Benign Breast Disease

Benign Breast Conditions

1. Cysts
• Often present as a palpable abnormality or cause of breast pain
• On physical exam, they are usually smooth, round, firm, and tender
• Peak incidence is between 35 and 50 years of age
• Classified as simple, complicated, or complex


1. Simple Cysts
• Simple cysts have thin walls and septa without a solid component
• Benign lesions with no risk of malignancy
• Small, asymptomatic simple cysts can be observed
• Palpable or symptomatic cysts can be aspirated under palpation or ultrasound guidance
• Only bloody cyst fluid needs to be sent for cytopathology
• Cysts that recur more than two times should be excised



2. Complicated Cysts
• Contain echogenic debris without solid components, thick walls, or thick septa
• Breast cancer risk is less than 1%
• Most are classified as BI-RADS 2, and are managed like simple cysts
• If the cyst is classified as BI-RADS 3, then the imaging should be repeated in 6 months, unless the patient desires biopsy or excision







3. Complex Cysts
• Contain both cystic and solid components, as well as thick walls and septa
• Usually classified as BI-RADS 4
• Require an image-guided core needle biopsy or a needle-localized excisional biopsy







2. Fibroadenoma
• Most common cause of a breast mass in women < 30
• Presents as a firm, round, smooth, rubbery, freely mobile mass
• Cannot be distinguished from cysts on mammogram
• Ultrasound shows a well-defined solid mass
• Neither a premalignant lesion nor a risk factor for breast cancer
• Excision is not mandatory, but it is often chosen to remove worry
• If a nonoperative approach is taken, then the diagnosis should be confirmed by a core-needle biopsy
• Rapid growth raises the suspicion of a phyllodes tumor, which cannot be distinguished from a fibroadenoma on core biopsy



3. Breast Pain
• Classified as cyclical or noncyclical
• Symptoms range from vague to debilitating pain


1. Cyclical Pain
• Often called fibrocystic breast disease
• Hormonally driven, usually presenting the week before the onset of menses and dissipating with the onset of menses
• May be associated with oral contraceptives or estrogen replacement therapy
• Symptoms are usually bilateral and diffuse and cease at menopause
• Patients may present with palpable lumps, which fluctuate in size and discomfort with the menstrual cycle
• Imaging is used selectively based on physical findings and whether the patient is up to date on screening


1. Treatment
• Support bras and sports bras during exercise are often recommended
• Warm compresses or ice packs provide relief to some women
• Topical NSAIDS (Diclofenac) have been validated in clinical trials
• Eliminating caffeine, a low-fat diet, primrose oil, and vitamin E are often recommended, but the evidence to support their efficacy is lacking
• Occasionally a short course of tamoxifen or danazol is necessary to relieve symptoms
• Often, the only treatment necessary is reassurance that breast pain is not a common symptom of breast cancer


2. Noncyclical Pain
• Not related to the menstrual cycle
• May be constant or intermittent, and is more likely to be unilateral
• Potential causes include cysts, fibroadenomas, or infections
• Extramammary causes include underlying bone disease, costochondritis, or fibromyalgia
• Treatment is directed to the underlying cause, if it can be identified


4. Nipple Discharge
• Discharge that is bilateral and multiductal is a common benign physiologic process
• Discharge that is spontaneous, unilateral, recurrent, and involving a single duct is suspicious and requires further investigation


1. Suspicious Nipple Discharge
• May be clear, blood-tinged, or bloody
• Most common etiology is a papilloma
• DCIS or invasive cancer accounts for 5% - 15% of cases
• Increasing age is predictive of the risk of breast cancer in women with nipple discharge
• Bloody nipple discharge is associated with a higher risk of breast cancer than nonbloody discharge
• Paget’s disease, eczema, and local infections may mimic nipple discharge


1. Breast Examination
• Observe for skin changes, symmetry, position of the nipples, skin retraction, dimpling, and ulceration or crusting of the nipple
• Determine which quadrant and duct is responsible by applying clockwise pressure around the areola


2. Imaging
1. Mammogram
• Should be obtained in all women ≥ 30 years old, although the sensitivity is low


2. Ultrasound
• Most useful study
• Focus is on the periareolar area
• Provides good visualization of dilated ducts and any nodules inside them
• Facilitates core needle biopsy or wire localization for surgery







3. Ductography
• Technically challenging procedure that requires cannulation of the involved duct
• Valuable when ultrasound does not visualize the lesion
• Negative ductography does not exclude a cancer



3. Surgical Treatment
• Papillomas are managed with a terminal duct excision through a circumareolar incision
• After complete excision, 17% - 20% of papillomas are found to contain cancer
• DCIS or invasive cancers are managed with either a partial mastectomy or mastectomy


5. Sclerosing Adenosis
• Mimics carcinoma both grossly and histologically
• Often contains microcalcifications which mimics DCIS
• Presents as a palpable mass or a suspicious finding on mammogram
• No significant malignant potential
• Excision is not required if the diagnosis is secure



6. Radial Scar
• Belongs to a group of lesions known as complex sclerosing lesions
• Mimics carcinoma both mammographically and on physical exam
• May present as a spiculated mass with skin dimpling
• Characterized pathologically by a central scar
• Usually requires excision to rule out an underlying carcinoma, which is found in 20% of cases



7. Fat Necrosis
• Can mimic cancer by producing a palpable mass
• On mammogram, may present as a spiculated mass with microcalcifications
• May be preceded by a history of trauma, prior breast surgery (reduction), or radiation treatment
• Often requires surgical excision to confirm the diagnosis
• No malignant potential