Benign Breast Disease
Most breast complaints are benign in nature. Despite this, most women with breast complaints "assume the worst" when a new problem is discovered. This is understandable, but to help allay these fears, an understanding of the benign breast disorders is needed.
Unlike breast cancer, benign breast diseases have often been difficult to understand, in part due to the variety of names that have been used to describe the various conditions.
There are many types of benign breast problems, but in general terms these can be classified according to the predominant symptom - pain, lumps, nipple problems and infections of the breast.
Breast pain is known as mastalgia, and can be caused by a number of different "diseases". The same is true of benign breast lumps, nipple disorders and indeed infections. What can be said though, is that in many cases what brings a woman to see her doctor is no more than an Anomaly of Normal Breast Development and Involution (ANDI).
The term ANDI is useful, since it implies that most of the benign disordered are in fact only physiological (i.e. normal) extremes - but still normal. This is important, since reassurance and explanation is often the only treatment that is required to treat a woman who has an "ANDI" problem with the breast.
When a benign problem goes beyond the ANDI category, it can truly be considered as an abnormality, and in these cases treatment may be required. However, even when there is a true abnormality, the problem is benign, and therefore not life-threatening as in the case of breast cancer.
Another area that causes concern is whether there is a risk of breast cancer in women who have benign breast disease. For the vast majority of cases there is no increased risk, but in a few specific benign conditions a small increase in the risk of breast cancer is observed. These conditions are mentioned below.
Investigation of benign problems essentially follows the same principles of "triple assessment" that are used in breast cancer. However, young women in particular may not require every test in order to diagnose a benign pathology.
Treatment of these disorders involves a combination of reassurance, medical treatments and surgery. Obviously when cancer is found incidentally in a patient with benign disease, this is dealt with in the normal fashion.
What now follows is a description of the main types of benign breast disorders, including their clinical presentation, diagnosis and treatment. Of note, Phyllodes tumours are not included in the following discussion, even though many consider them to be related to fibroadenomas. Instead, they are described on the breast cancer page because of their potential to exist in a malignant form.
Mastalgia means breast pain. Breast pain is extremely common, and for many women who attend hospital clinics, this is their main and only symptom. It should not be forgotten that mastalgia is a symptom, and therefore is not a specific disease in its own right. Instead, it usually indicates the presence of some underlying process or disease within the breast, which in most cases is benign.
In general terms, mastalgia can be one of two types - cyclical and non-cyclical - depending on the relationship to the menstrual cycle.
Cyclical mastalgia is the most common type. Virtually all women will experience a degree of pain or discomfort in their breasts at some time of their lives - this is normal and most often occurs in the week prior to menstruation.
In some women however, the pain can become quite severe, and in certain cases can result in problems with work, recreation and even marital relationships. When this occurs, cyclical mastalgia can be considered abnormal, and such patients usually seek advice and help from their doctor.
Due to the relationship with the menstrual cycle, it is thought that the cause of cyclical mastalgia is hormonal. It has been suggested that an abnormality in the secretion of prolactin is to blame, and certainly drugs that inhibit prolactin secretion can be of benefit in the treatment of this disorder (see below). There are also other suggestions that consumption of too much caffeine, or a deficient intake of essential fatty acids can also result in cyclical mastalgia. For this reason women are often advised to decrease their caffeine intake and are given evening primrose oil, both of which can help (see below).
The usual age of patients with cyclical mastalgia is around 30 - 40 years. In the mildest form, the pain lasts only a few days prior to menstruation. The number of symptomatic days varies however, and in a few women, they can experience pain for virtually the whole month, with relief occurring only at the time of menstruation.
Cyclical mastalgia normally affects both breasts, but can be unilateral. Many women also feel lots of "nodules" or "lumpiness" in the breast when the pain is present, and the upper outer quadrants of the breast are most commonly affected.
When triple assessment is performed on such patients, the following findings are typical. On clinical examination, there is often diffuse tenderness with lumpiness and nodularity. There is no single discrete lump to feel and there are no abnormalities with the nipple. Mammography typically shows no abnormality, but the breast tissue can appear glandular and dense. When cytopathology is taken in the form of an FNA, the result is benign.
Another form of assessment that it used to confirm the cyclical nature of the symptoms is a breast pain chart. This is given to the patient on attendance at the clinic, and they are asked to score their pain on a daily basis as either severe, mild or no pain at all. The commencement of menstruation is also recorded and after a couple of months it becomes apparent that the symptoms are cyclical in nature.
