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Benign Breast Disease
By: Neri Blanco, M.D.

by Neri M. Blanco, M.D.


Discussion:
Mastalgia
Mastitis
Breast Abscess
Fibroadenoma
Fibrocystic Change
Cysts
Nipple Disorders


Most breast complaints are benign. In order to not always assume the worst, understanding benign breast disease is necessary.

Mastalgia

Breast pain which can be cyclical or non-cyclical, depending on the relationship with menstruation. In most cases benign, it deserves at least a personal monthly breast exam and a physician’s breast exam. Further work-up with a mammogram, breast ultrasound, MRI, or surgery depends on the patient’s age, family or personal history, and physical exam.

Cyclical mastalgia is hormonal and usually occurs the week before menstruation. Women complain of lumpiness or nodules, and the upper outer quadrants are usually the most tender. There is a suggestion that caffeine and fatty foods may provoke mastalgia. For severe cyclical mastalgia, patients are advised to forego caffeine and take daily doses of primrose oil. Certain hormone-blocking drugs are also available, blocking the hormone prolactin which is believed to be to blame (danazol, bromocriptine).

Noncyclical mastalgia can have numerous causes, and breast cancer is one of them, therefore this requires thorough and comprehensive evaluation.

Tietz’s Syndrome is an inflammation of the junction between the ribs, the anterior chest cartilaginous attachments, and the breast bone or sternum. This leads to pain which can be confused for breast pain in many women. Treatment involves reassurance and non-steroidal drugs. For severe cases, anesthetic and steroid injections into the affected areas is available.

Mastitis

Inflammation or infection of the breast. Mastitis is caused in several ways: infection gains access to the breast tissue via the nipple and ducts, through broken skin, or by the bloodstream from infection at another site.

Superficial infections are called cellulitis and are treated with antibiotics alone. Deeper infections can lead to a breast abscess and requires both antibiotics and surgical intervention to drain the pus pocket.

Infection can also be related to surgery of or trauma to the breast. In the immediate postoperative period, the pocket or cavity left from surgery fills with inflammatory fluid. In 1 - 5%, this fluid can become infected, leading to longer healing times, compromised cosmetic results secondary to scar formation, and possible further surgical intervention. Infection can also delay further treatment, such as chemotherapy and radiation for breast cancer and reconstructive surgery with foreign bodies, ie. implants. This is why surgery or trauma to the breast should be assessed and followed by a medical professional.

Breast Abscess

Abscesses in the breast are most common during breast-feeding, but can result following surgery, trauma, or from infection at distant sites in the body. Symptoms include swelling, hardening of tissue, and reddening of the skin. If the infection becomes more generalized, this can lead to fevers, chills, nausea, vomiting, and malaise. If diagnosed early, antibiotics are the only treatment. But if infection leads to a large abscess, needle aspiration or surgical drainage is necessary.

Surgery requires opening and unroofing the abscess cavity, leaving this open to be packed with medicated gauze every day to allow for healing from the inside out. Depending on the size of the abscess cavity, full healing will take anywhere from a week to a month.

If a breast abscess is not related to breast-feeding and is close to the areola, it is most likely related to abnormal duct anatomy, and therefore, surgery is needed to excise the abscess cavity as well as the ducts. Again, the entire length of the tract or fistula between the abscess and abnormal ducts needs excision. Antibiotics in this case only help with exacerbations of infection but do not cure the problem.

Fibroadenoma

These are benign breast nodules that occur in young women, usually between the ages of 15 and 25. They are rubbery, smooth, and mobile on exam, and sizes vary between 1 - 3 cm.

Despite the fact that these tumors are easily diagnosed on physical exam and by age group, breast cancer, although rare, must still be ruled out. First step in assessment is a history, especially a family history of breast cancer, and a physical exam to check for size and mobility of the lesion and adenopathy in the axilla. Mammography is usually not necessary in young women because the dense breast tissue makes it hard to interpret and locate lesions. Ultrasound is the preferred diagnostic exam, followed by needle biopsy to determine if the lesion is benign or an excisional biopsy. Surgery, or excisional biopsy, is recommended for patients with large or painful fibroadenomas or those who are anxious about the possibility of malignancy despite reassurance.

Fibrocystic Change

Presence of single or multiple benign tumors or cysts in the breast. Not a disease but refers to symptoms and conditions associated with nodularity or lumpiness of the breast and mastalgia that follows a cyclical pattern. Usually occurs in pre-menopausal women age 30 - 40 years.

With age and persistent symptoms, fibrocystic changes in the breast can lead to focal cysts or nodules that need special attention. Mammography, ultrasound, and needle biopsy or aspiration of cystic fluid may be necessary. Suspicious finding still require surgical biopsy to exclude malignancy.

Cysts

These are fluid-filled cavities in the breast that are common in pre-menopausal women. They present as lumps, can be recurrent and bilateral, and are suspected to be cancers initially.

Mammography, ultrasound, and needle aspiration with fluid being sent out for cytology to rule out cancer are all part of the initial assessment. If fluid aspirated is bloody or if there is a residual mass after aspiration, then formal surgical biopsy should be performed to exclude malignancy.

Nipple Disorders

The most common problems with the nipple are inversion and discharge. Inversion can occur at birth or with aging. Later in life, it is caused by duct ectasia, or when the ducts become distended and fill with secretions. This causes fluids to back up and results in infection or mastitis. Symptoms of duct ectasia include discharge, which can be bloody, pain, a palpable lump beneath the nipple, and the appearance of a transverse slit caused by the inversion of the ducts. Treatment involves antibiotics for mastitis, needle aspiration or surgical drainage for possible abscesses, and surgical excision of the affected ducts.

Breast discharge is normal and can be clear, milky white, green, or brown. When bloody drain age is encountered, cancer must be ruled out. Again, mammography and ultrasound can help define the problem. Ductograms and ductal endoscopies are available in some centers. However, surgical exploration of the affected duct may be necessary for diagnosis as well as therapy.

Neri Blanco, M.D.