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Benign Breast Disease
Benign breast disease includes breast pain, breast lumps, or nipple discharge. The most common cause of breast nodularity and tenderness is fibrocystic change, which occurs in 60 percent of premenopausal women.
Benign breast lesions, which are discovered by breast palpation or mammography, have been subdivided into those that are associated with an increased risk of breast cancer and those that are not.
No increased risk of breast cancer
Fibrocystic changes
consist of an increased number of cysts or fibrous tissue in an otherwise normal breast. Fibrocystic changes do not constitute a disease state.
Fibrocystic disease
is diagnosed when fibrocystic changes occur in conjunction with
pain, nipple discharge, or a degree of lumpiness sufficient to cause suspicion of cancer.
Duct ectasia
is characterized by distention of subareolar ducts.
Solitary papillomas
consist of papillary cells that grow from the wall of a cyst into its lumen.
Simple fibroadenomas
are benign solid tumors, usually presenting as a well-defined,
mobile mass.
Increased risk of breast cancer
Ductal hyperplasia
without atypia is the most common lesion associated with increased risk of breast cancer.
Sclerosing adenosis
consists of lobular tissue that has undergone hyperplastic change.
Diffuse papillomatosis
refers to the formation of multiple papillomas.
Complex fibroadenomas
are tumors that contain cysts greater than 3 mm in diameter,
sclerosing adenosis, epithelial calcification, or papillary apocrine changes.
Atypical hyperplasia
is associated with a four to sixfold increased risk of breast cancer.
Radial scars
are benign breast lesions of uncertain pathogenesis that are occasionally
detected by mammography. Thus, histologic confirmation is required to exclude speculated carcinoma.
Symptoms and signs of benign breast disease
Women with fibrocystic changes can have breast tenderness during the luteal phase of the menstrual cycle. Fibrocystic disease is characterized by more severe or prolonged pain.
Women in their 30s sometimes present with multiple breast nodules 2 to 10 mm in size as a result of proliferation of glandular cells.
Women in their 30s and 40s present with solitary or multiple cysts. Acute enlargement of cysts may cause severe, localized pain of sudden onset. Nipple discharge is common, varying from pale green to brown.
Differential diagnosis
Breast pain:
Women with mastitis usually complain of the sudden onset of pain,fever, erythema, tenderness, and induration.
Large pendulous breasts may cause pain due to stretching of Cooper's ligaments.
Hidradenitis suppurativa can present as breast nodules and pain.
Chest wall pain induced by trauma or traumainduced fat necrosis, intercostal neuralgia,
costochondritis, underlying pleuritic lesions, or arthritis of the thoracic spine can mimic benign breast disease.
Nipple discharge
is uncommon in cancer and, if present, is unilateral. Approximately 3 percent of cases of unilateral nipple discharge are due to breast cancer; a mass is usually also present.
Nonspontaneous, nonbloody, or bilateral nipple discharge is unlikely to be due to cancer.
a. Purulent discharge is often caused by mastitis or a breast abscess.
b. Milky discharge commonly occurs after childbearing and can last several years; it also
may be associated with oral contraceptives or tricyclic antidepressants. Serum prolactin
should be measured if the discharge is sustained, particularly if it is associated with
menstrual abnormalities.
c. A green, yellow, white, grey, or brown discharge can be caused by duct ectasia.
Evaluation of nipple discharge for suspected cancer may include cytology and galactography. Occult blood can be detected with a guaiac test.
Clinical evaluation
History
The relationship of symptoms to the menstrual cycles, the timing of onset of breast lumps and their subsequent course, the color and location of nipple discharge, and hormone use should be assessed.
Risk factors for breast cancer should be determined, including menarche before age 12 years, first live birth at age >30 years, and menopause at age >55 years; the number of previous breast biopsies, the presence of atypical ductal hyperplasia on biopsy, obesity, nulliparity, increased age, the amount of alcohol consumed, and the number and ages of first-degree family members with breast cancer with two such relatives with breast cancer at any early age should be determined.
Physical examination.
The examination is performed when the breasts are least stimulated, seven to nine days after the onset of menses. The four breast quadrants, subareolar areas, and the axillae should be systematically examined with the woman both lying and sitting with her hands on her hips.
The specific goals of the examination are to:
- a. Delineate and document breast masses
- b. Elicit discharge from a nipple
- c. Identify localized areas of tenderness
- d. Detect enlarged axillary or supraclavicular lymph nodes
- e. Detect skin changes, noting the symmetry and contour of the breasts, position of the
nipples, scars, dimpling, edema or erythema, ulceration or crusting of the nipple
Classic characteristics of breast cancers:
- a. Single lesion
- b. Hard
- c. Immovable
- d. Irregular border
- e. Size >2 cm
Mammography
Although 90 percent or more of palpable breast masses in women in their 20s to early 50s are benign, excluding breast cancer is a crucial step in the evaluation. Mammography is recommended for any woman age 35 years or older who has a breast mass.
Mammography usually is not ordered routinely in women under age 35 years. The breast tissue in younger women is often too dense to evaluate the lump. Ultrasonography useful in these women to evaluate lumps and to assess for cysts.
Round dense lesions on mammography often represent cystic fluid. Solid and cystic lesions can often be distinguished by ultrasonography and mammography, and needle aspiration under ultrasound guidance further documents the cystic nature of the lesion.
Breast pain.
Women who present with breast pain as their only symptom often undergo mammography. Only 0.4 percent of women with breast pain have breast cancer. The vast majority of women have normal findings (87 percent); benign abnormalities are noted in 9 percent.
Ductal lavage.
The cytologic detection of cellular atypia can identify women with a higher risk of developing breast cancer.
Treatment
Fibrocystic disease.
The major aim of therapy in fibrocystic disease is to relieve breast pain or discomfort. Symptomatic relief also may be achieved with a soft brassiere with good support, acetaminophen or a nonsteroidal anti-inflammatory drug, or both.
1. Breast pain or discomfort may be relieved with a thiazide diuretic.
2. Avoidance of caffeine may provide some patients with relief of pain.
3. Vitamin E, 400 IU twice daily reduces breast pain.
4. Evening primrose oil in doses of 1500-3000 g daily, relieves breast pain in 30 to 80 percent.
5. Danazol in doses of 100 to 200 mg daily reduces breast pain. Common side effects include weight gain, acne, hirsutism, bloating, and amenorrhea.
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