Once assessment has been performed, and no serious abnormality found, thequestion of treatment then arises. Most women require no treatment at all - simple reassurance is all that is needed. For these patients, the knowledge that they do not have breast cancer is reassuring and they learn to live with the symptoms. Often, cyclical mastalgia will settle over the course of a few months, returning to "normal" pre-menstrual breast discomfort without any specific treatment.
For those women whose symptoms are severe however, treatment is required in the form of drugs. The simplest, and perhaps the most commonly used first treatment is evening primrose oil capsules. These are usually taken in a dose of 6-8 capsules per day for at least 2 months. They work by replacing essential fatty acids that may be deficient in the patient's diet. It is thought that mastalgia may be caused by such deficiencies in certain patients.
It should be remembered by patients, that evening primrose is not a pain-killer, and must be taken every day. Normally no effect is noted for the first 2-4 weeks, after which time symptoms will begin to settle if treatment is effective. Approximately 50% of patients will respond to this form of therapy, requiring no further treatment. They usually continue with the medication for a few months and many find that symptoms do not recur once the medication is stopped. The only significant side-effect that is reported is nausea, though this occurs in only 1% of all patients.
If evening primrose oil fails, and symptoms persist, the next drug that is often used is danazol (200 - 400 mg daily). This drugs acts by inhibiting follicle-stimulating hormone and leutenising hormone in the pituitary gland. It is very effective in treating breast pain, relieving symptoms in around 70% of patients. However, it is associated with significant side-effects that can occur in about 25% of patients on treatment. These side effects include acne, deepening of the voice (that can be permanent), hirsutism (facial hair), increase in weight and amenorrhoea (cessation of the menstrual cycle whilst on treatment). For these reasons, this drug is normally reserved for those women whose pain is severe and who are willing to risk the side-effects for the sake of symptom relief.
Another drug that is used to treat cyclical mastalgia is bromocriptine (2.5mg twice daily). This drug acts to lower the levels of prolactin secretion and is effective in 50% of cases. However, it can cause severe nausea, headaches and dizziness and for this reason many patients are unable to continue with it.
Non-cyclical mastalgia, as its name suggests, is pain in the breast that is not related to the menstrual cycle. A number of conditions can give rise to non-cyclical mastalgia, each with certain additional symptoms or clinical signs that aid diagnosis. Amongst these conditions is breast cancer, and for this reason it is important to investigate these patients before treatment is commenced.
This is an "ANDI" problem (see above) that is characterised by over-proliferation of the terminal duct lobules. It can cause impingement to adjacent nerve endings, thereby resulting in breast pain. It can also present as a painful lump or be detected on routine screening mammography as a calcified, "stellate" abnormality - an appearance that is not infrequently confused with breast cancer. Areas of sclerosing adenosis are often excised surgically during biopsy or needle-localisation procedures (when there is no palpable lesion but only mammographic
The definition of mastitis is inflammation or infection of the breast. However, there are a number of disorders that can give rise to this type of pathology, and these are best described separately, not only because they affect different parts of the breast in different ways, but also because their respective treatments and complications are also variable.
In broad terms, the sequence of events involved in the development of a breast infection is as follows. Firstly, an organism gains entry to the breast tissue, either via the nipple and ducts, through damaged or broken skin or from trauma. (In rare cases due to TB, infection can arrive at the breast via the bloodstream).
Depending on the site of entry, and the organism involved, a number of conditions can arise. Infection/inflammation involving the nipple and major ducts draining into it is called periductal mastitis. Superficial infections of the skin of the breast can lead to cellulitis. Deeper infections under the skin or within the breast tissue itself can give rise to breast abscesses. These can occur either during lactation (breast feeding) or non-lactation.
Whatever the cause of an abscess, if it lasts long enough, it can result in the development of a mammary fistula, in which the abscess cavity initially drains onto the surface of the breast, leaving a connection from the skin into the breast tissue that continually drains purulent material. In this way, chronic infection can be established.
Periductal mastitis is discussed in the section entitled, "Nipple disorders". Lactational and non-lactational breast abscesses as well as mammary fistulas are discussed in the next section, "Breast abscess".
