Benign Breast Problems
- What is benign breast disease?
The term of benign breast disease refers to the non-cancerous conditions which also do not have a potential to become breast cancer. They may or may not cause symptoms. When symptomatic, patients may present with a variety of complaints, including breast lump, nipple discharge, pain, imaging abnormality or a combination of these. The manifestations of a benign breast condition can overlap with those of breast cancer which makes the diagnosis between cancer and a benign condition an important and, at times, a difficult one. In addition, some of the benign findings may increase one's risk of developing breast cancer.
- What are some commonly occurring non-cancerous breast diseases?
Fibroadenoma, fibrocystic disease (with many subgroups), papilloma (papillomatosis), abscess/mastitis, mastalgia (breast pain), Mondor's disease and galactocele are among the most commonly seen benign breast conditions. Diagnosis and management of these conditions are discussed in the Breast Health Updates 3.
- What is fibroadenoma? Who gets it? How is does it present itself?
Fibroadenoma is a benign breast condition that commonly occurs in young women. It is the most common type of breast mass in teenagers and infrequently seen in women after 35 years of age. It tends to involute after menopause. The cause of fibroadenoma is not clear. Fibroadenoma usually presents as a lump found on breast examination. In approximately 15 to 20% of the cases, fibroadenoma are multiple in number. Patients may experience pain, but in most of the cases they do not have any symptoms. A fibroadenoma can also be non palpable found by breast ultrasound and/or mammography.
- How is fibroadenoma being diagnosed, treated and followed?
The first step for any woman who has found a breast lump is to have a breast examination by a doctor. The lump for a fibroadenoma is usually firm, well defined on palpation. In young women, ultrasound evaluation may be the only necessary study beyond doctor's examination. In women with 30 years of age or more, mammography is usually a part of the evaluation for any solid mass. On mammography, fibroadenoma frequently shows a mobile, well circumscribed round, oval or lobulated mass. In young women with dense breasts, the fibroadenoma may be missed by mammography. On the ultrasound, it typically appears as a homogeneous, ovoid or lobulated solid mass with a smooth border. The definitive diagnosis of fibroadenoma comes with tissue removal by a biopsy procedure. The biopsy can be done surgically to remove the entire mass or non-surgically to remove portion of the mass by a core needle.
A complete removal of the mass gives the patient a definitive diagnosis and eliminates the need for frequent follow-up. The margin clearance is not necessary as long as the entire mass and its capsule are removed. Recently, cryoablation (freezing) was used to destroy the growth without taking it out. Long-term result for recurrence after cryoablation of fibroadenoma is not available. Cryoablation shall only be applied when a diagnosis of fibroadenoma is certain. In some cases, periodic breast examination plus breast ultrasound are options. Women who are suitable for follow-up only usually have a long-standing history of a stable lump, small in size and benign in appearance on the initial ultrasound evaluation, and they are reluctant to have it removed. A core needle biopsy provides an added reassurance when the surveillance approach is chosen.
- What is cystosarcoma phyllodes?
Cystosarcoma phyllodes is an uncommon breast condition. The findings are very similar to that of fibroadenoma on breast examination, mammography or breast ultrasound. However, cystosarcoma phyllodes tends to occur in women older than those with fibroadenoma. It tends to occur in their late 30s to 50s, and it grows faster. On the ultrasound it may present as a solid cystic mass. Definitive tissue diagnosis is necessary when the diagnosis is being suspected.
- When is cystosarcoma phyllodes benign and when is it malignant?
The distinction between benign and malignant phyllodes tumors is made by microscopic examination. The features that separate the two conditions are the cells characteristics and tumor borders. The importance of making this distinction is that malignant phyllodes could spread to other organs, particularly to the lungs. They also have a propensity to recur locally after its original removal if the margins are not widely clear.
- How is the benign cystosarcoma phyllodes being treated?
Because the benign phyllodes tumor does not have a true capsule, it tends to recur. The treatment of choice is complete excision of the tumor with 1 to 2 cm of surrounding normal breast tissue. Clear margins after removal are the key to successful local control. Mastectomy is not necessary in most cases, unless the removal of a large tumor would cause an unsightly deformity of the breast.
- How is the malignant cystosarcoma phyllodes being treated?
