Benign Breast Conditions

The breast has two main types of tissues -- glandular tissues and supporting (stromal) tissues. The glandular part of the breast includes the lobules and ducts. In women who are breast feeding, the cells of the lobules produce milk, which is then carried inside the ducts (milk passages) to the nipple. The support tissue of the breast includes fatty tissue and fibrous connective tissue (ligaments that support the breast).

Any of these areas of the breast can undergo changes that cause you to have symptoms. The two main groups of breast changes are benign (not cancer) breast conditions and breast cancers. This document reviews the types of benign breast conditions. The most common benign breast conditions are fibrocystic change, benign breast tumors and breast inflammation. Breast cancer is discussed in detail in another American Cancer Society document.
Benign breast conditions are very common. If breast tissue is examined under the microscope, such changes can be found in nine out of ten women.
Unlike breast cancers, benign breast conditions are never life threatening. But rarely, these conditions can cause bothersome symptoms. And, certain benign conditions are linked with an increased risk of developing breast cancer.

Finding Benign Breast Conditions
These conditions usually cause a lump or area of thickening that is found by the woman while checking her breasts or by her doctor or nurse during a clinical breast examination. Other symptoms, such as pain or a discharge (other than milk) from the nipple may also make you aware of these conditions. Some benign breast conditions may not cause any symptoms, and may be found during a screening mammogram.

By being alert to any breast changes and having examinations according to American Cancer Society guidelines for early detection, you can find breast cancers at the earliest possible stage, when they are most treatable. In addition, these examinations can find certain benign breast conditions.

The American Cancer Society recommends that:
Yearly mammograms start at age 40 and continue for as long as a woman is in good health.
Clinical breast exams (CBE) should be part of a periodic health exam, about every three years for women in their 20s and 30s and every year for women 40 and over.
Women should report any breast change promptly to their health care providers. Breast self-exam (BSE) is an option for women for women starting in their 20s.
Women at increased risk (e.g., family history, genetic tendency, past breast cancer ) should talk with their doctors about the benefits and limitations of starting mammography screening earlier, having additional tests (e.g., breast ultrasound or MRI), or having more frequent exams.
If a change occurs, such as development of a lump or swelling, tenderness, skin irritation or dimpling, nipple pain or retraction (turning inward), redness, itching or scaliness of the nipple or breast skin, or a discharge other than breast milk, you should see your health care professional as soon as possible for evaluation. A lump that is painless, hard, and has uneven edges is more likely to be cancer, but some rare cancers are tender, soft, and rounded. For this reason, it is important that any new breast mass, lump or thickening be checked by a health care professional with experience in diagnosis of breast diseases. Most of the time, these breast changes are not cancer.

Diagnosing Benign Breast Changes
If screening tests or your symptoms suggest that you might have breast cancer or benign breast disease, the doctor will use one or more ways to find out which is present so that the best treatment can be chosen.

Medical history and physical exam
The first step is a medical history and physical examination. Your personal and family medical history will provide information about symptoms and your risk factors for breast cancer and benign breast conditions. A thorough breast physical examination will be done to locate any lump and feel its texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of the breast will be noted. The lymph nodes under the armpit and above the collarbones may be felt because swelling or firmness of these lymph nodes might indicate spread of breast cancer. In addition to the medical history and physical exam, imaging tests and a biopsy may be done.

Imaging tests for breast disease diagnosis
The two main imaging tests for breast diagnosis are the mammogram and ultrasound. For information about these and other imaging tests, refer to the American Cancer Society document on Mammograms and Other Breast Imaging Tests.

Diagnostic mammogram: A diagnostic mammogram is an x-ray of the breast of a woman who has a breast complaint (for example, a breast mass or nipple discharge) or who has something not normal (an abnormality) found on a screening mammogram. The two main types of abnormalities doctors look for on mammograms are masses and calcifications. Masses can be due to a cancer or a benign condition. Their size, shape, and edges help doctors judge whether a mass is likely to be a cancer.