Another cause of breast infection is a wound infection following surgery or trauma. Breast surgery often results in the formation of cavities within the breast where tissue has been removed. These fill up with inflammatory fluid and blood in the post-operative period, all as part of the normal healing process. Normally this would settle with time, but if infection sets in, an abscess and wound infection can occur.
This has a number of consequences for the patient. Firstly, an infection in the breast after surgery will take longer to heal and the final scar may look less cosmetic than a non-infected wound scar. Secondly, since many operations are done for cancer, the presence of a would infection can significantly delay the use of adjuvant therapy that may be needed as the next stage in a patient's cancer treatment.
For example, if a woman has a mastectomy and then requires chemotherapy, but develops a wound infection, the chemotherapy will normally be withheld until the infection has settled. The reason for this is that the chemotherapy, as well as killing off residual tumour cells that may have spread, will also suppress the patient's immune system to such an extent that their wound infection could worsen or indeed become life-threatening. In such cases chemotherapy has to be deferred until it is safe to be administered.
4. Breast Abscess
Breast abscesses are reasonably common during breast feeding. It is thought that the mode of entry of the causative organism (Staphylococcus aureus) is via cracked or damaged skin around the nipple caused by the infant's sucking.
The symptoms are of increasing pain in the breast, often at the edges followed by reddening (erythema), swelling and induration (hardening) of the tissue. Associated with this are the general symptoms of infection including nausea, fever, sweats and tachycardia.
The treatment of such infections, if diagnosed early, is with antibiotics. If it is suspected on clinical examination that pus is present within an abscess cavity, this can be drained by aspiration with a needle, followed by a course of antibiotics.
If however, a large abscess is present, or if antibiotic therapy fails to resolve the infection, surgical drainage may be required. This involves a general anaesthetic. An incision is made usually at the lower edge of the abscess to allow the pus out and ensure that it will continue to drain when the patient is sitting upright in the post-operative period. The wound is often packed initially with a wick soaked in antiseptic such as betadine and will not normally be closed with sutures. This helps to clean the wound and prevent bleeding. It also ensures that the wound stays open to allow any remaining infection to drain out. If the skin were to close immediately or soon after surgery, there would be a high chance that the infection would remain and the abscess would recur - hence why it is left open to close in its own time later.
Abscesses can also occur in women who are not breast-feeding. These non-lactational abscesses are usually associated with periductal mastitis and therefore tend to occur in women over 30 years of age. In these patients the abscess is located close to the edge of the areola. Once again treatment is by antibiotics, aspiration and if necessary, surgical drainage. In these cases however, it is often necessary to go back at a later stage to excise the abnormal ducts that were responsible for the infection. If this is not done, the development of a mammary fistula is more likely.
A mammary fistula is an abnormal connection between the ducts of the breast tissue and the skin. It will occur if an abscess is left to drain spontaneously. As a general rule in surgery, any infection, almost anywhere in the body, will find its own way to the surface eventually. In the breast, the point at which the abscess drains to the surface, will become the site of the fistula. In the case of abscesses resulting as a consequence of periductal mastitis, there is a high chance of a fistulous connection between the abnormal duct and the skin surface. In lactational abscesses this is less likely, especially if the abscess was properly drained surgically, though it can still occur.
The treatment of mammary fistulae is by excision. Antibiotics can help to settle infective exacerbations, but they will not cure the fistula, since this is essentially an anatomical abnormality.
Surgical excision of the fistula tract and the affected duct will allow the surrounding healthy breast tissue to heal normally.
Fibroadenomas are very common and almost invariably present as a lump in young women. Whilst they can occur in women of any age, they are by far more common in women aged 15 - 25 years. They are caused by a proliferation of the tissue around the breast lobule and normally have a rubbery texture on palpation. They are typically smooth, but can be lobulated and feel like many small lumps bundled into one. Their size varies, but is typically 1 -3 cm in diameter. They are also highly mobile on examination, and by virtue of this feature, have earned themselves the description of "breast mice". These tumours are totally benign and are not associated with an increased risk of breast cancer.
Women who come to the clinic with a lump that is thought to be a fibroadenoma, still need to have full triple assessment to confirm the diagnosis, and more importantly, to exclude cancer. Breast cancer is rare in this age group of patients, but without proper assessment there exists a risk that it could be missed on the rare occasion when it is present.