For those with the malignant cystosarcoma phyllodes, the clear margin is the key to success of local control and simple mastectomy is most frequently necessary to achieve this goal. The reasons for choosing mastectomy are multiple and may include: the frequent large size of malignant cystosarcoma phyllodes, an uncertain role of radiation in treating malignant cystosarcoma phyllodes and a high incidence of in breast recurrence. Because it could spread to lung or rarely to other organs, a CT scan of the chest or a chest x-ray should be checked at the time of diagnosis. It rarely spreads to the lymph nodes; therefore, there is no need to remove the nodes under the arm.
- What is a cyst and how is it being diagnosed?
Cysts are fluid filled pockets that originate from the ducts in breast tissue. It is part of the fibrocystic condition. The patient usually complains of a palpable and possibly painful mass in the breast. The mass may be fluctuating in size. Cysts could also be an incidental finding on a breast ultrasound. The mammography may suggest the presence of a mass-like finding, but the distinction between a solid and a cystic mass can only be made by the ultrasound. Cysts are more commonly seen in women aged 40 to 50 years of age and are the most common breast lump seen in this age group. When they are simple cysts and not causing any pain, they can be left without treatment. The others can be aspirated with a fine needle in the office with or without ultrasound guidance, depending on the location and size of the cyst. The fluid tends to be of greenish/brownish color, which does not require further cytology study. However, when the fluid is bloody or the mass is not resolved completely, the fluid should be submitted for cytological evaluation. The solid area should be biopsied with a core needle.
- What is a complex cyst and how is it being taken care?
Simple cysts, as previously explained, are pockets of fluid in the breast. On the ultrasound, they have smooth walls and are seen as a black area. In contrast, a complex cyst will usually have some irregularities inside, such as growths or debris, have thick and/or irregular walls or contain septations. When these characteristics are seen on the ultrasound, a biopsy should be performed to rule out a malignant process.
- What is galactocele and how is it being taken care?
Galactocele is an abnormality similar to a cyst, but filled with thick milk. Galactocele is usually round and freely mobile. It generally occurs after cessation of breastfeeding or when feeding frequency is significantly reduced. Needle aspiration is the choice for diagnosis and treatment. This needs to be performed with a large gauge needle as the content of a galactocele is thick and creamy. The fluid is sterile, but has a look of pus. Surgery is performed when needle aspiration is not possible or when it becomes infected.
- What is papilloma and how is it being diagnosed and treated?
A papilloma is an overgrowth of the breast tissue which protrudes into the lumen of the milk duct. Papilloma usually affects women between 30-50 years of age. Spontaneous nipple discharge is the first and a common complaint for this condition. This type of nipple discharge is usually clear or bloody. Occasionally, a small nodule can also be found. This type of papilloma is called solitary intraductal papilloma which is usually located underneath the nipple areolar area. When nipple discharge is present, an x-ray study called ductogram can be used to visualize the involved duct and to determine whether a mass exists in the duct. The treatment consists of removing the involved duct and the mass.
Different from the intraductal papilloma, papillomatosis involves many small papillomas deep in the breast involving a group of ducts or in the nipple. Different from tht solitary intraductal papilloma, papillomatosis tends to occur in younger women and frequently involves both breasts. Nipple discharge is not a frequent complaint or sign of papillomatosis. Mammography usually does not show the papillomas as they are frequently too small to be seen. When they are seen on the mammography, they might present as a little nodule or cluster of microcalcifications. The treatment of these conditions consists of complete excision of the lesion, with no need for clear margins. When the nipple is involved by papillomatosis, it can become ulcerative and may need a partial or complete nipple removal. Women with multiple papillomatosis should be followed by the treating doctors, as these women have an increased risk for developing breast cancer.
- What are the appropriate diagnostic studies for non-provoked nipple discharge?
The doctor will look into woman's history to explain the possible cause for this condition and he/she will also examine one's breasts to reproduce the nipple discharge and to make sure that there is no palpable lump. When the nipple discharge is reproduced during a woman's visit with her doctor, the fluid can be sent for cytological study to look for atypical or malignant cells. A negative test is not very useful, but a positive test advises a cancer treatment. When nipple discharge is provoked, involves both sides, arises from multiple ducts, and has a milky appearance, blood tests measuring levels of different types of hormones, may be all that is needed. An ultrasound of the nippleareolar area is helpful to evaluate the possible dilated duct with or without lumps. Women 30 years of age or older with non-provoked nipple discharge also need a mammography. Ductogram is useful in those with nipple discharge from a single ductal opening without a palpable mass or ultrasound abnormality.
- What conditions make surgery necessary for nipple discharge?
