• Clinical science

Benign breast conditions

Summary

There are a number of benign conditions that can affect the breasts, including congenital anomalies (e.g., supernumerary nipples), fat necrosis, mastitis, fibrocystic changes, gynecomastia, mammary ductal ectasia, and neoplasms such as fibroadenoma, phyllodes tumor, and intraductal papilloma. Fibrocystic changes result in the most common benign lesion of the breast, and, like the rest of these lesions, primarily affect women between the third and fifth decades of life. Although benign breast conditions may cause symptoms that mimic breast cancer, the majority of these lesions do not increase the risk of malignant disease. They are usually diagnosed with ultrasound and mammogram, but in some cases biopsy is required. Because of the benign character of these conditions, treatment does not generally involve surgery.

Overview

Epidemiology Clinical features Diagnosis Treatment
Fibrocystic changes
  • Most common benign lesion of the breast
Mastitis
  • Most common in nursing mothers
  • Clinical
Fat necrosis
  • < 3% of all breast lesions
  • Peak incidence: 50 years
  • Often associated with soft tissue trauma
  • Unnecessary
Galactocele
  • Most common benign breast lesion in lactating women
  • Frequently occurs during or after lactation
  • Painless, firm mass
  • Repeated needle aspiration or surgical excision if cysts are symptomatic
Gynecomastia
  • Firm, concentric mass at the nipple areolar complex, which may be tender
  • Mainly clinical
  • Mammogram (in ambiguous cases)
  • Only required in persistent cases
  • Medical therapy: testosterone replacement or tamoxifen
  • Surgery (subcutaneous mastectomy)
  • Treatment of the underlying cause
Fibroadenoma
  • Most common breast mass in women < 35 years
  • Solitary, well-defined, non-tender, rubbery, and mobile mass
  • Regular check-ups
Phyllodes tumor
  • Painless, smooth, multinodular lump
  • Variable growth rate
  • Generally > 3 cm
  • Ultrasound and/or mammogram
  • Core needle biopsy
  • Surgical excision
Intraductal papilloma
  • Peak incidence
    • Solitary lesions: ∼ 48 years
    • Multiple lesions: ∼ 41 years
  • Core needle biopsy
  • Surgical excision
Mammary duct ectasia
  • Unilateral greenish or bloody discharge
  • Nipple inversion
  • Firm, stable, painful mass under the nipple
  • Usually unnecessary
  • Antibiotic therapy if infected
  • Surgical excision for persistent lesions


References:[1]

Congenital anomalies of the breast

The mammary ridge regresses in the 7th–8th week of embryonal development. Disorders during this stage of development may lead to the following anomalies:

Fibrocystic changes

  • Definition: benign changes characterized by the formation of fibrotic and/or cystic tissue
  • Epidemiology
    • Most common benign lesion of the breast
    • Up to 50% of women are affected during their lifetime.
    • Primarily in premenopausal women 20–50 years of age
  • Etiology: unknown
  • Clinical features
  • Diagnosis
    • Physical exam
    • First-line: ultrasound and mammogram
      • Ultrasound: Findings range from normal appearance to focal regions of thick parenchyma; cysts may be present.
      • Mammogram (not recommended for women < 30 years): round or oval masses with clear borders; in some cases, dispersed calcifications
    • Fine-needle aspiration (after imaging confirms a cystic lesion): indicated if the patient is symptomatic and/or requests the procedure
    • Biopsy: confirms diagnosis if imaging is inconclusive
  • Treatment
    • General approach
      • If symptoms are mild, treatment is not required.
      • In case of severe symptoms: oral contraceptives, tamoxifen , or progesterone
      • Fine-needle aspiration or surgery
        • If a cyst causes severe pain, discomfort, or disfiguration
        • In case of proliferative lesions with atypical cells
      • Reevaluate the cyst after 4–6 weeks.
  • Prognosis: depends on the histologic subtype
    • Nonproliferative lesions do not increase the risk of cancer
    • Proliferative lesions with atypical cells (e.g., ductal epithelial hyperplasia) are associated with an increased risk of cancer

References:[2][3][4][5][6][7]

Mastitis

A fluctuant mass may indicate a breast abscess.

