ABM Clinical Protocol #30: Breast Masses, Breast Complaints, and Diagnostic Breast Imaging in the Lactating Woman

Abstract

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols, free from commercial interest or influence, for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient .

Introduction

BREASTFEEDING WOMEN MAY develop breast masses or complaints at any point during lactation. Symptoms may be related to lactation, such as a lactating adenoma, or may be due to a condition that coincidentally has manifested during the postpartum period. Understanding the importance of appropriate workup and imaging, as well as indications for referral to breast surgery, is essential to establishing a diagnosis and avoiding delay in care.

Breast symptoms require evaluation by physicians and/or lactation consultants and may also require diagnostic breast imaging and/or biopsy. The American College of Radiology (ACR) released new guidelines in 2018 regarding breast imaging of pregnant and lactating women. These guidelines state that all breast imaging studies and biopsies are safe for women to undergo while breastfeeding, and also provide recommendations for maximizing examination sensitivity and minimizing biopsy-related complications in this patient population.

When approaching a breastfeeding woman with breast symptomatology, it is helpful for providers to frame the workup based on the presence or absence of a palpable mass on examination ( Fig. 1 ). Some conditions always present as a mass, whereas others rarely have a palpable finding. However, several conditions have variable presentations and may manifest as a mass and/or another sign/symptom such as nipple discharge ( Fig. 2 ).

Quality of evidence is based on the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence (levels I–IV) and is noted in parentheses.

Breast Masses

The majority of persistent breast masses warrant diagnostic imaging. Although several breast masses may occur in the setting of lactation and are benign, imaging generally is required to distinguish these from non-lactation-specific breast masses. Both benign and malignant masses unrelated to lactation also may present during the postpartum period. Thus, clinicians should perform axillary and supraclavicular lymph node examinations on all women presenting with a breast mass. Specific masses and/or associated symptomatology may warrant referral to a breast surgeon for biopsy or intervention. The most common breast masses diagnosed during lactation are highlighted in Table 1 .