Any lump in the breast causes natural and perhaps not inappropriate anxiety, but by no means all lumps are breast cancer. In any women presenting with a breast lump it is important to try to differentiate those that are benign from those that may be malignant. Commonly the following features may be found on examination:
- A benign mass is usually three-dimensional, mobile and smooth, has regular borders, and is solid or cystic in consistency.
- A malignant mass is usually firm in consistency, has irregular borders, and may be fixed to the underlying skin or soft tissue.There may also be skin changes or nipple retraction.
Differentiation is often still not easy and to err on the side of safety is wise.
Common presenting features
A retrospective study of over 300 referrals in Sheffield found that the ages of the women ranged from 16 to 85 years with a mean and median age of 45 years:
- 200 women (66%) presented with a lump or lumpiness.
- 42 women (14%) presented with pain.
- 29 women (10%) had a skin and/or nipple problem.
- 31 women (10%) were concerned about their family history or reported other symptoms.
Only 23 women (8%) were diagnosed as having cancer, 180 (60%) were diagnosed as having benign breast disease, and 99 (33%) were diagnosed as normal. Of the 23 women with cancer:
- 22 were over 40 years of age.
- 21 women presented with a lump.
- One presented with pain.
- One presented with metastatic disease.
Surgeons assessed the appropriateness of GPs' referrals for 257 cases and judged that 122 (47%) could have been managed by a GP. Presentation can also be from abnormalities detected on breast imaging.
Classification of benign breast diseases
There are now two different classifications that are used. One is based on clinical and the other on pathological findings.
Pathologically they can be divided into three groups which provide an idea regarding potential future cancer risk:
- Non-proliferative disorders - no increased risk.
- Proliferative disorders without atypia - mild to moderate increase in risk.
- Atypical hyperplasias - substantial increase in risk (relative risk in the order of 4.1-5.3).
The clinical system seems more appropriate for clinicians:
- Physiological swelling and tenderness.
- Breast pain (not usually associated with malignancy).
- Palpable breast lumps.
- Nipple discharge including galactorrhoea.
- Breast infection and inflammation - usually associated with lactation.
Breast pain and nipple discharge are covered elsewhere and will not be considered further in this article.
It should be noted that the term fibrocystic disease is now regarded by many as redundant. Formerly, the term was used to describe all benign breast conditions, but this caused confusion in distinguishing between normal physiological changes and pathological ones.
Physiological swelling and tenderness
The breasts are active organs that change throughout the menstrual cycle and some degree of tenderness and nodularity in the premenstrual phase is so common that it may be considered as normal, affecting perhaps 50-60% of all menstruating women. It rapidly resolves as menstruation starts. It is also called mammary dysplasia and cystic mastopathy.
- Affected women tend to be aged between 30 and 50 years.
- It is less frequent in association with combined oral contraceptives and rare after the menopause.
- Oral contraceptives reduce the risk of benign breast disease generally.
- It may recur with HRT.
Management has included:
- Reduction or avoidance of caffeine.
- Vitamin E.
- Evening primrose oil.
However, good RCTs with placebo control seem few:
- The placebo response may be as high as 20%.
- A review found little evidence to support dietary intervention.
- Advising a good, well-supporting bra may be the best advice.
Early breast growth in girls or some growth of breast tissue in males is quite common. The breasts are the first of the secondary sexual characteristics to develop at puberty and there may be some early activity in quite young girls:
- Very early development may be asymmetrical and apparently unilateral, but examination will usually show some contralateral development too.
- Unless there are features of true precocious puberty (such as premature pubic hair) then just reassurance is required.
- Note height and weight on a centile chart, as early puberty often accompanies obesity.
Breast lumps in males
Boys may also display some breast development in the hormonal turmoil around puberty. Again, reassurance is required at this time of great personal insecurity. It is more likely to happen in Klinefelter's syndrome, but is by no means diagnostic.
- Gynaecomastia may accompany a number of diseases such as cirrhosis or be produced by a number of drugs.
- Male breast cancer does occur, but is rare.
Nodularity is also a normal, hormonally-mediated change with lumpiness of the breast and varying degrees of pain and tenderness:
- The symptoms are greatest about one week before menstruation and decrease when it starts.
- Examination may reveal an area of nodularity or thickening, poorly differentiated from the surrounding tissue and often in the upper outer quadrant of the breast.
- If the changes are bilaterally symmetrical, they are rarely pathological. If there is asymmetry it is acceptable to review the patient after one of two menstrual cycles, seeing her mid-cycle.
- If symptoms persist then referral should occur.
- Mammography is often used in older patients; however, for younger ones with denser breasts, ultrasound is usually better.
- Treatment is with analgesia and a good bra.
For other possible treatments, see separate article Breast Pain.
Palpable breast lumps
Many breast lumps are benign, especially in younger patients. Most benign lumps will be either cysts or fibroadenoma.
Discrete cysts that are clearly palpable may be safely treated by needle aspiration:
- After some local anaesthetic is injected, an ordinary green hub needle attached to a 10 ml syringe is inserted and the cyst is aspirated.
- It disappears beneath the examiner's fingers and both doctor and patient are reassured.
- Failure to aspirate, especially if it appears to be a solid lesion, requires urgent referral to a breast clinic.