Calcifications are tiny mineral deposits within the breast tissue that appears as small white spots on the films. Calcifications are divided into two types:
Macrocalcifications and
Microcalcifications

Macrocalcifications are coarse (larger) calcium deposits that are most likely changes in the breasts caused by things like aging of the breast arteries, old injuries, or inflammations. These deposits are associated with benign (noncancerous) conditions and do not require a biopsy. Macrocalcifications are found in about half the women over the age of 50, and in 1 in 10 women under the age of 50.

Microcalcifications are tiny specks of calcium in the breast. An area of microcalcification that is seen on a mammogram does not always mean that cancer is present. They may appear alone or in clusters. The shape and layout of microcalcifications help the radiologist judge how likely it is that cancer is present. In some cases, the microcalcifications do not even mean a biopsy is needed. Instead, a doctor may advise you to have a follow-up mammogram within 3 to 6 months. In other cases, the microcalcifications look more suspicious and a biopsy is needed.
A mammogram cannot prove that an abnormal area is cancer, but a diagnostic mammogram may show that an area of abnormal tissue (lesion) has a high likelihood of being benign (not cancer). For these, it is common to ask the woman to come back sooner than usual for a recheck, usually in 6 to 12 months. Or the diagnostic mammogram and breast exam may suggest that a biopsy is needed. This will tell whether or not the lesion is a cancer or a type of benign breast disease requiring surgery.

Breast ultrasound: Ultrasound, also known as a sonogram, is an imaging method that uses high-frequency sound waves to outline a part of the body. High-frequency sound waves are transmitted through the area of the body being studied. The sound waves produce echoes that are picked up and translated by a computer into an image that is displayed on a computer screen. No radiation exposure occurs during this test. Breast ultrasound is sometimes used to evaluate breast problems that are found during a mammogram or a physical exam. Ultrasound is useful for some breast masses and is the only way to tell if a fluid-filled cyst is present without placing a needle into it to draw out fluid.

Nipple discharge examination
If you have a nipple discharge, some of the fluid may be collected and placed onto glass slides. It is then examined under a microscope to see if any cancer cells are present. Most nipple discharges or secretions are not related to cancer. In general, if the secretion appears clear or milky, yellow, or green, cancer is very unlikely.

If the discharge is red or red-brown, suggesting that it contains fresh blood or old blood, it might be due to cancer, although infections or benign tumors are much more likely causes. Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that a breast cancer is not present. If a patient has a suspicious mass, a biopsy is necessary, even if the nipple discharge does not contain cancer cells.

If the discharge is not bloody, your doctor may not send the fluid to the lab for microscopic examination, particularly if your symptoms, your physical exam findings, and the color of the discharge suggest a benign condition rather than cancer.

Ductogram
A ductogram, also called a galactogram, is another test that is sometimes helpful in finding the cause of a nipple discharge. This is a type of x-ray test in which a fine plastic tube is placed into the opening of the duct into the nipple. A small amount of dye is injected, which outlines the shape of the duct on an x-ray picture and will show whether there is a mass inside the duct.

Biopsy
A biopsy may be done when something unusual is found on a mammogram, ultrasound or physical examination. A biopsy is the only way to tell if cancer or a benign breast tumor is present. All biopsy procedures remove a tissue sample for examination under a microscope. There are several types of biopsies, and each has advantages and disadvantages. The choice of which to use depends on your situation. Some of the factors your doctor will consider include:

How suspicious the lesion appears
How large it is
Where it is located in the breast
How many lesions are present
Other medical problems you may have
Your personal preferences.

Please discuss the advantages and disadvantages of different biopsy procedures with your doctor.

Fine needle aspiration biopsy (FNAB): FNAB uses a thin needle, which is even smaller than the needle used for blood tests. The needle can be guided into the area of the breast abnormality while the doctor is feeling the lump. If the lump can’t be felt easily, the doctor might use ultrasound or a method called stereotactic needle biopsy to guide the needle. With ultrasound, the doctor can watch the needle on a screen as it moves toward and into the mass. For stereotactic needle biopsy, computers map the exact location of the mass using mammograms taken from two angles.

