Benign Breast Disorders

Essentials of Diagnosis

• Painful, often multiple, usually bilateral masses in the breast.
• Rapid fluctuation in the size of the masses is common.
• Frequently, pain occurs or increases and size increases during premenstrual phase of cycle.
• Most common age is 30–50. Rare in postmenopausal women not receiving hormonal replacement.

General Considerations

This disorder is the most frequent lesion of the breast. It is common in women 30–50 years of age but rare in postmenopausal women who are not taking hormonal replacement medications. Estrogen hormone is considered a causative factor. There may be an increased risk in women who drink alcohol, especially between 18 and 22 years old. Fibrocystic disease encompasses a wide variety of pathologic entities. These lesions are always associated with benign changes in the breast epithelium, some of which are found so commonly in normal breasts that they are probably variants of normal breast histology but have nonetheless been termed a "disease."

The microscopic findings of fibrocystic disease include cysts (gross and microscopic), papillomatosis, adenosis, fibrosis, and ductal epithelial hyperplasia. Although fibrocystic disease has generally been considered to increase the risk of subsequent breast cancer, only the variants in which proliferation (especially with atypia) of epithelial components is demonstrated represent true risk factors.

Clinical Findings

Symptoms and Signs

Fibrocystic disease may produce an asymptomatic lump in the breast that is discovered by accident, but pain or tenderness often calls attention to the mass. There may be discharge from the nipple. In many cases, discomfort occurs or is increased during the premenstrual phase of the cycle, at which time the cysts tend to enlarge. Fluctuation in size and rapid appearance or disappearance of a breast mass are common in cystic disease. Multiple or bilateral masses are common, and many patients will give a history of a transient lump in the breast or cyclic breast pain.

Diagnostic Tests

Because a mass due to fibrocystic disease is frequently indistinguishable from carcinoma on the basis of clinical findings, suspicious lesions should be biopsied. Fine-needle aspiration cytology may be used, but if a suspicious mass that is nonmalignant on cytologic examination does not resolve over several months, it must be excised. Surgery should be conservative, since the primary objective is to exclude cancer. Occasionally, core needle biopsy will suffice. Simple mastectomy or extensive removal of breast tissue is rarely, if ever, indicated for fibrocystic disease.

Differential Diagnosis

Pain, fluctuation in size, and multiplicity of lesions are the features most helpful in differentiating fibrocystic disease from carcinoma. If a dominant mass is present, the diagnosis of cancer should be assumed until disproved by biopsy. Final diagnosis often depends on excisional biopsy. Mammography may be helpful, but the breast tissue in these young women is usually too radiodense to permit a worthwhile study. Sonography is useful in differentiating a cystic from a solid mass.

Treatment

When the diagnosis of fibrocystic disease has been established by previous biopsy or is likely because the history is classic, aspiration of a discrete mass suggestive of a cyst is indicated in order to alleviate pain and, more importantly, to confirm the cystic nature of the mass. The patient is reexamined at intervals thereafter. If no fluid is obtained or if fluid is bloody, if a mass persists after aspiration, or if at any time during follow-up a persistent lump is noted, biopsy is performed.

Breast pain associated with generalized fibrocystic disease is best treated by avoiding trauma and by wearing (night and day) a brassiere that gives good support and protection. Topical nonsteroidal anti-inflammatory gel may be of value. Hormone therapy is not advisable, because it does not cure the condition and has undesirable side effects. Danazol (100–200 mg twice daily orally), a synthetic androgen, has been used for patients with severe pain. This treatment suppresses pituitary gonadotropins, but androgenic effects (acne, edema, hirsutism) usually make this treatment intolerable; in practice, it is rarely used. Similarly, tamoxifen reduces some symptoms of fibrocystic disease, but because of its side effects it is not useful for young women unless it is given to reduce the risk of cancer. Postmenopausal women receiving hormone replacement therapy may stop hormones to reduce pain.

