASH is commonly a noncalcified, circumscribed mass or focal asymmetry on mammography and a circumscribed oval hypoechoic mass on US, which often requires biopsy for definitive diagnosis. Biopsy-proven PASH does not require further management; however, surgical excision may be considered for large symptomatic lesions or rapid interval growth.

Mastitis is inflammation of the breast and can be a cause for focal pain, typically with associated erythema and swelling (14,22,23). Lactational mastitis in patients who are breastfeeding is the most common type of mastitis and is typically diagnosed based on history and physical examination. US can be obtained to evaluate for underlying associated abscess and to guide aspiration for cultures if a fluid collection is identified (40). The classic appearance of mastitis on US is skin thickening and edema (Figure 5). Management of uncomplicated lactational mastitis is antibiotics and analgesics. Clinical follow-up is recommended, and diagnostic imaging with possible biopsy is indicated if symptoms persist despite appropriate antibiotic therapy.

Figure 5.

US appearance of lactational and nonlactational mastitis. A: Longitudinal (left) and transverse (right) US images at the area of pain and skin erythema in a recently postpartum patient demonstrate skin thickening (arrow), parenchymal edema, and lactational changes without a fluid collection. B: Similar clinical presentation and imaging appearance of mastitis in a nonlactating patient.

Nonlactational mastitis such as idiopathic granulomatous mastitis, lupus mastitis, and periductal mastitis can be associated with breast pain. Idiopathic granulomatous mastitis is an uncommon benign chronic inflammatory condition with imaging appearances that can overlap with lactational mastitis, abscess, and inflammatory breast cancer (41). Patients with idiopathic granulomatous mastitis can present with isolated breast pain (27). Biopsy is needed for diagnosis, and management options include observation, corticosteroids, immunosuppressants, or surgery for refractory cases.

Lupus mastitis is a very rare benign chronic inflammatory reaction of the subcutaneous adipose tissue of the breast in 2% to 3% of patients with systemic lupus erythematosus (42). Patients with lupus mastitis can present with breast pain, swelling, or a palpable mass and skin changes (43). Imaging features reflect the underlying histology of fat necrosis, which can include an ill-defined hyperechoic or hypoechoic mass on US and progressive development of coarse dystrophic calcifications (Figure 6) (44). Biopsy is typically needed for definitive diagnosis and to exclude malignancy, although a known history of systemic lupus erythematosus and classically benign dystrophic calcifications present in late-stage disease are highly suggestive of the diagnosis. Patients with lupus mastitis are most often treated with immunosuppressive therapy and may have a fluctuating clinical course with flares and remissions.

Figure 6.

Premenopausal female with known diagnosis of systemic lupus erythematosus presenting with chest pain. Axial (A) and coronal (B) postcontrast CT angiogram images of the chest are notable for incidental detection of dystrophic calcifications, ranging from thin curvilinear to large dense coarse calcifications (arrows), a characteristic imaging appearance seen in the later stages of lupus mastitis.

Periductal mastitis is a benign inflammatory condition that affects the subareolar ducts and can present with pain, erythema, or a palpable mass. Also known as plasma cell mastitis, periductal mastitis is associated with smoking, diabetes, and obesity. Treatment of periductal mastitis is with antibiotics and may require US-guided needle aspiration if an abscess is present (Figure 7).

Figure 7.

Postmenopausal female with right breast and nipple pain with skin erythema. A: Craniocaudal full (left) and magnification (right) mammographic views of the right breast demonstrate skin thickening and a focal asymmetry (arrows) in the subareolar region, which corresponds with the area of clinical concern. B: US imaging of the subareolar region demonstrates a complex fluid collection (arrow) with internal debris with increased vascularity in the periphery, consistent with abscess given the clinical history.

Mondor’s disease is thrombophlebitis of superficial vein(s) of the breast and can be associated with focal breast pain (14). Mondor’s disease is a rare benign clinical entity with a recent increase in incidence reported during the COVID-19 pandemic (45). The classic clinical presentation is a tender, palpable, subcutaneous, linear, cord-like structure. The mammographic appearance is a superficial tubular or beaded linear density (Figure 8). US shows a noncompressible hypoechoic tubular structure. Absence of venous flow is confirmed with color Doppler US. Diagnosis is made by history, physical examination, and imaging and should not require biopsy. Mondor’s disease is self-limited, and treatment is supportive with warm compresses and nonsteroidal anti-inflammatory medications for pain relief.

Figure 8.