This is a benign tumour that is common in young women, mostly aged under 40 years. It is composed of stromal and epithelial elements and probably represents increased sensitivity to oestrogens:
- Complex and multiple fibroadenomas are associated with a two-fold increase in the risk of breast cancer.
- They represent a hyperplasia or proliferation of a single terminal duct unit.
- Most stop growing at about 2 or 3 cm, but they can enlarge rather further.
- About 10% disappear each year.
- They tend to regress after the menopause.
- They occur in about half of women who receive ciclosporin after renal transplant.
- They are the most common tumour of the breast in those under 30 years old, but overall they are second to breast cancer.
- Juvenile fibroadenomas can occur in teenage girls.
Both mammography and ultrasound may be used to examine the lump:
- Ultrasound tends to be preferred in younger women with dense breasts, as mammograms are more difficult to interpret in this group. Routine mammography, as a population screening tool, is not performed below the age of 50 years.
- Imaging studies may fail to give a firm diagnosis and biopsy or excision may be required for peace of mind of both the patient and doctor.
- If there is confidence in the diagnosis then inactivity may lead to spontaneous regression, but the patient must be advised to check the lump regularly and to return if it starts to enlarge.
- Assessment often includes examination, imaging studies and fine-needle aspiration.
This is a rare tumour that tends to occur in women aged between 40 and 50 years:
- They may be benign, borderline or malignant.
- A benign tumour may re-appear after excision and may become malignant.
- Treatment is wide excision, including some normal breast tissue.
- Mammograms should be performed every two years thereafter.
It is a benign, warty lesion just behind the areola:
- A small lump may be noticed or a sticky, possibly blood-stained discharge.
- Women aged in their 40s are more likely to have just one, but younger women may have multiple lesions.
- Fine-needle aspiration or core biopsy may be used.
Benign hyperplasia can occur in the ducts or the lobes:
- Lobular carcinoma in situ may develop.
- Even this does not merit immediate operation; however, annual mammograms are recommended.
- Risk is increased where there is a positive family history of breast cancer.
This is a benign condition of sclerosis within the lobules:
- It may cause a lump, pain or be found on routine assessment.
- It can be very difficult to distinguish from malignancy and biopsy is often advised.
It tends to be large, fatty breasts in obese women that have this problem:
- It usually follows trauma.
- The lump is usually painless and the skin around it may look red, bruised or dimpled.
- Biopsy may be required, but if the diagnosis is confirmed, no further management is indicated.
Duct ectasia and periductal mastitis
See separate articles Mammary Duct Ectasia and Periductal Mastitis.
Infection or mastitis
Infection may be associated with lactation or, more rarely, occur at other times.
This is covered in greater detail in the separate article Puerperal Mastitis. Breast ducts become blocked with engorged milk, and bacteria enter from cracks in the nipple:
- An abscess develops in the peripheral part of the breast tissue.
- There may be engorgement of the breast and axillary lymphadenopathy.
- Warm compresses and paracetamol may give some relief.
- Encourage the patient to continue breast-feeding with the unaffected breast and, once let-down occurs in the affected breast, feed with the affected breast until it is completely empty.
- A 10-day course of a penicillinase-resistant antibiotic such as flucloxacillin is required.
- A localised abscess will require incision and drainage.
- Swabs should be sent for culture.
Spontaneous peripheral abscesses in non-lactating women are often associated with diabetes and immune compromise:
- Non-lactational mastitis produces periareolar abscesses, usually resulting from obstruction with cellular debris and lipid-laden material. Bacteria enter from the skin and produce periductal inflammation and abscess formation.
- There is a chronic recurrent course with noncyclical mastalgia, nipple discharge or retraction, peri-areolar abscess, subareolar mass or cellulitis of the overlying skin.
Any patient in whom presumed mastitis does not resolve completely after one month of treatment with antibiotics needs referral to exclude inflammatory breast cancer.
Further reading & references
- Breast Cancer Care
- Vaidyanathan L, Barnard K, Elniki DM; Benign breast disease: When to treat, when to reassure, when to refer - Review, Cleveland Clinic Journal of Medicine, May 2002
- Roubidoux MA; Breast Fibroadenoma Imaging, Medscape, Apr 2011
- Willett AM, Michell MJ, Lee MJR; Best practice diagnostic guidelines for patients presenting with breast symptoms, Association of Breast Surgery UK (2010)
- Breast cancer - suspected, Prodigy (July 2005)
- Laver RC, Reed MW, Harrison BJ, et al; The management of women with breast symptoms referred to secondary care clinics in Sheffield: implications for improving local services. Ann R Coll Surg Engl. 1999 Jul;81(4):242-7.
- Pearlman MD, Griffin JL; Benign breast disease. Obstet Gynecol. 2010 Sep;116(3):747-58. doi: 10.1097/AOG.0b013e3181ee9fc7.
- Dickson G; Gynecomastia. Am Fam Physician. 2012 Apr 1;85(7):716-22.
|Original Author: Dr Hayley Wilacy||Current Version: Dr Gurvinder Rull||Peer Reviewer: Prof Cathy Jackson|
|Last Checked: 07/03/2013||Document ID: 1440 Version: 25||© EMIS|
Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.