The role of caffeine consumption in the development and treatment of fibrocystic disease is controversial. Some studies suggest that eliminating caffeine from the diet is associated with improvement. Many patients are aware of these studies and report relief of symptoms after giving up coffee, tea, and chocolate. Similarly, many women find vitamin E (400 IU daily) helpful. However, these observations remain anecdotal.

Prognosis

Exacerbations of pain, tenderness, and cyst formation may occur at any time until the menopause, when symptoms usually subside, except in patients receiving hormonal replacement therapy. The patient should be advised to examine her own breasts each month just after menstruation and to inform her physician if a mass appears. The risk of breast cancer in women with fibrocystic disease showing proliferative or atypical changes in the epithelium is higher than that of women in general. These women should be followed carefully with physical examinations and mammography.

This common benign neoplasm occurs most frequently in young women, usually within 20 years after puberty. It is somewhat more frequent and tends to occur at an earlier age in black women. Multiple tumors are found in 10–15% of patients.

The typical fibroadenoma is a round or ovoid, rubbery, discrete, relatively movable, nontender mass 1–5 cm in diameter. It is usually discovered accidentally. Clinical diagnosis in young patients is generally not difficult. In women over 30, cystic disease of the breast and carcinoma of the breast must be considered. Cysts can be identified by aspiration or ultrasonography. Fibroadenoma does not normally occur after the menopause, but may occasionally develop after administration of hormones.

No treatment is usually necessary if the diagnosis can be made by needle biopsy or cytologic examination. Excision or vacuum-assisted core needle removal with pathologic examination of the specimen is performed if the diagnosis is uncertain. Cryoablation is being attempted as an alternative to excision. It is usually not possible to distinguish a large fibroadenoma from a phyllodes tumor on the basis of needle biopsy results.

Phyllodes tumor is a fibroadenoma-like tumor with cellular stroma that grows rapidly. It may reach a large size and if inadequately excised will recur locally. The lesion can be benign or malignant. If benign, phyllodes tumor is treated by local excision with a margin of surrounding breast tissue. The treatment of malignant phyllodes tumor is more controversial, but complete removal of the tumor with a rim of normal tissue avoids recurrence. Since these tumors may be large, simple mastectomy is sometimes necessary. Lymph node dissection is not performed, since the sarcomatous portion of the tumor metastasizes to the lungs and not the lymph nodes.

In order of decreasing frequency, the following are the commonest causes of nipple discharge in the nonlactating breast: duct ectasia, intraductal papilloma, and carcinoma. The important characteristics of the discharge and some other factors to be evaluated by history and physical examination are as follows:

1. Nature of discharge (serous, bloody, or other).

2. Association with a mass.

3. Unilateral or bilateral.

4. Single or multiple duct discharge.

5. Discharge is spontaneous (persistent or intermittent) or must be expressed.

6. Discharge produced by pressure at a single site or by general pressure on the breast.

7. Relation to menses.

8. Premenopausal or postmenopausal.

9. Patient taking contraceptive pills or estrogen.

Unilateral, spontaneous serous or serosanguineous discharge from a single duct is usually caused by an intraductal papilloma or, rarely, by an intraductal cancer. A mass may not be palpable. The involved duct may be identified by pressure at different sites around the nipple at the margin of the areola. Bloody discharge is suggestive of cancer but is more often caused by a benign papilloma in the duct. Cytologic examination may identify malignant cells, but negative findings do not rule out cancer, which is more likely in women over age 50. In any case, the involved duct—and a mass if present—should be excised. Ductography is of limited value since excision of the bloody duct system is indicated regardless of findings. Ductoscopy is being evaluated as a means of identifying intraductal lesions but is not yet practical.

In premenopausal women, spontaneous multiple duct discharge, unilateral or bilateral, most marked just before menstruation, is often due to mammary dysplasia. Discharge may be green or brownish. Papillomatosis and ductal ectasia are usually seen on biopsy. If a mass is present, it should be removed.