After hormonal/medication induced effects are ruled out, a persistent spontaneous bloody or clear nipple discharge calls for a surgery. The presence of a mass in association with a nipple discharge is also an indication for surgical removal. Surgery may also be chosen by patient to stop nipple discharge that is not suspicious.
- What are some of the common underlying conditions that cause bloody nipple discharge?
The majority of nipple discharges is benign. The younger the woman is the more likely it is benign. The intraductal papilloma is the most common abnormality that causes bloody or clear nipple discharge, followed by fibrocystic disease and duct ectasia, and less likely breast cancer.
- What is fibrocystic disease referring to?
The term fibrocystic disease refers to a large group of breast abnormalities. It may manifest as cysts, fibrosis and proliferative lesions. These abnormalities are all benign; however, certain features of fibrocystic disease may indicate an increased risk for development of breast cancer. The conditions are known as atypical ductal or lobular hyperplasia. Clinically, it is estimated that approximately 50% of women have fibrocystic disease and this number can be as high as 90% if one includes the reports of autopsy studies of women who died from non-related causes.
- What kind of symptoms or problems can fibrocystic disease cause?
Due to the large variety of conditions classified under the category of fibrocystic disease, symptoms are many as well. Complaints may include tenderness, discomfort, pain, palpable mass or nipple discharge. Symptoms might be absent in those with isolated imaging findings.
- When an assumed fibrocystic disease requires biopsy for confirmation?
The main reason for diagnosing fibrocystic disease is to rule out breast cancer, because many symptoms, signs and imaging presentation overlap with breast cancer. A biopsy of the breast lesion should be considered whenever malignant disease is suspected. When atypical cells are found by a needle biopsy, surgery is advised to rule out the presence of a cancer or precancerous condition.
- What is mastitis referring to?
The term mastitis refers to an inflammatory process of the breast tissue. Mastitis may happen because of blocked milk duct or infection. Various symptoms can be present alone or in combination, including tenderness/pain, nipple abnormality, ill-defined palpable mass, redness, swelling, nipple discharge, fever, etc. The diagnosis is made on a clinical ground. Mammography and/or ultrasound do not add more information in most cases. Because the breast with mastitis is very tender, compression of the breast for mammography is difficult and the quality of the film is frequently poor. Imaging studies are still helpful if one wishes to rule out the existence of abnormalities or abscess.
- Who is at increased risk for mastitis?
Mastitis and breast abscesses are mostly seen during the breastfeeding period. They are frequently caused by a bacteria called Staphylococcus aureus. They can also be caused by other types of bacteria, mycobacteria, fungus and foreign bodies.
- How are mastitis and abscess being treated?
Antibiotics are the main treatment. As a general rule, it is not necessary to stop breastfeeding in lactating women, as this could provoke breast swelling and prolong the infection. Mild warmth for local compress and manual milk pumping can be applied to speed the resolution. Failure to treat mastitis could result in a breast abscess which is a mass filled with purulent fluid. An abscess requires surgery for drainage and debridment in addition to the appropriate antibiotics. During surgery, a biopsy of the abscess cavity should be sent for pathologic examination to rule out cancer diagnosis.
- What is Mondor's disease and what causes it?
This disease is characterized by inflammation around an occluded vein that drains the blood flow of the breast. Typically, a vein in the lateral and/or lower aspect of the breast is affected which is cordlike and can cause retraction of the skin. Pain and tenderness along the inflammed and hardened vein are the major complaints. This condition usually happens after trauma to the breast, including breast surgery, radiation of the breast or injury. It is self-limiting and frequently resolves after 2 months. An anti-inflammatory agent can be used to minimize the pain.
- When considering medical history and breast exam, what characteristics make a breast lump likely to be a non-cancerous growth?
Both findings on physical examination and an individual's personal history may give the clue for the nature of a nodule or density. Confirmation sometimes is required by imaging studies and/or biopsy, depending on each case. Examples of important patient history include: duration of the condition, interval changes, shape/size and other characteristics of breast lumps, association with other symptoms or one's own medical history, family history of cancer, site and correlation with trauma, and patient's age. Important physical findings such as texture, size, borders, mobility in relation to the breast and adjacent structures (inverted nipple, skin dimpling, and fixation to skin or chest wall), appearance of the involved breast and enlarged lymph nodes under the arm or above the collar bone may all affect the doctor's impression regarding the abnormality. A growth is more likely to be benign when it is present for a long period of time without an overall enlargement. Young age is less likely to be associated with cancer and a strong family history increases one's risk. Most benign nodules have smooth borders and tend to be freely mobile without pulling the skin or adhering to the chest wall. Breast pain and size of the abnormality are poor indicators for the nature of the breast problems. Although a history of trauma to the area of the growth, breastfeeding, or pregnancy is likely to suggest a benign problem, breast cancer has been overlooked in these women.
