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4

Benign changes of the breast

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Contents

Objectives

When you have completed this module you should be able to:

Case study 1

A 30 year old woman with a breast lump is referred for an ultrasound scan and a mammogram. Both show the typical features of a fibroadenoma.

  1. What is a fibroadenoma?
  2. Is it malignant?
  3. What does a fibroadenoma feel like on palpation?
  4. At what age are fibroadenomas common?
  5. How should this woman be managed?

Case study 2

A 49 year old woman visits a district hospital as she has found a breast lump. She is very anxious as her mother died of breast cancer. A mammogram and ultrasound scan show a typical simple cyst. The medical officer aspirates green fluid from the cyst.

  1. What is a cyst?
  2. Is the cyst likely to be malignant?
  3. What should be done if the fluid was bloody?
  4. What further treatment is needed?
  5. What would happen if the cyst was not aspirated?
  6. What is the cause of simple breast cysts?

Case study 3

A woman aged 42 complains of tender, painful breasts especially in the day before her menstrual period starts. On clinical examination her breasts are normal. She asks whether it is normal to have painful breasts as she has not had this problem before.

  1. What is the probable cause of her painful breasts?
  2. Is this condition common?
  3. Where in the breasts does the pain usually occur?
  4. What is the correct management?
  5. Should she have a mammogram?

Case study 4

A 45 year old woman presents with discharge from her nipple. She first noticed the discharge 2 years ago. It has not changed and is only there when she squeezes her breast. Her mother was diagnosed with breast cancer at 44 years old.

  1. What are the important points to look for when the breast is examined?
  2. What investigations should the woman be sent for?
  3. What is the most likely diagnosis?
  4. Is she more likely to develop breast cancer as a result of having a discharge?

Introduction to benign changes to the breast

4-1 What normal changes are found in a woman’s breast as she gets older?

Many normal changes occur in a woman’s breast as she becomes older. Most of these are included in the concept of ANDI (aberrations of normal development and involution).

4-2 What conditions are included in ANDI?

ANDI includes all the benign changes that take place in the breasts with age. For example lumps may develop within the breast tissue. It is very important to remember that there is always a cause for a breast lump and that the diagnosis must fit the age of the patient. In this chapter, the various benign conditions will be looked at in more detail.

4-3 What is a breast lump?

A lump is a local area of firm tissue that can be felt in a breast. The lump is firmer than the surrounding breast. Usually a woman is concerned about a lump because she has not noticed it before.

4-4 Why are breast lumps important?

Because they may be malignant (a cancer). Fortunately most breast lumps are benign.

4-5 What does benign mean?

Benign means that the condition (e.g. a breast lump) is not malignant, i.e. not cancerous. A benign lump may increase in size but does not spread into the surrounding tissue to elsewhere in the body.

A benign lump may get bigger but does not spread.

4-6 What questions should be asked while taking a history from a woman with a breast lump?

4-7 What are common causes of a benign lump in the breast?

The two commonest causes of benign conditions associated with a breast lump are:

However, it is always possible that the lump may be malignant.

Most breast lumps are fibroadenomas or cysts.

Breast fibroadenomas

4-8 What is a fibroadenoma?

The woman may have one fibro­adenoma or many fibroadenomas (fibroadenomata). A fibroadenoma consists of both fibrous and glandular tissue.

Figure 4-1: Drawing of ultrasound view of a typical fibroadenoma. Note the normal tissue flowing past the lump and the white line under the lump.

Figure 4-1: Drawing of ultrasound view of a typical fibroadenoma. Note the normal tissue flowing past the lump and the white line under the lump.

4-9 Who usually gets fibroadenomas?

The majority of women who develop a fibroadenoma are under the age of 35. Therefore most new breast lumps in young women are fibroadenomas. After the age of 40, breast cancer becomes a commoner cause of a lump in the breast.

Fibroadenomas are usually seen in young women.

4-10 What do fibroadenomas feel like?

They are round and movable. They feel rubbery and tend to move under the fingers when the breast is examined.

4-11 What happens over time to fibroadenomas if they are not removed?

They tend to grow to a size of 1 to 3 cm and most stay at that size. However some will increase in size and may get to be 6 cm or larger. Over decades, they will tend to get smaller. It is common to have more than one fibroadenoma.

4-12 What investigations should a woman have if fibroadenomas are suspected?

A fibroadenoma cannot be definitely diagnosed using ultrasound scanning and cytology alone. If a core (Tru-cut) biopsy is not going to be performed then all 3 tests (clinical, ultrasound and cytology) must suggest that the lump is a fibroadenoma.