Triple assessment in the case of fibroadenomas involves a history and clinical examination that will reveal many of the clinical features outlined above. In young women, especially if they are nulliparous, mammography is not the radiological investigation of choice because the breast tissue is much denser and therefore the X-rays are more difficult to interpret. (Note: that is not to say that fibroadenomas can't be seen on mammography - on the contrary, they are well seen, but more so in older women whose normal breast tissue is less dense.) Instead of mammography, ultrasound is preferred. This will reveal a fibroadenoma as a discrete, solid, smooth mass within the breast. Fine needle aspiration is also performed on fibroadenomas as a routine and will invariably return a benign result.
The question then remains, if these are benign tumours, and do not increase the risk of breast cancer, what should be done about them?
Treatment of fibroadenomas depends on a number of factors. These include the position and size of the lump, whether or not there is any associated pain or discomfort, the anxiety of the patient and whether there are any unanswered questions from triple assessment. These points will now be discussed briefly.
Large fibroadenomas, can often be confused with Phyllodes tumours, which have a propensity for malignancy. Therefore, even though fibroadenomas are benign, if there is any doubt that the patient may have a Phyllodes tumour, excision biopsy should be performed. Tumours over 4-5 cm in diameter can fall into this category, and in many centres tumours of this size are removed routinely. The other reason why size can determine the need for excision, is in the woman with small breasts and a large fibroadenoma. In these patients the tumour may be cosmetically unsightly, and therefore excision is required. Finally, when a tumour is initially left in the breast without surgery, but is then seen to be growing rapidly, it is best to excise it (a) because it may be a Phyllodes tumour and (b) because if it continues to grow, a much larger operation may be required at a later date.
Fibroadenomas can sometimes be associated with breast pain. When this occurs, it may be necessary to excise them for symptom control. This however is uncommon.
Patient anxiety is another important factor in determining surgery. Despite reassurance from negative triple assessment, some women are unhappy with the prospect of a lump being left in their breast, and in order to relieve this understandable anxiety, excision can be performed.
Finally, if any aspect of the triple assessment is inconclusive, or if their is any suggestion of a suspicious or malignant problem, excision of the lump for formal pathological examination is mandatory, to exclude a more sinister cause for the lump.
If surgery is not performed, one of three things may happen to the fibroadenoma. Firstly, it may simple resolve of its own accord over a period of months or years. Secondly, it may stay the same and remain in the breast for many years. Finally, it may continue to increase in size, in which case excision is recommended as outlined above.
6. Fibrocystic Change
The description of benign breast disorders is confused by the number of different terms used to describe various conditions - many of which are similar, and many of which are not. Fibrocystic change is not a disease as such, but instead is a general term that refers to a group of anomalies, symptoms and conditions that form part of the spectrum of breast pathology. It is included here because the term is still used clinically, and therefore deserves a general description of its implication.
Broadly speaking, fibrocystic change refers to anomalies of development and involution (ANDI). It is the main benign diagnosis in women of the 30 - 40 year age group. If young women get fibroadenomas as their main benign complaint, and pre-menopausal women get breast cysts as theirs, then the gap, i.e. in women between 30 - 40, is filled with fibrocystic change.
Amongst the symptoms are cyclical mastalgia, lumpiness and nodularity. As age progresses, cysts become more frequent. Patients can also develop areas of such pronounced nodularity that the presence of a lump may be felt.
Whatever the combination of symptoms, standard triple assessment is applied. Clinical examination is directed at finding focal abnormalities, such as lumps or pain. These are then assessed radiologically with mammography in this age group, and with FNA.
In the majority of cases, no significant radiological or pathological abnormality is identified, and simple reassurance is all that is required as a treatment. The exception to this rule, is when a discreet lump is felt, or when triple assessment reveals any suspicious features. In these cases, formal biopsy is usually required to exclude malignancy, since the risk of breast cancer increases after the age of 35 and a false negative assessment has to be considered.
Breast cysts are most common in the pre-menopausal years and in women who take hormone replacement therapy at any age. They are essentially fluid-filled cavities within the breast tissue and are important for a number of reasons.
Firstly, breast cysts cause considerable anxiety. They present as lumps in women of an age where breast cancer is more likely, so naturally they are assumed to be cancers when first discovered.
Secondly, there is evidence that having recurrent cysts in the breast may increase the risk of breast cancer slightly.
Thirdly, some breast cancers can present as cysts, and may therefore cause diagnostic confusion.
Finally, they are often recurrent and bilateral, requiring several visits to the out-patient clinic for assessment.
