Benign Breast Disease http://www.patient.co.uk/doctor/Benign-Breast-Disease.

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Any lump in the breast causes natural and perhaps not inappropriate anxiety, but by no means all lumps are breast cancer. After history of breast lumps and breast examination the problem is differentiation: A benign mass is usually three-dimensional, mobile and smooth, has regular borders, and is solid or cystic in consistency. A malignant mass is usually firm in consistency, has irregular borders, and may be fixed to the underlying skin or soft tissue.

There may also be skin changes or nipple retraction. Differentiation is often still not easy and to err on the side of safety is wise.

When an adult woman presents with a lump in her breast and the doctor thinks it may be malignant, then an urgent referral should be made.1

Common presenting features

A retrospective study of over 300 referrals in Sheffield found that the ages of the women ranged from 16 to 85 years with a mean and median age of 45 years:2 200 women (66%) presented with a lump or lumpiness 42 women (14%) presented with pain 29 women (10%) had a skin and/or nipple problem 31 women (10%) were concerned about their family history or reported other symptoms

Only 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer: 22 were over 40 years of age 21 women presented with a lump

One presented with pain One presented with metastatic disease

Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP.

Premature thelarche

Early breast growth in girls or some growth of breast tissue in males is quite common. The breasts are the first of the secondary sexual characteristics to develop at puberty and there may be some early activity in quite young girls: Very early development may be asymmetrical and apparently unilateral, but examination will usually show some contralateral development too. Unless there are features of true precocious puberty (such as premature pubic hair) then just reassurance is required. Note height and weight on a centile chart, as early puberty often accompanies obesity.

Breast lumps in males Boys may also display some breast development in the hormonal turmoil around puberty. Again reassurance is required at this time of great personal insecurity. It is more likely to happen in Klinefelter's syndrome, but is by no means diagnostic. Gynaecomastia may accompany a number of diseases such as cirrhosis or be produced by a number of drugs. Male breast cancer does occur, but is rare.

Fibrocystic disease This is a term that is now regarded by many as redundant. Formerly, the term used to be used to describe all benign breast conditions, but this caused confusion in distinguishing between normal physiological changes and pathological ones.

There are now 2 different classifications that are used. One is based on clinical and the other on pathological findings. The clinical system seems more appropriate for clinicians: Physiological swelling and tenderness. Nodularity. Breast pain is not usually associated with malignancy. Palpable breast lumps. Nipple discharge including galactorrhoea. Breast infection and inflammation - usually associated with lactation.

Breast pain and nipple discharge are covered elsewhere and will not be considered further.

Physiological swelling and tenderness

The breasts are active organs that change throughout the menstrual cycle and some degree of tenderness and nodularity in the premenstrual phase is so common that it may be considered as normal, affecting perhaps 50 or 60% of all menstruating women. It rapidly resolves as menstruation starts. It is also called mammary dysplasia and cystic mastopathy. Affected women tend to be between 30 and 50. It is less frequent in association with combined oral contraceptives and rare after the menopause. Oral contraceptives reduce the risk of benign breast disease generally.3 It may recur with HRT.

Recommended management has included: Reduction or avoidance of caffeine. Vitamin E. Pyridoxine. Evening primrose oil.

However, good RCTs with placebo control seem few: The placebo response may be as high as 20%. A review found little evidence to support dietary intervention.4 Advising a good, well-supporting bra may be the best advice.5

Breast cysts

Discrete cysts that are clearly palpable may be safely treated by needle aspiration:6 After some local anaesthetic is injected an ordinary green hub needle attached to a 10 ml syringe is inserted and the cyst is aspirated. It disappears beneath the examiner's fingers and both doctor and patient are reassured. Failure to aspirate, especially if it appears to be a solid lesion, requires urgent referral to a breast clinic.

Nodularity

Nodularity is also a normal, hormonally-mediated change with lumpiness of the breast and varying degrees of pain and tenderness: The symptoms are greatest about 1 week before menstruation and decrease when it starts. Examination may reveal an area of nodularity or thickening, poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast. If the changes are bilaterally symmetrical, they are rarely pathological. If there is asymmetry it is acceptable to review the patient after one of two menstrual cycles, seeing her mid-cycle. If symptoms persist then referral should occur. Mammography is often used in older patients, but for younger ones with denser breasts, ultrasound is usually better. Treatment is analgesia and a good bra.

For other possible treatments, considered under the heading of 'Breast Pain', click here.

Palpable breast lumps Many breast lumps are benign, especially in younger patients: The Canadian Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer produced guidelines for the management of benign lumps too.7 Most benign lumps will be either cysts or fibroadenoma.

Fibroadenoma

This is a benign tumour that is common in young women, mostly under 40. It is composed of stromal and epithelial elements and probably represents increased sensitivity to oestrogens: Complex and multiple fibroadenomas are associated with a two-fold increase in the risk of breast cancer.8,9 They represent a hyperplasia or proliferation of a single terminal duct unit. Most stop growing at about 2 or 3 cm, but they can enlarge rather further. About 10% disappear each year. They tend to regress after the menopause. They occur in about half of women who receive ciclosporin after renal transplant. They are the commonest tumour of the breast under 30 years old, but overall they are second to breast cancer. Juvenile fibroadenomas can occur in teenage girls.

Both mammography and ultrasound may be used to examine the lump: Ultrasound tends to be preferred in younger women with dense breasts as mammograms are more difficult to interpret in this group. Routine mammography as a population screening tool, is not performed below the age of 50. Imaging studies may fail to give a firm diagnosis and biopsy or excision may be required for peace of mind of both the patient and doctor. If there is confidence in the diagnosis then inactivity may lead to spontaneous regression, but the patient must be advised to check the lump regularly and to return if it starts to enlarge. Assessment often includes examination, imaging studies and fine needle aspiration.