The best test to confirm the diagnosis of a fibroadenoma is a core biopsy.

4-13 What is a core (Tru-cut) biopsy?

This is a small sample of tissue taken with a special core (Tru-cut) biopsy needle. The tissue is then examined under a microscope (histology). The advantage of this method is that it causes minimal trauma and does not require the whole lump to be removed. However, if there is any doubt about the result of the core biopsy it is best to remove the lump.

A core biopsy will give a tissue diagnosis and will also sample some of the surrounding tissue. A core biopsy showing typical changes would give a definite diagnosis.

If in doubt take the lump out.

4-14 What happens to a fibroadenoma during pregnancy?

It gets bigger during the pregnancy but will go back to the original size at the end of pregnancy or may even decrease in size.

4-15 Are fibroadenomas associated with an increased risk of breast cancer?

There is a slightly higher risk of developing breast cancer. Anyone who is older than 35 and develops a new fibroadenoma should have mammograms once a year after the age of 40.

What is most important is that a cancer may feel like a fibroadenoma.

A breast cancer may feel like a fibroadenoma.

4-16 How should fibroadenomas be treated?

If a confident diagnosis of fibroadenomas has been made they can be left with no treatment. However, they should be taken out if they are very big (greater than 5 cm) or painful. They should also be taken out if the women is intending to fall pregnant as it can be very worrying for her if she has a breast lump increasing in size during her pregnancy.

Breast cysts

4-17 What are cysts?

Cysts are benign (non-cancerous) lumps in the breast that are filled with fluid. The fluid may be yellow, green or very dark.

There may be microcysts (very small cysts) or macrocysts (larger cysts). Macrocysts are larger than 1 cm and may be felt as a lump. Usually small cysts can only be seen on a mammogram and ultrasound scan.

The cysts may not be distended with fluid in which case they are soft. A cyst is like a balloon. The more it is filled up, the more it is palpable. If it is only partially filled, it may not be palpable as it is soft. Therefore it is possible to have large cysts that cannot be felt.

Figure 4-2: A drawing of an ultrasound scan of a cyst showing the typical black appearance. Note the white line underneath and the normal tissue flowing over the lump. The fluid removed from the cyst is typically greenish and is sometimes thick.

Figure 4-2: A drawing of an ultrasound scan of a cyst showing the typical black appearance. Note the white line underneath and the normal tissue flowing over the lump. The fluid removed from the cyst is typically greenish and is sometimes thick.

4-18 What causes cysts?

Cysts are associated with shrinkage of the lobes of the breast (involution). This occurs with age so cysts commonly occur in women in their 40s. One in ten women will get cysts that can be felt at some point in their lives. Even more will have cysts on a mammogram or ultrasound scan.

Breast cysts are common in women in their 40s.

4-19 What problems may cysts cause?

Cysts cause anxiety because the woman may fear she has cancer. The cyst may also be tender.

4-20 What happens to cysts?

If they are untreated, they tend to disappear after menopause. Women who are on HRT (hormone replacement therapy) may continue to get cysts.

4-21 How should cysts be investigated?

As they generally occur in women over 40 years of age, they should have a mammogram to make sure they are simple cysts. It must not be assumed on clinical examination alone that a breast cyst is benign.

4-22 How should cysts be treated?

The most important thing is to make a diagnosis and make sure it is not a cancer. Some cysts should be aspirated.

4-23 Which cysts should be aspirated?

Not all cysts need to be aspirated. However, a cyst should be aspirated if:

A 23G needle can be put into a cyst to drain it. This is called fine needle aspiration (FNA). It will provide relief for the woman if it is a painful cyst and will also give an instant diagnosis. If the fluid is not blood stained, it does not need to be sent off for cytology. Blood from a cyst indicates that the cyst may be malignant. All bloody fluid must be sent for histology.

Blood from a cyst indicates that the cyst may be malignant.

4-24 What is fibrocystic change?

Fibrocystic change is a very common cause of lumpy, tender breasts usually seen in women between 30 and 50 years of age. The changes are due to the variation on hormonal levels during the menstrual cycle. Many small lumps of glandular tissue, cysts and areas of fibrosis occur.

Cysts may be macrocysts (greater than 1 cm) or smaller in which case they are called microcysts.

Painful breasts

4-25 What is mastalgia?

Mastalgia means tender or painful breasts.

4-26 Who gets mastalgia?

Over 70% women will get mastalgia at some time in their lives. It is nearly always associated with normal breasts. It is commonest in adolescence and in women in their 40s.

If women are not taking HRT and are over 40 years of age, they may not have mastalgia but may have musculoskeletal pain (pain in the muscles or joints).

