Benign diagnosis
Adenosis, an increase in the number of acini within lobules, occurs frequently as part of fibrocystic change. Papillomata may be solitary or multiple, superficial or deep. Breast abscesses are now less common than they used to be, occurring mainly in women aged between 18 and 50 years. Non- lactational abscesses can occur: Periareolar infection is usually in younger women. The inflammation is around non-dilated, sub-areolar ducts, known as peri-ductal mastitis. Cysts commonly occur and may be of no clinical significance. They are benign and may be solitary or multiple. Fibroadenoma is a benign neoplasm, which arises from the epithelium and stroma. They are considered to be aberrations of normal development. Inflammatory conditions of the breast include:- Mastalgia (breast pain) may be cyclical or non-cyclical. Nipple discharge is one of the important symptoms of breast disease. It is essential to refer a patient with this symptom if :- Nipple discharge may be clear, milky, purulent, blood-stained or frank blood. A discharge may be unilateral or bilateral. Phyllodes tumours are rare fibroepithelial neoplasms that range from benign (will not metastasise and low probability of recurrence) to malignant (high probability of recurrence and likely to metastasise) in their behaviour.
Adenosis, sclerosing adenosis, radial scars
Benign papillary neoplasms
Breast abscess
Cysts and fibrosis
Epithelial hyperplasia
Fibroadenoma
Inflammatory conditions
Mastalgia
Nipple discharge
Phyllodes
Adenosis , sclerosing adenosis, radial scars
Sclerosing adenosis includes an additional proliferation of myoepithelial cells associated with a very small increased risk for subsequent breast cancer development.
Apocrine metaplasia may develop in adenosis. Microglandular adenosis is a benign gland-like proliferation but not resembling lobules. Patients with the above conditions can be reassured.
Radial scar (or complex sclerosing lesion if < 10mm), is a lesion characterised by central elastosis usually containing single ducts and surrounded by a variety of benign changes, including epithelial hyperplasia, adenosis and cyst formation.
These lesions are frequently calcified and have irregular stellate shapes. Mammographically, these lesions cannot be differentiated from carcinomas and are characteristically seen better on one mammographic view than another. They can be associated with in-situ or invasive carcinomas. Excision is usually advised.
Patients who have had a benign radial scar removed can be reassured and no further treatment is usually necessary. Benign
papillary
neoplasms
Solitary benign papillary tumours are more common and tend to be centrally located.
Multiple papillomata are usually peripherally located and may be associated with a slightly increased risk for development of carcinoma.
Florid nipple papillomatosis and sub-areolar duct papillomatosis are hyperplastic proliferative lesions, displaying a variety of pathological appearances, including adenosis and papillomatosis patterns. Breast abscess
The infection can affect the skin of the breast or may occur secondary to a lesion in the skin or to an underlying lesion. Breast abscesses are either
Smoking is an important aetiological factor. 90% of women affected are smokers. The infection may be due to aerobic or anaerobic organisms. Presentation is of periareolar inflammation (with or without a mass) or a well established abscess. Central breast pain, nipple retraction and discharge are associated symptoms.
Mammary duct ectasia is often confused with the above condition. It occurs in older women and is characterised by sub-areolar duct dilatation with less peri-ductal inflammation. Clinically, this condition presents as a nipple discharge.
Periareolar infections are treated by appropriate antibiotics (e.g. co-amoxiclav) with aspiration or incision and drainage. Underlying malignancy and hence referral for investigation, must be considered if resolution does not occur after appropriate treatment. Repeated drainage of abscesses may cause a mammary duct fistula. This condition is treated with excision under antibiotic cover.
Peripheral non-lactational breast abscesses are less common and can be associated with systemic conditions e.g. diabetes, trauma, steroid treatment. Treatment is by repeated aspiration or incision and drainage.
Primary infection of the skin of the breast may present as cellulitis or an abscess. These abscesses are recurrent and are seen in women who are overweight and who have large breasts. Cellulitis may also be a complication of surgery or radiotherapy. Treatment is usually with appropriate antibiotics and aspiration or drainage.
Lactational abscesses, or acute puerperal mastitis, usually develop 2-3 weeks post-partum. Clinically, they present with a painful lump with erythema and oedema. Systemic upset is common. Treatment is with massage and appropriate antibiotics, repeated aspiration and occassionally surgery. Patients should be encouraged to continue breast feeding from the unaffected breast during treatment with antibiotics. (Refer to relevant product data sheet for suitability during lactation.) Cysts
and fibrosis
Hormonal imbalance is considered of aetiological importance. Cysts are common in the 5 years before the menopause.
The cysts can be aspirated if the doctor feels confident in the procedure.
However up to 3% of cysts have accompanying breast cancer and if the doctor does aspirate a cyst then absence of all other lesions should be ensured.
Consider referral for confirmation of the diagnosis, aspiration or if post-aspiration thickening exists. Ultrasonography is the investigation of choice in the diagnosis of breast cysts only if there is doubt or equivocal clinical evaluation or inability to aspirate the cyst. Epithelial hyperplasia
Ductal hyperplasia is a proliferation of the ductal epithelium and may be mild, moderate or florid. It displays a characteristic cytological and architectural appearance.
Atypical ductal hyperplasia involves at least two ducts and has some but not all the characteristics of ductal carcinoma-in-situ.
This lesion is associated with an increased risk for developing breast cancer, particularly with a positive family history.
The absolute risk of breast cancer developing in a woman with atypical hyperplasia without a family history is 8% at 10 years. With a first degree relative affected by breast cancer, the risk is 20-25% at 15 years.
Atypical lobular hyperplasia is a proliferative disorder of lobules, which has some of the features of lobular carcinoma-in-situ. It is also associated with an increased risk for developing breast cancer. Fibroadenoma
They are most common in pre-menopausal women and are associated with a slight increase in risk of subsequent development of breast cancer, if there are associated proliferative changes.
Juvenile fibroadenoma occur in younger women and are usually more cellular lesions and can be very large (8-9cm).
A definitive diagnosis of fibroadenoma can be made by a combination of clinical examination, ultrasonography and fine needle aspiration cytology. Inflammatory conditions
Mastalgia
Cyclical breast pain is not usually associated with malignant breast disease and is commonly regarded as physiological.
A careful history needs to be taken in order to establish the diagnosis. A diary of events and timings is very helpful.
Prolonged, severe pain is regarded as abnormal. Referral should be considered if there is any doubt.
There may or may not be a palpable mass. Nodularity is often associated with cyclical mastalgia. Focal nodularity is a common cause of a breast lump. Referral is necessary for further investigation. Nipple discharge
The two common causes of a blood or blood-stained discharge are duct papilloma and duct carcinoma.
Galactorrhoea is not a sign of breast cancer and not a risk factor for it. Any patient complaining of a nipple discharge must be examined clinically. Phyllodes
Up to 20% recur locally after excision. In the more malignant lesions it is the sarcomatous element that recurs and approximately 25% metastasise.
Initial treatment is by wide local excision, and mastectomy is often required. The role of radiotherapy and chemotherapy in treating these lesions is not clear.
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