Benign Breast Disease

The breast tissue cycles hormonally during the menstrual phase, similarly to the uterus. The breasts increase in size and volume by 50% approximately 2 weeks prior to menses. This is often heralded by breast tenderness or mastalgia. The breast usually returns to their premenstrual state approximately one week after menses. This is often called mastitis or fibrocystic disease (actually condition, as 90% of women have fibrocystic changes) but represents a normal condition of the breast. The symptoms can be alleviated many times by reducing caffeine intake (coffee, tea, cola and chocolate), taking vitamin E, or taking Evening Primrose Oil, generally within three to four months.. Ninety percent of the time, breast tenderness is benign or not malignant (cancer). Breast cancer is usually painless.

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Generally seen in older women and not related to the menstrual cycles. Non-cyclic mastalgia may be related to a variety of medications (estrogen replacement, lanoxin, pepcid, thiazide diuretics, etc., or arthritic changes of the thoracic spine). Improvement occurs with anti-inflammatories.

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These benign tumors usually present as a mass in the breast during adolescence and young adulthood. These masses can enlarge and become tender during menstrual cycle and can become quite large. With increasing age, fibroadenomas may calcify and with this calcification, have a typical mammographic appearance. Rarely are fibroadenomas associated with malignancy.

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Appearing during pregnancy or during lactation, they likewise present as a mass (lump) in the breast and are similar to fibroadenomas.

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Normally, ten to fifteen ducts open on the surface of the nipple. Seventy percent of women will periodically have nipple discharge. If the discharge is cloudy green, cloudy yellow or milky, from multiple ducts in both breasts, the discharge is usually benign. Galactorrhea (milky discharge) may be associated with hypothyroidism (low levels of thyroid hormone) or pituitary adenomas (benign growths of the pituitary). Determination of TSH (thyroid stimulating hormone) and prolactin levels (blood tests) may indicate these as potential sources of nipple discharge. Many medications can likewise be associated with nipple discharge. Benign multiduct nipple discharge is not an indication for surgical biopsy

Bloody or serous (clear yellow) nipple discharge from a single duct and noted spontaneously, in nightgowns or bras, are concerning for underlying problems and should be evaluated by a physician. Only a third of these discharges are malignant but they represent one of the warning signs for cancer. Galactography or mammary duct excision (surgical procedure to remove the duct) generally reveal an intraductal papilloma, a benign growth of the breast ducts.

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This term, is generally used by clinicians to describe the induration (swelling) and tenderness associated with the menstrual cycle. Pathologically, (under the microscope) these changes are characterized by the formation of cysts (fluid filled sacs) of various sizes, stromal fibrosis (scarring of tissue surrounding the functional breast units) and a variety of proliferative lesions (increased layers of cells lining the ducts). These changes are present in 90% of women and can therefore not be classified as a disease but represent the normal changes in the breast with increasing age.

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a.	Nonproliferative lesions: cysts, apocrine change, calcifications, fibroadenomas and hyperplasia (increased number of cell layers lining the breast ducts, more than two but no more than four layers of epithelial cells). The risk of developing breast cancer is not increased in this group.
b.	Proliferative lesions without atypia: florid hyperplasia (more than four layers of epithelial cells), sclerosing adenosis and intraductal papillomatosis. Women with these changes on a breast biopsy are at slight increased risk for developing breast cancer, 1.5 to 2 times the risk of the general population. Hyperplasia Normal duct Intraductal hyperplasia Intraductal hyperplasia with atypia Intraductal carcinoma in situ Invasive ductal cancer -
c.	Atypical Hyperplasia: Multiple cellular layers that may involve lobular or ductal elements. Women with these changes are at increased risk for developing breast cancer, 4.5 to 5 times the risk of the general population. With the addition of a positive family history of breast cancer and these findings on a breast biopsy the risk doubles to 8 to 10 times the risk of the normal population.
d.	Lobular Carcinoma in situ: Although this sounds like cancer, it is still benign proliferative breast disease (hyperplasia, atypical hyperplasia). These women are at increased risk for the development of breast cancer, 15%-35% over the next fifteen years. Although an indication for prophylactic mastectomy, many women have undergone bilateral mastectomy for this condition when close clinical follow-up may suffice. Infiltrating ductal carcinoma of the breast is the most common cell type in those individuals that proceed on to breast cancer and the tumors develop equally in either breast. Consideration should be given to chemoprevention of breast cancer with Tamoxifen.

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Generally associated with a history of trauma, fat necrosis presents as a firm mass in the breast. Clinically and by mammography it may be indistinguishable from carcinoma of the breast. The diagnosis is usually made by breast biopsy.

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Subareolar abscess presents with pain and redness of the nipple areolar complex. The abscess is generally polymicrobial (more than one bacterium) and usually seen in smokers. Treatment of the abscess is by incision and drainage.

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Seen within the first weeks after the onset of breast-feeding, the breast usually inflamed (erythematous or red) warm and tender in a wedge shaped distribution. Cracked nipples usually cause this condition. The organism responsible for this infection is usually staph aureus and this condition will respond to antibiotics. If not treated promptly, this condition may lead to breast abscess requiring surgical drainage.

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• 70% of women will periodically have nipple discharge.
• 90% of women have fibrocystic changes.
• Breast cancer is the most common malignancy in women.