Benign breast conditions

Last updated: April 13, 2022

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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 of benign breast conditions
Disorder Epidemiology Clinical features Diagnostics Treatment
Congenital anomalies of the breast
  • Affect 1–6% of the general population [1]
  • Clinical
  • Surgical correction
Mastalgia [2]
  • Very common (esp. in women 30–50 years of age)
  • Approx. 70% of all women will experience mastalgia at some point in their lives.
Fibrocystic changes
  • Most common benign lesion of the breast
  • Premenstrual breast tenderness
  • Multiple breast nodules bilaterally
Mastitis
  • Most common in nursing mothers
  • Clinical
Fat necrosis
  • Unnecessary
Mammary duct ectasia
  • Usually unnecessary
  • Antibiotic therapy if infected
  • Surgical excision for persistent lesions
Gynecomastia
  • Firm, concentric mass at the nipple-areolar complex, which may be tender
  • Mainly clinical
  • Mammogram (in ambiguous cases)
Breast hypertrophy
  • Rare condition
  • Enlarged breasts (symmetrical or asymmetrical)
  • Mastalgia
  • Muscular discomfort and/or pain
  • Tension sensation around the neck, shoulders, and upper back
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
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
  • Surgical excision
Intraductal papilloma
  • Peak incidence
    • Solitary lesions: ∼ 48 years
    • Multiple lesions: ∼ 41 years
  • Surgical excision
Lobular carcinoma in situ (LCIS)
  • No specific findings (no mass or calcifications)
  • Usually incidental biopsy finding.
  • After core needle biopsy:
    • Clinical and imaging follow-up
    • Usually no treatment is necessary
Breast cysts
  • Single or multiple breast masses
  • Variable size (microcysts, gross cyst, clusters) and texture (smooth, soft, firm)
  • May be painful or tender
  • Usually movable
  • Regular check-ups
Mondor disease

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

  • Amastia: absence of breast tissue and nipples
  • Polymastia: presence of accessory breast tissue
  • Athelia: absence of nipples
  • Polythelia: presence of accessory nipples
  • Poland syndrome [3]
    • Unilateral aplasia/hypoplasia of the pectoralis muscles and breast with associated fingers abnormalities (e.g., brachysyndactyly)
    • Most commonly develops on the right side

Overview

  • Definition: benign changes characterized by the formation of fibrotic and/or cystic tissue [4][5]
  • Epidemiology
    • Most common benign lesion of the breast
    • Primarily in premenopausal women 20–50 years of age
    • Up to 50% of women are affected during their lifetime.
  • Etiology: unknown

Histologic subtypes [6]

Clinical features

Diagnostics [8]

  • Physical exam
  • Ultrasound and mammography (first-line)
    • Ultrasound
      • Findings range from normal appearance to focal regions of thick parenchyma.
      • Сysts may be present.
    • Mammography (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 [9]

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.

Benign inflammatory conditions of the breast include infectious mastitis and noninfectious inflammatory mastitis (e.g., fat necrosis of the breast, mammary duct ectasia).

Mastitis

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

Breast abscess [15]

A fluctuant mass may indicate a breast abscess.

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

Fibroadenoma

Phyllodes tumor [24]

Intraductal papilloma

  • Definition: solitary or multiple benign lesions that arise from the epithelium of the lactiferous breast ducts [25]
  • Epidemiology: peak incidence: 40–50 years
    • Multiple lesions: ∼ 41 years
    • Solitary lesions: ∼ 48 years
  • Etiology: unknown
  • Clinical features [26]
    • Solitary lesions (also known as central papilloma)
    • Multiple lesions (also known as peripheral papilloma)
      • Usually asymptomatic but may cause nipple discharge in rare cases
      • Peripheral lesions
      • Smaller compared to solitary lesions
  • Diagnostics
  • Treatment: surgical excision of the affected duct
  • Prognosis
    • Generally excellent; for most lesions, there is no risk of malignant transformation
    • Lesions with atypical hyperplasia are associated with an increased risk of breast cancer

Intraductal papilloma is the most common cause of bloody nipple discharge.

Lobular carcinoma in situ (LCIS) [29]

Histological classification of LCIS [30]
Types Characteristics
Classic LCIS (CLCIS)
Nonclassic LCIS [33] Pleomorphic LCIS (PLCIS)
Florid LCIS (FLCIS)
  • Marked distortion and distention of the terminal duct lobular units
  • Form a mass-like appearance
  • Apocrine features may be present.
  • Central necrosis and microcalcifications
  • Clinical features
    • Asymptomatic; no specific findings (no mass or calcifications)
    • Approx. 55% are multicentric and approx. 35% are bilateral [30]
  • Diagnostics [34]
  • Management
    • After core needle biopsy
      • Follow-up, including imaging
      • Usually no treatment is necessary
    • Surgical excision is recommended for:
    • Excisional breast biopsy (i.e., following surgical excision)
      • CLCIS: no further surgery is necessary
      • Nonclassic LCIS: evaluation of surgical margins and reexcision to negative margins is recommended

Overview

Types and pathophysiology [36][37]

Physiological gynecomastia

Pathological gynecomastia

Some Hormones Cause Fulminant Kleavage: Spironolactone, Hormones, Cimetidine, Finasteride, Ketoconazole cause gynecomastia.

Idiopathic gynecomastia

  • Up to 25% of patients

Clinical features

Diagnostics [45]

Differential diagnoses

Treatment [46]

References: [51]

Overview

Clinical features

  • Firm, nontender mass, typically located in the sub-areolar region
  • Pain suggests secondary infection.

Diagnostics [52]

Primarily a clinical diagnosis

Differential diagnosis

Differential diagnosis of galactocele
Content Ultrasound Mammography
Pseudolipoma
  • Fat content very high
Cystic mass with fat-fluid level
  • Fresh milk, and variable proportions of fat and water
  • Fat-fluid level on mediolateral view
Pseudohamartoma
  • Circumscribed mass with characteristic heterogeneous density due to the presence of fat radiolucencies

Treatment

  • Usually not necessary (most cases resolve spontaneously)
  • Repeated needle aspiration or surgical excision for symptomatic cysts

Prognosis

Overview

Clinical features

Diagnostics

Treatment

Prognosis [53]

  • Cyclical mastalgia
    • Usually resolves spontaneously within 3 months of onset
    • Typically relapses and remits
  • Noncyclical mastalgia
    • Resolves spontaneously in approx. 50% of patients
    • Usually responds poorly to treatment
  • Definition: a well-circumscribed collection of fluid within the breast that is influenced by hormonal changes
  • Epidemiology [54]
  • Classification
    • Solitary breast cyst (most common): a single, circumscribed collection of fluid within the breast
    • Multiple breast cysts: multiple, circumscribed collections of fluid within the breast
    • Simple breast cysts: smooth, thin, regularly shaped walls that are completely filled with fluid
    • Complicated breast cysts: thin-walled cysts filled with fluid and debris
    • Complex breast cysts : thick-walled or septated masses, with intracystic or other solid components
  • Clinical features
    • Single or multiple breast masses
    • May be painful or tender
    • Variable size (microcysts, gross cyst, clusters) and texture (smooth, soft, firm)
    • Usually movable
  • Diagnostics: The preferred initial study depends on the woman's age.
  • Management
    • Simple and complicated cysts
      • Mostly benign; do not require intervention
      • If the cyst is large, painful, and/or has signs of infection: ultrasound-guided fine-needle aspiration
      • Rarely, complicated cysts are diagnosed as probably benign: clinical follow up in 6 months and repeat imaging
    • Complex cysts

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