Once the needle is in place, fluid can often be drawn out if any is present. Bloody or cloudy fluid can mean either a benign cyst or cancer. If the lump is solid, small tissue fragments are drawn out. Solid lumps may be due to cancer or to several types of benign breast conditions. Cells from the cyst fluid or small tissue fragments from a solid mass are sent to the lab, where they are placed onto glass slides and treated with stains to make them more visible under the microscope. Microscopic examination of FNAB samples can tell whether most breast abnormalities are benign or cancerous. In some cases, FNAB does not provide a clear answer and another type of biopsy is needed.

Triple test: This is not an actual test or procedure. It is a way of correlating the results of the breast physical examination, mammogram, and the FNA biopsy. If all three of these appear benign, the lesion can indeed be considered to be benign with about 98% accuracy. If any one of these is in disagreement, more tests (needle core biopsy or surgical biopsy) should be done.

Core needle biopsy (CNB): The needle used in a core biopsy is larger than that used in FNA biopsy. It removes a small cylinder of tissue (about 1/16 inch in diameter and ½ inch long) from a breast abnormality. The biopsy is done with local numbing medicine (local anesthesia) in the doctor's office or clinic. As with FNA biopsy, a core biopsy can sample abnormalities felt by your doctor as well as smaller ones pinpointed by ultrasound or stereotactic methods.

Two types of special devices used for taking a core biopsy are:

Mammotome - During a Mammotome biopsy, also called a vacuum-assisted biopsy, a surgeon inserts a tube larger than those used in a typical core needle biopsy into the breast tissue. The doctor then uses suction to draw a cylinder of breast tissue into the tube, and a small rotating knife cuts and removes the tissue (cores) for examination. The needle is inserted only once and rotates to get the needed cores. The Mammotome is performed with local anesthesia.

ABBI - The Advanced Breast Biopsy Instrument (ABBI) uses a rotating circular knife to remove a larger cylinder of tissue for examination. The ABBI procedure removes more tissue than FNAB, CNB, or the Mammotome. Newer instruments are now available that work similar to the ABBI but do not remove as much breast tissue. These are done with local anesthesia as well.

Surgical biopsy: In some cases, surgery may be needed to remove all or part of the lump for examination under a microscope. An excisional biopsy is used to remove the whole lesion (breast abnormality such as a lump or area containing calcifications) as well as a surrounding margin of normal appearing breast tissue. This biopsy usually can be done in the hospital outpatient department with local anesthesia. Sometimes you will receive medicines to help you relax during the procedure. This procedure can sometimes be done with local anesthesia in your doctor’s office.

The surgeon may use a procedure called a wire localization during an excisional breast biopsy of a small lump that is hard to locate by touch. It may also be used in an area that looks suspicious on the x-ray (due to calcifications, for example) but does not have a distinct lump. After numbing the area with local anesthesia, a thin hollow needle is placed into the breast and x-ray pictures are taken to guide the needle to the suspicious area. A thin wire is placed through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed, and the surgeon uses the wire as a guide to locate the abnormal area to be removed.

Having a fine needle aspiration or core biopsy instead of an excisional biopsy, can sometimes offer more surgery choices for treatment if the lump is found to be cancer. An example would be the skin sparing breast conserving mastectomy.

The accuracy rates for FNAB, CNB, Mammotome, ABBI, and surgical biopsy are similar. The accuracy of each method depends on the experience of the doctor with that method. This is especially true with methods that remove smaller amounts of tissue (FNA and core needle biopsy) and, therefore, require more accurate placement of the needle. Each type of biopsy has advantages and disadvantages. The choice of which to use depends on each patient's situation and needs. Some of the factors to consider include how suspicious the lesion appears, how large it is, where in the breast it is located, how many lesions are present, other medical problems the patient may have, and her personal preferences. Women are encouraged to discuss the advantages and disadvantages of different biopsy types with their doctors.

Fibrocystic Changes
Fibrocystic changes include a range of changes within the breast involving both the glandular and stromal tissues. In the past, this was called "fibrocystic disease". Because this condition affects at least half of all women at some point, it is more accurately defined as a "change" rather than a "disease".