Phyllodes tumour

This is a rare tumour that tends to occur in women between 40 and 50. They may be benign, borderline or malignant. A benign tumour may re-appear after excision and may become malignant. Treatment is wide excision, including some normal breast tissue. Mammograms should be performed every 2 years thereafter.

Duct ectasia and periductal mastitis

Duct ectasia affects women approaching the menopause. Smoking increases the risk.10 The ducts behind the nipple become dilated and may be get blocked with fluid, leading to a discharge from the nipple and it may be bloody. The epithelium of the duct may become ulcerated and lead to pain and infection. A lump may develop and the nipple may become retracted. A bloody discharge may also suggest intraduct carcinoma and a retracted nipple may suggest malignancy so referral to a breast clinic is required. Excision of the duct is advised to establish the diagnosis and treat the condition.11,12

Periductal mastitis affects younger women more than duct ectasia, but the symptoms are similar, as is management.

Intraduct papilloma

It is a benign, warty lesion just behind the areola: A small lump may be noticed or a sticky, possibly blood-stained discharge. Women in their 40s are more likely to have just one, but younger women may have multiple lesions. Fine needle aspiration or core biopsy may be used.

Atypical hyperplasia Benign hyperplasia can occur in the ducts or the lobes: Lobular carcinoma-in-situ may develop. Even this does not merit immediate operation, but annual mammograms are recommended. Risk is increased with a positive family history of breast cancer.

Sclerosing adenosis

This is a benign condition of sclerosis within the lobules: It may cause pain or be found on routine assessment. It can be very difficult to distinguish from malignancy and biopsy is often advised.

Fat necrosis

It tends to be large, fatty breasts in obese women that have this problem:

It usually follows trauma. The lump is usually painless and the skin around it may look red, bruised or dimpled. Biopsy may be required, but if the diagnosis is confirmed, no further management is indicated.

Infection or mastitis Infection may be associated with lactation or, more rarely occur at other times: With lactation

This is covered in greater detail in the separate record called 'puerperal mastitis'. Breast ducts become blocked with engorged milk, and bacteria enter from cracks in the nipple. An abscess develops in the peripheral part of the breast tissue. There may be engorgement of the breast and axillary lymphadenopathy. Warm compresses and paracetamol may give some relief. Encourage the patient to continue breast-feeding with the unaffected breast and, once letdown occurs in the affected breast, feed with the affected breast until it is completely empty. A 10-day course of a penicillinase-resistant antibiotic such as flucloxacillin is required. A localised abscess will require incision and drainage. Swabs should be sent for culture.

Without lactation

Spontaneous peripheral abscesses in non-lactating women are often associated with diabetes and immune compromise. Non-lactational mastitis produces periareolar abscesses, usually resulting from obstruction with cellular debris and lipid-laden material. Bacteria enter from the skin and produce periductal inflammation and abscess formation. There is a chronic recurrent course with noncyclical mastalgia, nipple discharge or retraction, periareolar abscess, subareolar mass or cellulitis of overlying skin.

NB: inflammatory breast cancer causes pain, redness and induration of the skin, usually affecting the dependent portion of the breast. Symptoms progress very rapidly and within a month the breast may have the peau d'orange appearance.

Any patient in whom presumed mastitis does not resolve completely after 1 month of treatment with antibiotics needs referral to exclude inflammatory breast cancer.

Document references Breast cancer - suspected, Clinical Knowledge Summaries (2005) Laver RC, Reed MW, Harrison BJ, et al; The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services. Ann R Coll Surg Engl. 1999 Jul;81(4):242-7. [abstract] Dayal M, Barnhart KT; Noncontraceptive benefits and therapeutic uses of the oral contraceptive pill. Semin Reprod Med. 2001 Dec;19(4):295-303. [abstract] Horner NK, Lampe JW; Potential mechanisms of diet therapy for fibrocystic breast conditions show inadequate evidence of effectiveness. J Am Diet Assoc. 2000 Nov;100(11):1368-80. [abstract] Neinstein LS; Breast disease in adolescents and young women. Pediatr Clin North Am. 1999 Jun;46(3):607-29. [abstract]

Heisey R, Mahoney L, Watson B; Management of palpable breast lumps. Consensus guideline for family physicians. Can Fam Physician. 1999 Aug;45:1926-32. [abstract] No authors listed; The palpable breast lump: information and recommendations to assist decisionmaking when a breast lump is detected. The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ. 1998 Feb 10;158 Suppl 3:S3-8. [abstract] Dupont WD, Page DL, Parl FF, et al; Long-term risk of breast cancer in women with fibroadenoma. N Engl J Med. 1994 Jul 7;331(1):10-5. [abstract] Hartmann LC, Sellers TA, Frost MH, et al; Benign breast disease and the risk of breast cancer. N Engl J Med. 2005 Jul 21;353(3):229-37. [abstract] Rahal RM, de Freitas-Junior R, Paulinelli RR; Risk factors for duct ectasia. Breast J. 2005 JulAug;11(4):262-5. [abstract] Vargas HI, Romero L, Chlebowski RT; Management of bloody nipple discharge. Curr Treat Options Oncol. 2002 Apr;3(2):157-61. [abstract] Gray RJ, Pockaj BA, Karstaedt PJ; Navigating murky waters: a modern treatment algorithm for nipple discharge. Am J Surg. 2007 Dec;194(6):850-4; discussion 854-5. [abstract]