Benign Breast Conditions

It is natural for any symptom in the breast to cause anxiety. Breast cancer is estimated to be the most commonly diagnosed cancer in females in Australia. In 2019 19,345 persons (19,371 women and 164 men) are projected to be diagnosed with this condition (source: https://breast-cancer.canceraustralia.gov.au/statistics). Around 3% of primary care consultations relate to breast symptoms, however, the majority of these will be from benign conditions.

Current guidelines advise consideration of referral for all unexplained breast lumps, with urgency determined by patient and imaging features. Benign breast disease symptoms may include pain, nipple discharge, nodularity and swelling. It may be difficult to differentiate benign from malignant conditions. Most breast clinics aim to see women referred with breast symptoms within a couple of weeks. Some common benign breast conditions are outlined below.

Common presenting features may include:

  • Physiological swelling and tenderness
  • Nodularity
  • Breast pain (not usually associated with malignancy)
  • Palpable breast lumps
  • Nipple discharge including galactorrhoea
  • Breast infection and inflammation

Cyclical mastalgia

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 up to two thirds of all menstruating women. It rapidly resolves as menstruation starts. Conditions to exclude by history and examination are infection, pregnancy and malignancy.

Pregnancy

Normal changes to the breasts during pregnancy and breast-feeding include:

  • Tenderness, discomfort or pain
  • Increase in size
  • Areolar and nipple changes: darkening of colour, enlargement of nipples, enlargement of the Montgomery glands on the areola
  • Leaking of colostrum or milk

Problems during breast-feeding may include sore or cracked nipples, thrush, engorgement, etc.

Fibrocystic change is the most common benign breast disorder and most often presents with pain and nodularity. This usually affects women aged 20-50 and appears to be hormonal in aetiology. Women present with lumpiness of the breast and varying degrees of pain and tenderness:

  • The symptoms are greatest about one 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 symptoms persist patients should be referred for assessment
  • Mammography is often used in older patients; however, for younger ones with denser breasts, ultrasound is usually better
  • Treatment is often with reassurance, analgesia and a well-fitting bra

For more information see: https://patient.info/doctor/breast-pain-pro

Many breast lumps are benign, especially in younger patients. Most benign lumps will be either cysts or fibroadenomas.

Breast cysts

Cysts are common between the ages of 35 and 50. They are palpable as discrete lumps. They cannot be reliably distinguished from solid tumours on clinical examination. Cysts are readily identified on imaging (mammography and ultrasound). They often do not need aspiration unless they are symptomatic or indeterminate on imaging, as they often reoccur. Many will settle spontaneously.

Fibroadenomas

These are benign tumours that are common in young women and are most common in peri-menopausal women. They are the most common type of breast lesion (up to 7% of women will present with a palpable breast cyst in their lifetime). Fibroadenomas arise in breast lobules and are composed of fibrous and epithelial tissue. They present as firm, non-tender, highly mobile palpable lumps. Hormonal fluctuations appear to be involved in development.

As with all unexplained lumps, referral should be made to a specialist breast clinic. Women are assessed by the triple assessment of examination, imaging (first-line choice is ultrasound before age 40, mammogram after) and needle biopsy (not necessarily required under the age of 25). They are often treated with surgical excision but this may not be necessary if they are small and the diagnosis is confirmed. Most stop growing at about 2 or 3 cm.

Phyllodes tumour

This is a rare tumour that tends to occur in women aged between 40 and 50 years and may be difficult to distinguish from a fibroadenoma. It may be benign, borderline or malignant. A benign tumour may reappear after excision and may become malignant. Treatment is wide excision, including some normal breast tissue. Follow-up is needed, although practice varies on how this is done and there are no national guidelines.

Intraductal papilloma

This is a benign, warty lesion usually central in the breast.

  • A small lump or a sticky, blood-stained discharge
  • Triple assessment is required in a specialist breast clinic, with examination, imaging and biopsy

Atypical hyperplasia

This is a benign hyperplasia which can occur in the ducts or the lobes.

  • Atypical hyperplasia is associated with approximately a 29% risk of breast cancer over 25 years
  • Risk is increased where there is a positive family history of breast cancer
  • Follow-up is required where atypical hyperplasia has been detected.

Sclerosing adenosis

This is a benign condition of sclerosis within the lobules.

  • It may cause a lump, pain or be found on routine assessment
  • It can be very difficult to distinguish from malignancy and biopsy is often advised
  • Follow-up is generally not required as there is no malignant potential

Fat necrosis

Fat necrosis is more likely to occur in larger, fatty breasts women but can occur in any woman and even occasionally in men.

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

Infection (mastitis) may be associated with lactation or, more rarely, occur at other times.

With lactation

Breast ducts become blocked with engorged milk, and bacteria enter from cracks in the nipple.

  • There may be engorgement of the breast and axillary lymphadenopathy
  • Warm compresses and analgesia such as ibuprofen or paracetamol may give some relief
  • Breast feeding should be encouraged to continue if possible
  • A penicillinase-resistant antibiotic (e.g. flucloxacillin) may be required
  • An abscess may develop in the peripheral part of the breast tissue and may require drainage (repeated aspiration or surgical drainage)
  • Swabs should be sent for culture

Without lactation

Spontaneous peripheral abscesses in non-lactating women may be associated with diabetes and immune compromise. Smoking and nipple piercings can predispose to non-lactational mastitis.

  • Inflammation and abscesses may result from obstruction of milk ducts with cellular debris
  • Symptoms may be chronic and recurrent with noncyclical mastalgia, nipple discharge or retraction, peri-areolar abscess, subareolar mass or cellulitis of the overlying skin

NB: inflammatory breast cancer causes pain, redness and induration of the skin. Symptoms progress very rapidly. Anyone in whom presumed mastitis does not resolve completely and who has residual breast change should be considered for inflammatory breast cancer and referral should be made for further evaluation.

Information above adapted from: https://patient.info/doctor/benign-breast-disease