4-27 What is the typical history of mastalgia?

The pain is commonly in the upper outer quadrant of the breast as that is where most of the breast tissue is. The classic history is that pain increases before the menstrual period and gets better afterwards. This is so-called cyclical mastalgia.

The breast pain in cyclical mastalgia gets better after menstruation.

4-28 What questions should be asked about pain in the breast?

4-29 What is usually found on breast examination in a woman with mastalgia?

Generally the breasts are normal on examination. It is important to always examine the breasts carefully when a woman presents with mastalgia as some women who find a lump are too nervous to say they have a lump so instead say they have pain.

4-30 How should women with mastalgia be investigated?

Women over 40 should have a mammogram. Although cancer is very rarely associated with mastalgia, many women will not feel better until they know they have not got cancer.

Breast cancer is not a cause of mastalgia except in obvious and advanced cases.

4-31 How can cyclical mastalgia be treated?

Most women with mastalgia are concerned that they have breast cancer. Thoughtful and appropriate reassurance of this concern is the key treatment for mastalgia. Mastalgia is not a disease that requires medical intervention and medication.

Beside reassurance, the best common sense advice is for the woman to get a new bra! Nearly half of all women wear the wrong sized bra. Bras are expensive but they are cheaper than doctors. Most women will be relieved if they know they have not got cancer.

If there is no improvement, lots of remedies have been tried. The only drugs that have been shown to work are non-steroidal anti-inflammatory agents e.g. Brufen and Voltaren. They should ideally be given as a skin cream to rub onto the painful area so there are no side effects. Antibiotics and diuretics have no role.

Some people report that evening primrose oil improved their pain, but it has not been shown to work in big trials.

Most women with mastalgia will get better after reassurance that they do not have cancer.

Non-cancerous changes of the nipple-areola complex

4-32 What are important non-cancerous changes in the areola and nipple?

Changes under the nipple and areola (nipple-areola complex) include:

4-33 What is duct ectasia?

Duct ectasia is the dilatation of the ducts under the nipple-areola complex. Its is part of the normal ageing process of the breast. Normally the ducts are about 1 mm in diameter. However, with age, they become wider and blocked.

Although it is generally seen in older women, it may present at a younger age.

These changes are normal with ageing and usually do not cause problems.

4-34 What is periductal mastitis?

Periductal mastitis (PDM) is an inflammatory condition of the nipple and retroareolar region. This commonly results in localised sepsis with small abscesses, scarring and purulent drainage from the nipple. The nipple may be pulled in which can cause an inverted nipple. The problem with periductal mastitis is making the diagnosis.

Ductal ectasia and periductal mastitis are important, as many of the features caused by these conditions are similar to the changes found with cancer. Ductal ectasia may result in periductal mastitis.

4-35 Who gets ductal ectasia and periductal mastitis?

Generally women in their 60s but much younger women may get the same changes.

4-36 What problems can be caused by ductal ectasia and periductal mastitis?

4-37 What investigations should be done?

All women over 40 should have a mammogram and the fluid from the discharge should be sent off for cytology.

Most women will need to be sent to a breast unit for a diagnosis to be made as ductal ectasia and periductal mastitis may mimic breast cancer.

4-38 How should these women be treated?

The most important thing is to make an accurate diagnosis. The conditions themselves do not need to be treated but the complications must be correctly managed.

4-39 Is nipple inversion always abnormal?

No. Nipple inversion (turned or pulled inwards) is usually normal. It is only abnormal if a nipple used to be everted (sticking out) and becomes inverted. The commonest cause is ductal ectasia or periductal mastitis but a cancer can also cause nipple inversion.

Ductal ectasia or periductal mastitis are common causes of nipple inversion but a cancer must be ruled out.

4-40 How should cracked nipples be managed?

This is very common in breastfeeding mothers. It may cause pain with breastfeeding and can result in mastitis or an abscess. A little breast milk should be left on the nipple at the end of each feed. The nipple must be kept dry between feeds. If it becomes a problem, antibiotic cream can be applied.

4-41 What is a keratin pearl?

A keratin pearl is a small yellow bead which appears on the nipple. This is very common and requires no treatment.

4-42 How is eczema of the nipple managed?

Eczema of the areola is very itchy and particularly common in women who have eczema elsewhere. It is important to distinguish it from Paget’s disease of the nipple which is a sign of cancer. Paget’s disease begins in the nipple and is associated with flattening of the nipple. To determine whether it is Paget’s disease or eczema a biopsy should be taken if it does not rapidly improve with steroid cream.

4-43 How is a biopsy of the areola or nipple performed?