Fibrocystic changes are most common in women of childbearing age, but can affect women of any age.

Diagnosis of fibrocystic changes
In most cases, typical symptoms include cysts, lumpiness, and areas of thickening, tenderness, or pain. Cysts often enlarge and become painful just before the menstrual period, due to the effect of monthly hormone changes. Cysts tend to be more noticeable just before the menstrual period starts. Sometimes, one of the lumps may be more firm or have other features raising the concern about cancer. When this happens, a needle biopsy or a surgical biopsy may be needed to make sure that cancer is not present.

Importance of Microscopic Features in some Cases of Fibrocystic Changes
Many different changes can be found when breast tissue affected by fibrocystic change is viewed under the microscope. Most of these changes reflect the way the woman’s breast tissue has responded to monthly hormone changes, and have little other importance. However, some changes may indicate slightly or moderately increased risk of developing breast cancer later on. By understanding some of the words doctors use to describe these changes, you can better understand how serious they are and if extra tests will be needed to check for cancer.

Fibrosis: As the term "fibrocystic" suggests, the two main features are fibrosis and cysts. Fibrosis refers to the prominence of fibrous tissue, the same material that ligaments and scar tissues are made of. Areas of fibrosis feel "rubbery", firm, or hard to the touch. Fibrosis does not increase your breast cancer risk and does not need any special treatment.

Cysts: Cysts are spaces filled with fluid lined by breast glandular cells. They start out as a build up of fluid inside breast glands. Microcysts are too small to feel, and are found only when tissue is looked at under the microscope. If fluid continues to build up, macrocysts are formed. These can be easily felt and may reach one or two inches across. As they grow, stretching of the surrounding breast tissue may cause pain. A round, movable lump, especially one that is tender to the touch suggests a cyst. Breast ultrasound is often used to confirm this. Fine needle aspiration can confirm the diagnosis of a cyst and, at the same time, drain the cyst fluid. Removing the fluid may reduce pressure and pain. Fluid may return, and more aspirations may be necessary. Having one or more cysts does not affect your risk of later developing breast cancer.

Epithelial hyperplasia: Epithelial hyperplasia (also known as proliferative breast disease) is an overgrowth of the cells that line either the ducts or the lobules. When hyperplasia involves the duct, it is called ductal hyperplasia or duct epithelial hyperplasia. When it affects the lobule, it is referred to as lobular hyperplasia. Based on how it looks under the microscope, hyperplasia may be grouped as usual type (without atypia) or atypical.

Usual hyperplasia indicates a very slight increase in a woman’s risk of developing breast cancer. The risk is 1 ½ to 2 times that of a woman with no breast abnormalities. Atypical hyperplasia indicates a moderate increase in risk of 4 to 5 times that of women with no breast abnormalities.
About 1 in 10 women with atypical ductal hyperplasia will develop invasive carcinoma within 10 years of their biopsy.

About 7 in 10 biopsies done for benign breast conditions do not contain any hyperplasia.

About 26% have usual hyperplasia and only 4% (4 women in 100) have atypical hyperplasia.

Epithelial hyperplasia is usually diagnosed with a core needle biopsy or surgical biopsy. A diagnosis of hyperplasia, particularly atypical hyperplasia, usually means you will need closer follow-up with your doctor such as more frequent breast physical examinations and a special effort to get yearly mammograms. This is because having hyperplasia increases the chance of developing a breast cancer in the future.

Adenosis: Adenosis is a common finding in biopsies of women with fibrocystic changes. Adenosis refers to enlargement of breast lobules, which contain more glands than usual. If many enlarged lobules are found near one another, this collection of lobules with adenosis may be large enough to be felt. There are several names for this condition, including aggregate adenosis, tumoral adenosis or adenosis tumor. It is important to note that even though this term contains the word "tumor," this condition is benign and is not a cancer. Sclerosing adenosis is a special type of adenosis in which the enlarged lobules are distorted by scar-like fibrous tissue.