Breast pain secondary to superficial thrombophlebitis (Mondor’s disease). A: Mediolateral oblique mammographic view (left) demonstrates a new, prominent vessel (arrow) in the superior right breast that corresponds with a tender, rope-like mass on clinical examination indicated with a BB skin marker, which is not present on the prior screening mammogram (right). B: US images demonstrate a superficial, tubular, hypoechoic structure with no internal vascularity (arrows). C: Mediolateral oblique view from the subsequent screening mammogram after conservative management demonstrates interval resolution.

Severe trauma is another cause of breast pain (Figure 9). Blunt trauma to the breast commonly occurs from seat-belt injuries from motor vehicle accidents (46). Pain may be associated with ecchymosis or a palpable mass at the site of injury. Fat necrosis is a common manifestation of breast trauma, reflecting adipose tissue death usually from lack of blood supply, and has been reported in patients with isolated breast pain (13,18,29). Patients may not recall the inciting trauma, particularly those with large breasts. Classically benign imaging features of fat necrosis on mammography include an oval fat-containing mass with circumscribed margins (oil cyst), which may develop rim calcifications over time. Trabecular thickening may be present because of soft tissue edema. US findings can be less specific and may show an anechoic or mixed echogenicity mass with increased echogenicity of the surrounding fat. Biopsy may be indicated if imaging features are not classically benign. Hematoma is also associated with breast trauma; it presents as a high-density mass on mammogram and has a variable appearance on US depending on chronicity.

Figure 9.

Breast pain associated with severe trauma. A: Postmenopausal woman presents with a tender palpable area of concern in the lower inner left breast after a motor vehicle accident. Craniocaudal (left) and mediolateral oblique (right) mammographic views of the left breast demonstrate a focal asymmetry (circles) underlying the BB skin marker at the clinical area of concern. B: US images demonstrate a corresponding area of parenchymal hyperechogenicity with scattered oil cysts (top; arrow) with no significant internal vascularity (bottom) in a pattern consistent with post-traumatic seat-belt injury. C: For patients with a history of high-speed motor vehicle collision, blunt force trauma to the chest can result in hematoma that may have associated active contrast extravasation (arrow) demonstrated on axial contrast-enhanced chest CT.

Iatrogenic trauma is another cause of breast pain (5). Acute causes may include a postoperative fluid collection (seroma or hematoma). Persistent postsurgical mastalgia, defined as pain lasting longer than 3 months, is a common sequela of breast cancer surgeries (lumpectomy or mastectomy) and noncancer surgeries (47). Lymphedema may also be a cause for pain; it is caused by abnormal swelling in the arm or breast from impaired lymphatic drainage.

Complications related to breast implants, including rupture and capsular contracture, can also be a cause for breast pain (Figure 10). Saline implant rupture is diagnosed clinically as loss of breast shape and skin sagging. Integrity of silicone breast implants are best evaluated using breast MRI without intravenous contrast. Capsular contracture, which is caused by excessive fibrotic foreign body reaction, can also be associated with breast pain. Capsular contracture is diagnosed with physical examination without imaging.

Figure 10.

Breast implant rupture can be associated with focal breast pain. A: Saline implant rupture is diagnosed by physical examination and can be incidentally seen as a partially collapsed hyperintense retropectoral implant (arrows) containing a valve on axial (left) and sagittal (right) T2-weighted MR images. B: Full craniocaudal mammographic view of the left breast (left) demonstrated high-density material along the lateral aspect of the prepectoral silicone implant (arrow) consistent with extracapsular implant rupture. Silicone-sensitive sagittal noncontrast breast MR image (middle) shows the “keyhole” sign (arrow) of intracapsular rupture and multiple high signal oval masses outside the implant, consistent with extracapsular rupture (right; circle). C: US images demonstrate a silicone implant disrupted by a “snowstorm” appearance (arrows) of free silicone with marked posterior acoustic shadowing consistent with extracapsular rupture.

Malignant causes for focal breast pain are rare. Reported histologies include invasive ductal carcinoma, invasive lobular carcinoma, and ductal carcinoma in situ (14,25–27). Inflammatory breast carcinoma is a rare, aggressive type of breast cancer that can present with rapid onset of diffuse breast pain, swelling, erythema, and diffuse dimpling of the skin (peau d’orange) (Figure 11) (5). It has also been proposed that perineural invasion on histopathology may be a potential driver for pain associated with breast cancer (48).

Figure 11.