Patients with mastitis should continue breastfeeding to reduce the risk of a breast abscess!

References:[9][10][11][12][13]

Fat necrosis of the breast

References:[14][15]

Mammary duct ectasia

  • Definition: subareolar periductal chronic inflammatory condition defined by dilated mammary ducts which are eventually clogged [16]
  • Etiology: inspissated luminal secretion stasis leading to periductal inflammation and fibrous obliteration
  • Epidemiology
  • Clinical features
  • Diagnosis
    • Mammogram and/or ultrasound: noninvasive imaging modalities can determine duct diameter [17]
    • If any suspicious or inconclusive imaging findings, perform a biopsy: shows a central cavity filled with neutrophils and secretion surrounded by inflamed and/or fibrotic breast parenchyma, with obliteration of the ducts
  • Treatment
    • Usually not necessary (most cases resolve spontaneously)
    • Antibiotic therapy if infected
    • Surgical excision for persistent lesions

Mammary duct ectasia is the most common cause of greenish discharge.

Benign breast neoplasms

Fibroadenoma

  • Definition: : benign breast tumor with fibrous and glandular tissue
  • Etiology: unknown, but a hormonal relationship has been established (increased estrogen, e.g., during pregnancy or before menstruation, may stimulate growth)
  • Epidemiology
  • Clinical features: mostly solitary : , well-defined, non-tender, rubbery, and mobile mass
  • Diagnosis
    • Ultrasound: well-defined mass
    • Mammogram: well-defined mass that may have popcorn-like calcifications
    • If imaging is inconclusive: fine-needle aspiration showing fibrous and glandular tissue
  • Treatment: regular check-ups

Phyllodes tumor

  • Definition: rare fibroepithelial tumor with histology similar to that of fibroadenoma
  • Etiology: unknown
  • Epidemiology
  • Clinical features
    • Painless, smooth, multinodular lump in the breast
    • Variable growth rate: may grow slowly over many years, rapidly, or have a biphasic growth pattern
    • Average size 4–7 cm
  • Diagnosis
  • Treatment
    • Surgical excision
    • In case of recurrence: total mastectomy
  • Prognosis

Intraductal papilloma

  • Definition: solitary or multiple benign lesions that arise from the epithelium of breast ducts
  • Etiology: unknown
  • Epidemiology
    • Peak incidence: 40–50 years
      • Solitary lesions: ∼ 48 years
      • Multiple lesions: ∼ 41 years
  • Clinical features
    • Solitary lesions
    • Multiple lesions
      • Usually asymptomatic but may cause nipple discharge in rare cases
      • Peripheral lesions; smaller than solitary papilloma
  • Diagnosis
    • If lesion is palpable: Core needle biopsy is confirmatory and rules out malignancy.
      • Shows papillary cells with fibrovascular core
    • Otherwise: ductogram
  • Treatment: surgical excision of the affected duct
  • Prognosis: generally excellent

References:[18][19][9][20][21][22][23][24][25][26][27]

Gynecomastia

Types and pathophysiology
Physiological gynecomastia
Pathological gynecomastia
Idiopathic gynecomastia
  • Up to 25% of patients

References:[28][29][30][31][32][33][34][35][36][37]

Galactocele

  • Definition: milk retention cyst located in the mammary gland
  • Epidemiology
    • Most common benign breast lesion in lactating women
    • Frequently occurs during or after lactation
  • Pathophysiology: obstruction of lactiferous duct → distention of the duct due to collection of milk and epithelial cells → cyst formation
  • Clinical features
    • Soft, nontender mass; typically located in the sub-areolar region
    • Pain suggests secondary infection.
  • Diagnosis
    • Primarily a clinical diagnosis
    • Fine needle aspiration: milky substance (diagnostic and therapeutic)
    • Ultrasound: complex mass; findings depend on the fat and water content of the cyst
    • Mammography (rarely indicated): galactoceles may appear as an indeterminate mass or a mass with the classic fat-fluid level
  • Treatment
    • Usually not necessary (most cases resolve spontaneously)
    • Repeated needle aspiration or surgical excision for symptomatic cysts
  • Prognosis: good; no increased risk of subsequent breast cancer

References:[38]