Milky discharge from multiple ducts in the nonlactating breast occurs in certain endocrine syndromes, as a result of hyperprolactinemia. Serum prolactin levels should be obtained to search for a pituitary tumor. Thyroid stimulating hormone (TSH) helps exclude causative hypothyroidism. Numerous antipsychotic drugs and other drugs may also cause milky discharge that ceases on discontinuance of the medication.

Oral contraceptive agents or estrogen replacement therapy may cause clear, serous, or milky discharge from a single duct, but multiple duct discharge is more common. The discharge is more evident just before menstruation and disappears on stopping the medication. If it does not stop and is from a single duct, exploration should be considered.

Purulent discharge may originate in a subareolar abscess and require removal of the abscess and related lactiferous sinus.

When localization is not possible, no mass is palpable, and the discharge is nonbloody, the patient should be reexamined every 2 or 3 months for a year, and mammography should be done. Cytologic examination of nipple discharge for exfoliated cancer cells may rarely be helpful in diagnosis. However, the duct may be catheterized and lavage performed to evaluate cells for atypia. Recently, a small scope has been developed to examine the ductal system (ductoscopy), and its use may identify an intraductal tumor.

Fat necrosis is a rare lesion of the breast but is of clinical importance because it produces a mass, often accompanied by skin or nipple retraction, that is indistinguishable from carcinoma. Trauma is presumed to be the cause, though only about 50% of patients give a history of injury. Ecchymosis is occasionally present. If untreated, the mass effect gradually disappears. The safest course is to obtain a biopsy. Needle biopsy is often adequate, but frequently the entire mass must be excised, primarily to exclude carcinoma. Fat necrosis is common after segmental resection, radiation therapy, or flap reconstruction after mastectomy. During nursing, an area of redness, tenderness, and induration may develop in the breast. The organism most commonly found in these abscesses is Staphylococcus aureus. In the early stages, the infection can often be treated while nursing is continued from that breast by administering an antibiotic such as dicloxacillin or oxacillin, 250 mg four times daily for 7–10 days (see Puerperal Mastitis, Obstetrics). If the lesion progresses to form a localized mass with local and systemic signs of infection, surgical drainage is performed and nursing is discontinued. A subareolar abscess may develop (rarely) in young or middle-aged women who are not lactating. These infections tend to recur after incision and drainage unless the area is explored during a quiescent interval, with excision of the involved lactiferous duct or ducts at the base of the nipple. Otherwise, infection in the breast is very rare unless the patient is lactating. In the nonlactating breast, inflammatory carcinoma is always considered. Thus, findings suggestive of abscess or cellulitis in the nonlactating breast are an indication for incision and biopsy of any indurated tissue. If the abscess can be percutaneously drained and completely resolves, the patient may be followed conservatively.   During nursing, an area of redness, tenderness, and induration may develop in the breast. The organism most commonly found in these abscesses is Staphylococcus aureus. In the early stages, the infection can often be treated while nursing is continued from that breast by administering an antibiotic such as dicloxacillin or oxacillin, 250 mg four times daily for 7–10 days (see Puerperal Mastitis, Obstetrics). If the lesion progresses to form a localized mass with local and systemic signs of infection, surgical drainage is performed and nursing is discontinued. A subareolar abscess may develop (rarely) in young or middle-aged women who are not lactating. These infections tend to recur after incision and drainage unless the area is explored during a quiescent interval, with excision of the involved lactiferous duct or ducts at the base of the nipple. Otherwise, infection in the breast is very rare unless the patient is lactating. In the nonlactating breast, inflammatory carcinoma is always considered. Thus, findings suggestive of abscess or cellulitis in the nonlactating breast are an indication for incision and biopsy of any indurated tissue. If the abscess can be percutaneously drained and completely resolves, the patient may be followed conservatively.