Local anaesthetic is injected under the skin. If a punch biopsy is available, a small circle of full thickness skin should be biopsied.

If no punch biopsy is available, a 23G needle may be used to tent up a small area of skin so that is can be biopsied.

4-44 HIV infection

Women with HIV infection have an increased incidence of nipple and breast infections when breastfeeding.

4-45 What causes nipple pain?

This is particularly common in breastfeeding women or women around the time of menopause. In breastfeeding women, it may be caused by a cracked nipple or an infection. The commonest organisms causing infection are Candida or Staphylococcus. They should be treated with an antifungal or an antibacterial cream.

The cause of nipple pain around the time of menopause is not known and women should be reassured after they have had a normal mammogram. It is important to examine all women with nipple pain.

4-46 How should nipple polyps be managed?

A nipple polyp is an abnormal but non-cancerous growth from the wall of a duct. They are usually attached by a stalk. Nipple polyps are relatively common and may become a problem in breastfeeding mothers as they can lead to bleeding during feeding. If they are a problem, local anaesthetic can be injected into the nipple and they can be removed. Ideally this should be done after a woman has stopped breastfeeding.

Nipple discharge

4-47 What questions should be asked if a woman has a nipple discharge?

4-48 When is a nipple discharge worrying?

When both a nipple discharge and a breast lump are present the lump must be investigated.

4-49 When is a nipple discharge normal?

One in five women can squeeze a small amount of fluid from the nipple. The discharge is usually either greenish in colour or thick (like toothpaste). This is normal and does not need to be investigated.

However, a discharge that occurs on its own without squeezing the nipple may not be normal especially if there are large amounts of discharge.

4-50 What type of fluid can be discharged?

Four types of fluid are commonly discharged from the nipple:

A bloody nipple discharge is always abnormal.

4-51 What investigations should be done?

4-52 What is the commonest cause of a greenish discharge?

Duct ectasia is the commonest cause of a thin or thick greenish discharge.

4-53 Why is a bloody or watery discharge a worry?

Because about 10% women with a bloody or watery discharge will have a cancer causing the discharge. This percentage is much higher if there is also a breast lump.

4-54 What is the commonest cause of a bloody discharge?

The commonest cause of a bloody discharge is an intraductal papilloma. The discharge is usually from one duct only.

4-55 What is an intraductal papilloma?

An intraductal papilloma is a growth in a duct. The closer the growth is to the nipple, the more likely it is to be non-cancerous. The further away from the nipple, the more likely it is to be a papillary cancer. All intraductal papillomas need a histological (tissue) diagnosis. This usually means removal of the papilloma.

An intraductal papilloma generally presents with bleeding from a single duct.

Figure 4-3: Intraductal papilloma

Figure 4-3: Intraductal papilloma

Infections of the breast

4-56 What causes infections of the breast?

They may be caused by any of the following:

4-57 What are the commonest associated problems in the breast which may lead to breast infections?

Abscesses near the areola area may be seen in smokers and may cause a fistula. These women are generally in their 30s. Abscesses throughout the breast may open in different areas and tend to be seen in slightly older women.

4-58 What are the commonest immune system causes?

4-59 What pathogens cause breast abscesses?

Always look for a cause when a woman has a breast infection.

4-60 What questions should be asked about an infection in the breast?

4-61 What is an abscess?

An abscess is a collection of pus. Clinically, an abscess has overlying red shiny skin and has a soft fluctuant feel to it. If the abscess is deep, it may be hard and tender. Sometimes, it drains spontaneously and the patient presents with pus draining from the abscess.

As blood cannot get into the centre of a pus collection, antibiotics alone are not enough. Therefore the pus must be drained either by an incision and drainage or by using a 14G needle and aspirating the pus under local anaesthetic. This is better done under ultrasound guidance. Antibiotic cover should be given if the abscess is aspirated. Use a broad spectrum antibiotic because often more than one type of bacteria is present.

4-62 What is the further management of a breast abscess after drainage?

The patient should be given an oral broad-spectrum antibiotic, such as augmentin, and seen again in 10 days time. A simple infection should have resolved by then and a mammogram can now be done if the patient is older than 40 years. An ultrasound scan should be done in younger women.

It is less painful for the woman to have a mammogram once the infection has cleared and the result is easier to interpret.

4-63 What is the difference between mastitis and an abscess?

Mastitis is infection of the breast without pus formation. An abscess is an infection with pus formation. Mastitis may be treated with antibiotics but may go on to become an abscess.

4-64 Can breast cancer present like a breast infection?

Yes. Inflammatory breast cancer can present with the signs and symptoms of a breast infection.