- What are the appropriate studies to investigate a palpable mass?
Depending on the age, family history, and suspicion level, a mammography is usually the first test for most women. A directed ultrasound is the study of choice in young women or women with less concerned findings and in those with a negative mammography. A breast MRI is another available imaging study but this should be reserved when mammography and breast ultrasound are uncertain or negative in the presence of a palpable abnormality. The need for a biopsy (surgical or with needle) depends on the degree of suspiciousness raised by all of these evaluations. When the breast mass is suspicious on the examination, a negative breast imaging study should not discourage the biopsy.
- When does a non-palpable abnormality on the mammography require further confirmatory studies?
A non-palpable abnormality on the mammography is usually found on the screening films. The screening mammography consists of 2 images of each breast. When an abnormality is detected, additional images/views are frequently needed to better evaluate it. This additional imaging study is called diagnostic mammography. However, some breasts are difficult to be evaluated by mammography because of the excessive density of the breasts. An ultrasound directed to the concerned area shown on the mammography may be helpful. When ultrasound is not conclusive or negative in the presence of a questionable finding, breast MRI or a biopsy may be considered for further evaluation. When the mammographic finding is highly suspicious, other imaging studies may not be necessary, and a biopsy might be the only required test.
- What are the features indicating benign microcalcifications?
The shape and distribution are the two most important features to separate benign microcalcifications from malignant ones. When they cannot clearly be seen on the screening mammography, magnification and spot compression views are helpful to better visualize them. Scattered, large, round and regular-shaped microcalcifications are characteristically benign. Vascular microcalcifications are also benign and they appear along the blood vessels. The "milk of calcium" that are inside small cysts are also considered benign.
- What are the frequent characteristics associated with cancerous microcalcifications?
Tiny calcifications with various shapes (known as pleomorphic), clustered or linear or branching in appearance, and new development since the last mammography are more concerning ones. When this kind of microcalcifications is associated with a breast mass or asymmetrical density, it further increases the possibility of finding cancer. All these findings require tissues to be examined under the microscope for a diagnosis.
- What are the procedures frequently used to obtain tissue diagnosis?
Two methods are commonly used to obtain tissue for diagnosis of breast abnormalities. These are the surgical biopsy and the core needle biopsy. The surgical biopsy is frequently performed under local anesthesia with or without intravenous sedation. A small skin cut (incision) is made to reach the abnormality in the breast. The surgical biopsy can be incisional (removal of a portion of the abnormality) or excisional (removal of the entire abnormal lesion). The core needle biopsy is performed with local anesthesia with the guidance of a palpable mass, an ultrasound, a mammography or an MRI through a tiny skin cut, allowing the needle to pass through. The selection of the type of biopsy usually comes as a joint decision between doctor and patient. When a tissue diagnosis is being considered, talk to your doctor to stop all medicines that may cause excessive bleeding.
- What kind of lump on the mammography is characteristically associated with a benign condition?
A lump on mammography with round and smooth borders and a halo sign (darker line surrounding the anterior edge of a mass), especially if the appearance is stable over a long period of time, are usually benign. When the density is uniform or the nodule has a darker center are also suggestions of a benign finding.
- What kind of lump on the mammography is characteristically associated with a cancer diagnosis?
When a mammography mass is excessively dense and has spiculated (i.e. with borders containing small projections or "tentacles") or irregular borders with or without suspicious microcalcifications, it is more likely to be cancerous. Lumps on mammography of post-menopausal women, especially newly appeared ones, should be carefully examined. Similarly, lumps in women with a previous history of breast cancer or a high risk family history for breast cancer should be evaluated more carefully. Some of the mammography findings have an undetermined look and a 6-month repeat study may be necessary.
- If a lump is palpable but not shown on the mammography, what would be the appropriate steps to take?
A negative mammography does not eliminate the fact that a mass is present in the breast. A directed ultrasound and a breast MRI can be all helpful to visualize the abnormality. Depending on the degree of concern of the physician, a biopsy could be performed for a more definitive assessment. Negative imaging studies of a palpable mass do not imply that there is no pathology in the breast.