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Benign breast disease

VOL: 97, ISSUE: 47, PAGE NO: 32

Victoria Harmer, BSc, AKC, RN, DipBreastCare, is breast care nurse specialist, St Mary's Hospital, London

Up to 30% of women will require treatment for a benign breast condition at some time in their lives (Baum et al, 1994). The term 'benign breast disease' covers many types of disorder, from abnormalities of development to inflammations and infections. This article describes some of them.

Up to 30% of women will require treatment for a benign breast condition at some time in their lives (Baum et al, 1994). The term 'benign breast disease' covers many types of disorder, from abnormalities of development to inflammations and infections. This article describes some of them.

Anomalies of normal development and involution include mastalgia (breast pain), fibroadenomas and cysts. Other disorders include duct ectasia, epithelial hyperplasia, duct papilloma, lipoma, mastitis, galactocele, fat necrosis and congenital disorders (Baum et al, 1994).

Mastalgia
On being questioned, 77% of a screening population said they had recently experienced breast pain (Mansel, 2000). However, many women accept mastalgia as a normal consequence of changes in their menstrual cycle.

Mastalgia can be divided into two types, cyclical and non-cyclical (Mansel, 2000), and pain diaries can be used to establish whether a complaint of breast pain is cyclical or non-cyclical. On a chart showing the days of the month and when the menstrual cycle occurs, the patient records when the breast pain is mild or severe and notes when there is no pain.

Cyclical mastalgia

When women experience an increase in breast pain from mid-cycle onwards, this is termed cyclical mastalgia. The breasts develop areas of tender lumpiness and normal changes often associated with the menstrual cycle, such as fullness, discomfort and heaviness, are heightened.

The breasts are tender, especially in the outer half. Pain usually stops on menstruation but can vary in severity from cycle to cycle. The condition can last for years, affecting activities of daily living.

Drugs are available for the treatment of mastalgia and may be prescribed once a pain chart has been completed so the doctor has a better idea of the pattern of the breast pain. Doctors usually prescribe gamolenic acid (evening primrose oil) first. This treatment has few side-effects, but it can take up to four months before a patient notices any benefit.

If there has been no relief after four months, danazol or bromocriptine may be prescribed. These drugs should not be given to women taking oral contraceptives and side-effects, including nausea, weight gain and facial hair, are common. They are usually given for six months, after which they should be stopped, although they can be prescribed again if there is a severe recurrence.

It is thought that breast pain recurs in about half of all patients treated, with many experiencing milder pain. Tamoxifen does not have a licence for use in breast pain, although some women find it helpful in a low dose (Mansel, 2000). Goserelin, a hormone antagonist, is effective but requires monthly injections and induces a postmenopausal state while the woman is taking the treatment.

Non-cyclical mastalgia

This usually affects older women. It can be random or continuous, often localised in the chest wall, or may present as diffuse breast pain. Some women have a single localised area in the breast (a trigger spot), and many respond to an injection of local anaesthetic and steroid. Sometimes there is a painful and inflamed area between the breastbone and the front end of a rib (Tietze's syndrome), for which specific injection treatment is again recommended.

Non-cyclical breast pain can be eased by the 24-hour use of a firm-support bra and treated with non-steroidal, anti-inflammatory drugs or those used for cyclical mastalgia, using gamolenic acid first (Mansel, 2000).

Fibroadenoma
Fibroadenomas develop from a lobule in the breast and fall under the same hormonal control as the rest of the breast tissue. They make up 13% of all palpable lumps and 60% of all lumps in women aged under 20 (Dixon and Mansel, 2000).

There are four types of fibroadenoma: common, giant (usually measuring more than 5cm in diameter), juvenile (occurring in adolescent girls) and phyllode tumours (distinct pathological entities, although not always differentiated from fibroadenomas).

Fibroadenomas can be identified through triple assessment (a clinical examination, imaging and cytology). Some disappear, one-third get smaller and less than 10% increase in size over time.

They can be left in the breast, or if the patient wishes they may be surgically removed (Dixon and Mansel, 2000). If removed, they will not leave a deficit in the breast as the normal breast tissue will compensate.

Cysts
Cysts are slightly more common in women who are 40-50 years old and can be identified through triple assessment. They feel like smooth, discrete lumps. These fluid-filled sacs appear suddenly and are often associated with pain. They may present in one or both breasts.