Inflammatory breast cancer can mimic a breast infection.

4-65 What other conditions seen on a mammogram may mimic breast cancer?

Some non-cancerous conditions can look like a cancer on a mammogram. These cause a lot of anxiety and need a biopsy:

4-66 What is meant by a lumpy breast?

This is a term used so commonly that it has become almost meaningless. Some women do have very firm dense breasts. Others have much softer breasts. In general, the younger the women, the denser the breasts. However, some older women have firm lumpy breasts. They generally have fibrocystic change.

4-67 Which benign changes are associated with an increased risk of breast cancer?

Before the formation of breast cancer, the breast becomes more hyperplastic (the cells are busier and multiply faster). This may lead to areas of atypical hyperplasia. In the next module, it can be seen how atypical hyperplasia may develop into ductal carcinoma in situ (DCIS) and then into invasive breast cancer.

Older women who develop a new fibroadenoma should be considered to be at increased risk of cancer.

Case study 1

A 30 year old woman with a breast lump is referred for an ultrasound scan and a mammogram. Both show the typical features of a fibroadenoma.

1. What is a fibroadenoma?

It is an area of breast tissue consisting of both fibrous and glandular tissue.

2. Is it malignant?

No, it is benign and a common aberration of normal development and involution (ANDI).

3. What does a fibroadenoma feel like on palpation?

It is firm and very mobile. Most fibroadenomas are less than 3 cm in size.

4. At what age are fibroadenomas common?

The majority of women who develop a fibroadenoma are under the age of 35 years.

5. How should this woman be managed?

An ultrasound scan and a fine needle aspiration should be done for cytology. Reassurance alone is all that is needed if the clinical examination, imaging and cytology all suggest a fibroadenoma. If the diagnosis is still uncertain a core biopsy is needed.

Case study 2

A 49 year old woman visits a district hospital as she has found a breast lump. She is very anxious as her mother died of breast cancer. A mammogram and ultrasound scan show a typical simple cyst. The medical officer aspirates green fluid from the cyst.

1. What is a cyst?

Cysts are benign (non-cancerous) lumps in the breast that are filled with fluid. They are common in women in their 40s.

2. Is the cyst likely to be malignant?

No, as green fluid is typically aspirated from a benign cyst.

3. What should be done if the fluid was bloody?

It should be sent for cytology as bloody fluid suggests that the cyst may be malignant.

4. What further treatment is needed?

If the cyst has been fully aspirated it will probably disappear. As the scans were normal and the fluid not bloody she can be reassured that she does not have cancer.

5. What would happen if the cyst was not aspirated?

It would slowly disappear on its own.

6. What is the cause of simple breast cysts?

Cysts form when glandular tissue shrinks in older women.

Case study 3

A woman aged 42 complains of tender, painful breasts especially in the day before her menstrual period starts. On clinical examination her breasts are normal. She asks whether it is normal to have painful breasts as she has not had this problem before.

1. What is the probable cause of her painful breasts?

Mastalgia. The pain is typically worse in the days before a menstrual period and disappears when the period starts.

2. Is this condition common?

Yes. Most women will have painful breasts at some stage of their lives.

3. Where in the breasts does the pain usually occur?

In the upper quadrant as this is where most of the breast tissue is found.

4. What is the correct management?

The pain and tenderness are often much less if the woman wears a bra which fits correctly.

5. Should she have a mammogram?

Yes. All women over 40 years with any breast complaint should have a mammogram. A normal result will reassure her that the pain is not due to cancer.

Case study 4

A 45 year old woman presents with discharge from her nipple. She first noticed the discharge 2 years ago. It has not changed and is only there when she squeezes her breast. Her mother was diagnosed with breast cancer at 44 years old.

1. What are the important points to look for when her breast is examined?

Both breasts must be carefully examined and a lump must be excluded. Look for nipple inversion. The nipple should be squeezed gently (the patient can be asked to do it) and any discharge should be inspected. Note whether any discharge is from a single duct or multiple ducts. Note what colour the discharge is.

2. What investigations should the woman be sent for?

A mammogram. The woman is over 40 years old and she has a family history of breast cancer. If the mammogram is normal, the discharge greenish and from more than one duct, and there are no lumps, she can be reassured. Otherwise she should be investigated further.

3. What is the most likely diagnosis?

Ductal ectasia is the most likely diagnosis as the discharge has been there for 2 years and has not increased. With ductal ectasia the discharge is usually green and can be thick or thin.

4. Is she more likely to develop breast cancer as a result of having a discharge?

Not if the diagnosis is ductal ectasia.