When areas of adenosis and sclerosing adenosis are large enough to be felt, it may be hard for the doctor doing the breast physical exam to distinguish these lumps from a breast cancer. Calcifications (deposits of mineral material) may form in adenosis, in sclerosing adenosis, and in cancers, further confusing the situation.

Fine needle aspiration biopsy of adenosis can usually show whether the lump is benign. A core needle biopsy can usually identify the mass as adenosis, but a surgical biopsy is needed in some cases to be sure cancer is not present.

Some studies have found that women with adenosis have about the same (slightly increased) risk of developing breast cancer as do women with usual hyperplasia (about 1.5 - 2 times the risk of the general population with no breast changes).

Treating symptoms of fibrocystic change
Although research has made much progress in recognizing types of fibrocystic change that increase breast cancer risk, there has been much less progress toward understanding why this condition causes symptoms in some women. Progress in relieving these symptoms has also been slow.

For a very small number of women with painful cysts, draining the fluid by FNA can help relieve symptoms. Many other women without any large cysts have breast pain and tenderness.
Some women report that their breast symptoms improve if they avoid caffeine and other stimulants (methylxanthines) found in coffee, tea, chocolate, and many soft drinks. But scientific studies did not find those stimulants to have a significant impact on symptoms. Still, many women and their doctors feel that avoiding these foods and drinks for a couple of months is worth trying.

Because breast swelling toward the end of the menstrual cycle is painful to some women, some doctors recommend that women reduce salt in their diets or take diuretics (drugs to remove salt and fluid from the body). But scientific studies find diuretics to be no better than pills that do not have any medicine in them (placebo).

Several vitamin supplements have been considered, but none are proven to be of any use and some have dangerous side effects if taken in large doses.

Steroid hormones, such as those in oral contraceptives have been tried, but had limited benefit.

Fibroadenoma
Fibroadenomas are benign tumors made up of both glandular breast tissue and stromal (fibroconnective) tissue. They are most common in young women in their twenties and thirties, but they may occur at any age. Some fibroadenomas are too small to feel and can be seen only under the microscope, but some are several inches across. They tend to be round and have borders that are distinct from the surrounding breast tissue, so they often feel like a marble within the breast. Some women have only one fibroadenoma, but others may have several. Fibroadenoma can be easily diagnosed by fine needle aspiration or needle core biopsy.

Many doctors recommend removing fibroadenomas, especially if they continue to grow or if they change the shape of the breast. Sometimes (especially in middle aged or elderly women) these tumors will stop growing or even shrink on their own, without any treatment. In this case, as long as the doctors are certain the masses are really fibroadenomas and not breast cancer, surgery to remove them may not be needed. This approach is useful for women with many fibroadenomas that are not growing. In such cases, removing them all might mean removing a lot of nearby normal breast tissue, causing scarring that would change the shape and texture of the breast. This could also make future physical examination and mammograms harder to interpret. But, it is important for women who do not have fibroadenomas removed to have a breast physical exam at regular intervals to make sure the mass is not continuing to grow. Sometimes one or more new fibroadenomas will grow after one is removed. This simply means that another fibroadenoma has formed and not that the old one has come back.

Phyllodes Tumors
Phyllodes (also spelled phylloides) tumors are a rare type of breast tumor that, like a fibroadenoma, contains two types of tissue -- stromal (connective) breast tissue and glandular breast tissue. In contrast, carcinomas (the usual type of breast cancer) develop in the ducts or lobules of the breast’s glandular tissue. The difference between phyllodes tumors and fibroadenomas is that there is an "overgrowth" of the fibroconnective tissue in the phyllodes tumor. The cells that make up the fibroconnective tissue part can look abnormal under the microscope. Depending on how they look under the microscope, phyllodes tumors may be classified as benign, malignant, or of uncertain malignant potential (the chance of the tumor becoming cancer is uncertain).