Inflammatory breast cancer is a rare cause for diffuse breast pain with associated swelling and skin erythema. A: Craniocaudal (left) and mediolateral oblique (right) mammographic views of the left breast demonstrate skin thickening (arrows) and edema of the left breast with axillary lymphadenopathy after diagnostic imaging was obtained following a failed course of antibiotics for presumed mastitis. B: US demonstrates skin thickening (left; arrow) and acoustic shadowing (right; arrow) in the deeper tissues of the breast. Results of skin punch biopsy were consistent with lymphatic spread of carcinoma. C: FDG PET/CT performed for staging demonstrates increased uptake in the left breast (arrow) with skin thickening and uptake within a left level 1 axillary lymph node (arrow) in this patient with biopsy-proven inflammatory breast cancer with metastatic axillary lymphadenopathy.

Extramammary pain

It is important to differentiate true mastalgia from extramammary pain originating from a source outside the breast, such as chest wall, heart, lung, or esophagus. A common musculoskeletal cause is costochondritis, which may be reproduced by palpation of the costochondral junction along the medial breast (49). Referred pain from shoulder bursitis has also been reported (50). Breast pain can also occur from shingles (herpes zoster) presenting as a dermatomal area of intense burning pain followed by a vesicular rash (51). Cervical radiculopathy is another cause of extramammary pain, which may be revealed by additional history regarding neurologic symptoms and upper extremity neurologic examination (52,53).

Management

Careful clinical evaluation with diagnostic imaging when indicated can exclude malignancy and may identify an underlying cause of mastalgia to guide treatment options. Management of idiopathic mastalgia should focus on providing reassurance and bra support as the first-line approach (5,6,32). Educational materials can be given to patients at the end of their diagnostic imaging visit. Up to 85% of women with mastalgia will show improvement after reassurance of not having breast cancer (6). A well-fitting, supportive bra that reduces strain on the suspensory ligaments of the breast can be effective for pain relief (6). Oral or topical nonsteroidal anti-inflammatory drugs are also recommended (6,32).

Lifestyle changes such as reduction in caffeine intake and a low-fat diet may be beneficial, as are alternate therapies such as acupuncture or massage therapy (6,32). However, there is limited scientific evidence regarding the effectiveness of these approaches. A systematic review published in 2018 found that 2 of 3 studies reported some symptomatic improvement with caffeine reduction but concluded that there is insufficient evidence for recommending caffeine reduction for treating mastalgia (32). The overall health benefits of a reduced-fat diet for individuals with excessive dietary fat intake as an adjunct approach to other first-line treatments for mastalgia seem appropriate (32).

Evening primrose oil is a natural source of essential fatty acids and has been used for mastalgia. However, systematic reviews and a meta-analysis of 13 randomly assigned control trials focused on the effectiveness of evening primrose oil for treating mastalgia have concluded that evening primrose oil had no difference in reducing breast pain compared with placebo control or other treatments (32,54). Thus, evening primrose oil is not recommended for treatment of mastalgia (32).

Vitamin E is a supplement with antioxidant properties that has also been used for treatment of cyclical mastalgia. A meta-analysis of 11 studies published in 2019 demonstrated that vitamin E reduced both the duration and severity of cyclical breast pain compared with placebo (55). However, the authors of the meta-analysis recommended further research given the high heterogeneity and poor quality of the included studies.

For severe refractory cases persisting beyond 6 months, referral to a breast or women’s health specialist is recommended. Hormonal-based treatment with tamoxifen or danazol can be considered, but a comprehensive discussion of side effects is required before initiation. Surgical excision is not recommended for management of idiopathic mastalgia (32).

Conclusion

Breast pain is a common clinical scenario with a variety of causes. Diagnostic imaging is recommended for patients with clinically significant focal pain, and imaging most often has negative results or reveals benign findings. It is important for radiologists to know the differential diagnoses for cyclical and noncyclical breast pain and recognize the imaging appearances for common benign and rare malignant etiologies associated with breast pain. A thorough clinical history, physical examination, and diagnostic imaging when indicated can exclude malignancy and may identify an underlying cause of mastalgia to guide treatment options.

Funding

This study was supported by NIH grant R01 CA272571, University of Wisconsin Carbone Cancer Center Support grant NIH P30 CA014520, and the Department of Radiology at the University of Wisconsin School of Medicine and Public Health.

Conflict of interest statement

A.H.B., G.J.S., S.W.D., K.A.R., C.R.H., and N.O.B. have no conflicts to declare. A.M.F. receives book chapter royalties from Elsevier, Inc., and has served on an advisory board for GE Healthcare. The Department of Radiology at the University of Wisconsin School of Medicine and Public Health receives research support from GE Healthcare.

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