Cysts can be aspirated and sometimes resolve as a result. If the aspirated fluid is stained with blood, a specimen should be sent to the cytology laboratory. According to research from one centre, patients with multiple cysts have a slightly increased risk of developing breast cancer, but the magnitude of this risk is not clinically significant (Dixon and Mansel, 2000).

Duct ectasia
This usually affects older women who present with nipple discharge. The discharge is often of a cheesy nature, or the patient may have a breast mass that is hard or doughy, or nipples that have retracted (become slit-like).

Duct ectasia is a result of the age-related shortening and dilation of the milk ducts. These reduce in size when their purpose has been fulfilled, leading to the retention of secretions within them.

Patients with single-duct nipple discharge should have smears taken which are sent to the cytology laboratory to rule out an intraductal carcinoma - a cancer contained within the walls of the milk ducts (known as ductal carcinoma in situ, or DCIS). Patients with duct ectasia may require the surgical removal of milk ducts (microdochectomy).

Epithelial hyperplasia
This condition arises when there has been an overgrowth in the lining of the terminal duct lobular unit. The degree of hyperplasia can be graded as mild, moderate or florid, and patients may present with general lumpiness of the breast, a lump or nipple discharge. Moderate and florid hyperplasias do not usually require clinical follow-up.

If cytology shows that the cells display atypical features, the condition is called atypical ductal hyperplasia. Surveillance should be organised as women with ADH have an increased risk of breast cancer (Dixon and Sainsbury, 1998).

Sclerosing adenosis/complex sclerosing lesion/radial scar
This is a benign lesion, though it may be associated with epithelial hyperplasia and sometimes ADH. A small percentage of these lesions contain DCIS and most breast specialists would recommend excision.

Duct papilloma
These are benign lesions of the milk duct or ducts. Patients usually present with a single-duct nipple discharge, rarely in association with a small palpable mass. The management of a duct papilloma includes surgical excision of the duct (microdochectomy) and, if the discharge is not too prolific, professional reassurance (Blackwell and Grotting, 1996).

Nipple discharge
This can be single-duct or multiduct. Multiduct nipple discharge is not thought to indicate cancer and can be caused by use of the contraceptive Pill or hyperprolactinaemia. Single-duct nipple discharge is thought to be more indicative of cancer, although about 93% of cases are benign and include intraduct papillomas, duct ectasia and fibrocystic disease. Only 5-8% of single-duct nipple discharge is found to be DCIS.

Lipoma
Lipomas are also benign tumours that can occur in the breast as they do anywhere else in the body. They may be left with no clinical follow-up or can be surgically removed for cosmetic reasons.

Mastitis/breast abscess
With mastitis the breast is inflamed and the tissue becomes painful, hot, red and swollen. It is commonly caused by infection during breastfeeding, when bacteria can enter the breast through a cracked nipple. Antibiotics can be used to treat this and a breast pump can provide relief as it encourages emptying of the ducts (Baum et al, 1994). In some cases, an abscess may form which will need either multiple aspirations or drainage.

If breastfeeding is not taking place, periductal inflammations may occur near the nipple area. These may progress to abscess formation, in which case it should be treated as such.

In some cases the abscess discharges itself and forms a mammary duct fistula. A fistula may also be caused by surgical drainage. Mammary duct fistulae should be treated by a fistulotomy or fistulectomy and not by simply draining them as they will recur.

Galactocele
This is a cyst that can occur during pregnancy or breastfeeding. It is caused by the blockage of a milk duct, probably due to inspissated (thickened) breast milk. This condition may resolve spontaneously or require aspiration.

Fat necrosis
Fat necrosis often occurs after breast trauma. It usually presents as an ill-defined lump which may be mistaken for a cancer during mammography and clinical examination. Triple assessment should take place to aid diagnosis and a core biopsy should be taken if suspicion persists.

Gynaecomastia
This is a benign breast condition that occurs in men when there is an increase in the normal amount of breast tissue. It is seen in 30-60% of boys aged between 10 and 16, but 80% of cases resolve spontaneously within two years. Surgical removal of the breast tissue is an option if the condition persists (Dixon and Mansel, 2000).

Conclusion
Benign breast conditions can be extremely worrying for patients as there is always a fear of malignancy. Most patients should be reassured by a definite diagnosis, although other treatment may be required. Patients with benign breast disease need ongoing support from health professionals and a continued awareness of if or when there are any other changes in the breast. If a patient has a cysts, for example, the doctor should check each new cyst/lump through triple assessment to ensure that the lesion is benign.

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