The fluid within a breast cyst is normally either clear or turbid and can be any colour from pale to black. Normally, no blood is seen when they are aspirated, but this should alert to the possibility of breast cancer when it is present. The amount of fluid varies. Typically the volume aspirated is between 2 - 10 mls, but can be considerably more. As mentioned above, they present as a lump in the breast that is normally smooth and fluctuant on clinical examination.
Initial assessment is the same as for any lump - clinical examination, mammography or ultrasound and aspiration cytology. Ultrasound is excellent for showing the cystic nature of these lesions, though they are also conspicuous on mammography if of sufficient size. Aspiration however, confirms the diagnosis and is normally all that is required as a treatment.
Upon aspiration, typical fluid is seen. Afterwards the breast is re-examined and if no further palpable abnormality is felt, and if there is nothing on radiology to cause concern, the diagnosis is confirmed and no more need be done. Patients are reassured and warned that the cyst may recur or that they may develop further cysts in the same or other breast.
The exception to this is when blood is aspirated from a cyst (even if the cyst totally disappears) or when there is a residual palpable abnormality. In these cases, a biopsy is often needed to exclude cancer, though a period of observation for a short time may be justified in certain cases depending on the results of mammography and cytopathology. Blood-stained cystic aspirates are usually sent to pathology for analysis, whereas normal cystic fluid is usually discarded.
8. Nipple disorders
For many women, the reason they attend a breast clinic is due to a problem with the nipple. The nipple may be affected by a number of pathologies, and a number of symptoms are encountered. The most common symptoms affecting the nipple are inversion and discharge. Inversion can be present from birth, and is therefore not considered to be abnormal for such a woman. However, nipple inversion later in life, when the nipple was previously in its normal everted position, often signifies a new problem with the breast.
Some of the main conditions that affect the nipple will now be discussed.
Periductal mastitis / duct ectasia
Periductal mastitis is a form of breast infection. Major ducts draining into the nipple become distended (ectasia), and fill with secretions. These then become infected and cause inflammation (mastitis). As time passes, the infection can become chronic and result in the formation of scar tissue that pulls the nipple inwards. In addition, patients with periductal mastitis often have nipple discharge that can occasionally be bloody. Such discharge is usually from the affected duct(s) and is often bilateral. Patients can also experience pain and the presence of a palpable lump beneath the nipple is not uncommon.
If the infection becomes severe enough, an abscess can form. Unless adequately drained, this may point and discharge onto the surface of the breast, and in so doing it commonly creates a mammary fistula.
The nipple discharge and inversion seen in association with this condition tends to occur in older patients. When nipple inversion occurs, a typical "transverse slit" appearance is seen.
On mammography, duct ectasia can sometimes cause microcalcification, and dilated ducts can also be seen. Testing nipple discharge for abnormal cytology is carried out especially when there is blood staining, but often the results are unhelpful. For this reason, surgery is often required to treat these patients with persistent symptoms or with diagnostic uncertainty.
The treatment of periductal mastitis depends in part on the clinical presentation. At one end of the spectrum, abscesses are drained with excision of the affected ducts. Duct excision is also required in milder cases where discharge is persistent enough to cause staining of clothing, where pain is predominant and where nipple inversion is to be corrected. At the time of surgery, it is possible to evert the nipple to its normal position.
Papillomas are benign tumours usually of a single major duct. They often cause blood-stained discharge from the nipple and therefore raise the suspicion of breast cancer. They are not always found near the nipple however, and can present in other parts of the breast. In such cases, discharge is not as common. They are normally excised and diagnosis confirmed on pathology.
Breast cancer can present as a problem with the nipple. Paget's disease is a form of nipple eczema where cancer cells have spread up the ducts and out onto the surface of the nipple. When it occurs, this is most often secondary to DCIS. Breast cancer can also cause distortion of the nipple and discharge. Unilateral nipple inversion and bloody discharge, especially if associated with a lump near the nipple should raise the suspicion of breast cancer and full investigation is warranted.
It should not be forgotten that pregnancy and lactation are a normal causes of nipple discharge. Occasionally, blood-stained discharge is seen during pregnancy, but this rarely indicates anything serious.
Discharge of milk outside pregnancy is also possible, and this phenomenon is called galactorrhoea. This can be due to a number of causes including certain drugs as well as certain types of cancer. However, it is often normal, occurring in relation to the menopause and menarche.