Phyllodes tumors are usually benign but on very rare occasions may be malignant, rarely having the chance to metastasize (spread). In the past, both benign and malignant phyllodes tumors were referred to as cystosarcoma phyllodes. Benign phyllodes tumors are treated by removing the mass and a 2 cm (about 1 inch) area of normal breast tissue from around the tumor. A malignant phyllodes tumor is treated by removing it along with a wider margin of normal tissue, or by mastectomy (removing the entire breast) if needed. Malignant phyllodes tumors do not respond to hormone therapy and are less likely than most breast cancers to respond to chemotherapy or radiation therapy.

Intraductal Papilloma
Intraductal papillomas are wartlike growths of gland tissue and fibrovascular tissue (fibrous tissue and blood vessels). Papillomas often involve the large milk ducts near the nipple. These result in a bloody nipple discharge. Papillomas may also be found in small ducts in areas of the breast further from the nipple. In this case there will often be several growths and may also have epithelial hyperplasia. Although papillomas may be suspected in a nipple discharge exam, many doctors do not feel the test is useful. If the papilloma is large enough to be felt, a needle biopsy can be done. The usual treatment is to remove the papilloma and a part of the duct it is found in, usually through an incision at the edge of the areola (the darker colored area around the nipple).

Granular Cell Tumor
Granular cell tumors are rare in the breast. Most are found in the skin or the mouth, but they are uncommon even in those places. They are almost always benign.

Most granular cell tumors of the breast can be felt as a movable, firm lump. They are usually about ½ to 1 inch across. Their firmness may raise the possibility of cancer, but a fine needle or core needle biopsy can tell them apart from cancers.

This tumor is usually cured by removing it and a small area of normal breast tissue. Granular cell tumors do not increase a woman’s risk of developing breast cancer later in life.

Fat Necrosis
Fat necrosis happens when an area of the fatty breast tissue is damaged. This is usually the result of injury to the breast. It can also occur after surgery or radiation therapy. Because the body is trying to repair the damaged tissue, the area becomes replaced by firm scar tissue. Because most breast cancers are also firm, areas of fat necrosis with scarring can be difficult to distinguish from cancers by a breast physical exam. A needle biopsy, or sometimes a surgical excision, will be needed to decide if cancer is present.

Some areas of fat necrosis will respond differently to injury. Instead of forming scar tissue, the fat cells die and release their contents. This will form a sac-like collection of greasy fluid called an oil cyst. Oil cysts can be diagnosed by fine needle aspiration, which also serves as a treatment.

Mastitis
Mastitis is an infection that most often affects women who are breast-feeding or who have had a break or crack in the skin. Cracking of the skin around the nipple allows bacteria from the skin surface to enter the breast duct where they grow and cause inflammation (redness). The inflammatory cells release substances that fight the infection, but also cause tissue swelling and increased blood flow. These changes cause the surrounding area to be painful and the overlying breast skin to be red and warm to the touch. This condition is treated with antibiotics. Some cases of mastitis lead to a breast abscess or collection of pus (inflammatory cells and fluid). Abscesses are treated by surgically draining the pus.

Inflammatory breast cancer has symptoms that are similar to mastitis. Because of this it can be misdiagnosed or have a delay in diagnosis. If antibiotic treatment does not help, and inflammatory breast cancer has not been ruled-out, then a biopsy of the skin may be needed to make sure it is not cancer.

Duct Ectasia
Duct ectasia is a common condition that tends to affect women in their 40s and 50s. The most common symptom is a green or black, often thick, sticky discharge. The nipple and the surrounding breast tissue may be tender and red. Sometimes scar tissue around the abnormal duct causes a hard lump that may be confused with cancer. This condition sometimes improves without any treatment, or with warm compresses and antibiotics. If the symptoms do not go away, the abnormal duct is removed through an incision at the border of the areola.

References
Harris JR, Lippman ME, Morrow M, Osborne CK. Diseases of the Breast. Philadelphia: Lippincott Williams & Wilkins; 2000.
Marchant D. Breast Disease. Philadelphia: Saunders; 1997.
Mansel RE, and Bundred, NJ. Color Atlas of Breast Diseases. London: Mosby-Wolfe Medical Communications, 1997.
Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society Guidelines for Breast Cancer Screening: Update 2003. CA Cancer J Clin 2003;53:141-169

Adapted from American Cancer Society