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Benign Breast Conditions

Majority of the breast complaints are benign in nature.
Women with breast complaints understandably often “assume the worst”. However, an understanding of the benign breast disorders is essential to help relieve unnecessary stress.

Benign breast problems are of several types; but in general, they are classified according to the predominant symptom as – lumps, pain, nipple problems, and infections. The majority of breast lumps are benign. The likely cause of the breast lump may vary based on the age of the patient.

Never the less, most if not all breast condition must be subjected to Triple Assesment, a combination of clinical examination, imaging, and nonsurgical biopsy. A biopsy is only avoided when there are clearly benign and non-suspicious findings on imaging.

Below you will find a number of common benign breast conditions.

Localized Nodularity

Localized nodularity is a common finding reflecting the presence of lumpy or nodular breast tissue. It is generally noticed in the upper outer quadrants of the breasts, typically in younger women. This often reflects a physiological change e.g. puberty, cessation of breast feeding. Most women previously diagnosed with “fibrocystic disease” may have nodular, lumpy breasts.

The symmetrical and cyclical nodularity (i.e. same on both sides and changing with the menstrual cycle) in young women can be managed with proper clinical surveillance of around 2–3 months. Any asymmetric, localised nodularity or thickening in older women (>30 years) requires further investigation.

Fibroadenomas

Fibroadenomas are harmless lumps of glandular and fibrous tissue. Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple), and are surrounded by glandular, fibrous and fatty tissue. Typically, fibroadenoma develops from a lobule and later the glandular tissue and ducts grow over the lobule, forming a solid lump. Fibroadenoma’s in breasts may feel firm and rubbery and will have a smooth texture.

Fibroadenomas are not cancerous and do not increase the risk of breast cancer. Nonetheless, as fibroadenomas contain some normal breast tissue cells, a cancer can develop within it although the possibility of developing cancer within a fibroadenoma is no higher than developing it elsewhere in the breast.

About one in six (15%) women have fibroadenoma at some time in their life. Fibroadenomas make up about 12% of all the symptomatic breast masses. They are most common in women aged 20 to 40 and with peak incidence in 21–25 year age group. In women over the age of 50 years, fibroadenoma occurs in less than 5% of the population. Although, the exact cause of fibroadenomas is unknown, they are subject to hormonal influences. Fibroadenomas can be solitary or multiple, palpable or impalpable. They often become painful before the end of the menstrual cycle.

Fibroadenomas can be detected as a palpable lump, or by a mammogram or a breast ultrasound. The majority (80%) of fibroadenomas occur as a single lump, however, having many fibroadenomas scattered throughout the breasts is also possible.

Fibroadenoma may vary in size from a few millimetres to five or more centimetres in diameter. Usually, fibroadenomas remain at the same size. Nonetheless, some get smaller and eventually disappear over time. A very small number of fibroadenomas get bigger, particularly in teenage girls. Pregnancy and breastfeeding can also make the fibroadenoma bigger. Most palpable fibroadenomas are of 1–3cm in size. Some can grow to more than 5cm and are called giant fibroadenomas.

Fibroadenomas may have similar density as the surrounding breast parenchyma, and are often not visible in mammography. In mammography, they appear as well-defined dense lobulations and may contain calcification. On ultrasound, fibroadenomas appear as a well-circumscribed, homogeneous, ovoid lesions, classically with smooth edges. Gentle lobulations may also be present. In a few cases, calcification can also be seen within the lesion. Any suspected fibroadenoma that shows atypical features clinically or on imaging requires pathological diagnosis by needle biopsy.

Larger fibroadenomas (>3–4 cm diameter), lesions with atypical features or those significantly increased in size should be considered for excision biopsy, regardless of patient age and triple testing results. You will be asked to follow up with your physician if the fibroadenoma gets bigger or shows a noticeable change.

Most fibroadenomas can be left alone if they remain stable in size over time. Removal is indicated if there is a significant increases in size, there are symptoms such as pain, if there is anxiety about the lump or if there are any features on imaging that raise concern.

Cysts

Cysts are fluid entrapments in the breast tissue, which are common in women in the age group of 35–50. They usually cease with menopause, but are common in women taking Hormone Replacement Therapy (HRT). Approximately 7% of women may have a palpable cyst at some point of their lives. Researchers stated about half of the women who attend breast clinic complain about cysts. Breast cysts are often impalpable, asymptomatic and are usually found incidentaly on routine imaging. Cysts can also appear as lumps that are smooth, soft to firm, mobile, and sometimes tender. Cysts under tension can be firm to hard and tender on examination.

Cysts appear as well defined round densities on mammography. On ultrasound, cysts appear as well defined round or oval anechoic (black) lesions. It is difficult to differentiate the cysts with ‘atypical’ features such as internal echoes or thick walls and the solid lesion on ultrasound. Atypical cysts though asymptomatic may require aspiration under the guidance of ultrasound and a sample will be sent for cytological assessment.

The cystic fluid can be drained using a fine needle. Cyst fluid can vary in colour and consistency. The fluid can be clear or coloured- yellow, green, orange, or black. Cyst fluid usually appears as a watery, ‘straw-coloured’ fluid.

Cysts are harmless, but consult your physician if you feel a new lump. A cyst that is asymptomatic and has typical benign features does not require treatment. Patients should be assured that a benign cyst does not significantly increase their risk of breast cancer. Follow up is not required unless the cyst is symptomatic.

Women with cysts causing significant discomfort can be considered for aspiration to provide symptomatic relief. A palpable lump that has the typical features of a simple cyst on ultrasound does not require aspiration to confirm the diagnosis.

Surgery is rarely recommended for treating cysts unless an uncomfortable cyst keeps recurring even after repeated aspiration and lesions do not resolve or aspiration depicts an atypical or suspicious cytology.

Breast cysts are not cancerous, and cysts do not increase breast cancer risk. However in some cases, cysts look unusual so more investigations are performed to be sure a cancer is not missed.

Women who get many cysts should not fall into a false sense of security and ignore new breast lumps. It is essential to get every new breast lump examined immediately.

Less Common Benign Breast Lumps

Fat Necrosis

Breasts are made up of lobules, ducts, glandular, fibrous, and fatty tissue. The trauma or damage of breast tissue can lead to a lump formation known as fat necrosis. Necrosis refers to cell death. The damage to the fatty breast tissue can occur following breast surgery such a breast reduction and breast reconstruction, or radiotherapy to the breast. It can also result from direct injury or trauma to the breasts.

Fat necrosis appears like a firm painless lump, but some women may have tenderness or even pain. The skin around the lump may look red, bruised, or occasionally dimpled. At times fat necrosis can cause the nipple to retract inwards. Although fat necrosis is benign, it often looks like breast cancer. These lumps of breast tissue may appear as malignant breast tumours on mammograms and other imaging studies. The mass may look dense; have an irregular shape, a spiky border, and a collection of micro calcifications. Therefore, for a proper diagnosis full triple assessment is required.

Fat necrosis often resolves on its own. If the lump does not disappear over time, or increases in size, a small surgery may be recommended to remove the lump. Fat necrosis can be observed in women of any age. It is a benign breast condition and does not increase breast cancer risk.

Australian Medical Association Health Sydney Local Health District THE UNIVERSITY OF SYDNEY BreastSurgANZ Royal Australasian College of Surgeons General Sergeons Australia Daisi