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Common Breast Diseases

Fibroadenoma
This disease most frequently appears in women age 20-40. It appears as a painless rubbery mass and can be either a single mass or multiple masses. Fibroadenomas may increase slightly with the menstrual cycle. It is the most common mass found in girls prior to puberty and is not pre-cancerous.

Fibrocystic Change (Lumpy Breast)
This condition is by far the most frequently occurring breast disease. It is most often seen in women between 35 and 50. It is usually seen as the breasts' response to hormonal levels rising and failing from month to month over the years.

After many years of this repeated hormonal stimulation, nearly all women's breasts develop some degree of lumpiness. This type of breast lumpiness is also incorrectly known as mammary dysplasia or chronic mastitis. Lumpy breasts may be accompanied by pain or tenderness that fluctuates with the menstrual cycle, becoming more noticeable prior to menstruation.

When this type of lumpiness occurs in a small localized area of a woman's breast, producing a lump, it may require a surgical biopsy or needle aspiration to determine the exact nature of the lump.

Many types of treatment are being used to ease the symptoms of lumpy breasts-some with dramatic results. Some of the treatments that have helped a variety of women include mild analgesics, warm compresses or sleeping bras, a low-salt diet especially in the latter half of the menstrual cycle, restriction of caffeinated and decaffeinated foods and drinks (coffee, tea, colas, chocolate, and cocoa), vitamin E supplement, and a special hormone treatment, which can only be prescribed by a doctor and is used in the most severe cases.

Ductal Papillomas
This condition occurs most often in women between age 45 and 50 and generally appears as a bloody or clear discharge from the nipple. It is a benign tumor in the duct that cannot be felt. (Breast cancer can also produce a discharge.)

Mammary Duct Ectasia
This is a disease unique to women near or past menopause. It is caused by ducts beneath the nipples becoming dilated or clogged with fatty material, occasionally producing a lump. There is frequently itching or burning around the nipple and sometimes a thick discharge.

Fat Necrosis
Fat necrosis is a thickening or scarring in the fatty tissue that is caused by an injury to the breast. It can occur at any age.

Galactocele
It is a milk cyst (clogged milk duct) usually associated with childbirth, in both breast feeding and non-breast feeding mothers.

FIBROADENOMAS
Fibroadenomas are the most common benign solid tumors of the breast tissue. They may be seen at any time after puberty, but occur most frequently in women in their third decade and represent the most common breast tumors in women younger than 25 years of age. These tumors may also be seen in postmenopausal patients, but it is most likely that the fibroadenomas in these patients develop prior to menopause and become clinically apparent with involution of the surrounding breast tissue. Fibroadenomas occur more frequently in African-American women. Fibroadenomas are hormonally responsive and may increase in size toward the end of each menstrual cycle. Pregnancy may induce considerable enlargement of these tumors. Clinically, fibroadenomas are painless, well-circumscribed, freely movable tumors with a rounded, lobulated, or discoid configuration. They have a characteristic ultrasonographic appearance with sharp borders, uniform internal echoes, and are wider than higher. If they have a very characteristic appearance they can be followed with regular reexamination or tissue diagnosis may be made with fine needle aspiration biopsy or core biopsy.

CYSTS
Gross cysts (macrocysts) are the most common dominant lump found in the breast. A gross cyst is a distinct entity consisting of a palpable fluid filled sac within the breast tissue. These cysts may occur in patients as young as 25 years of age, but are most common in those between ages of 35 and 50 years. Most commonly the development of gross cysts ceases with menopause although occasionally a postmenopausal patient will develop a gross cyst particularly if she has been receiving estrogen replacement therapy.

Cysts in the breast may vary tremendously in size and number and may be microscopic or macroscopic. They appear to originate from the terminal duct-lobular unit (TDLU) primarily through hormonally regulated dilatation and failure to shrink after menstruation or they may arise from an obstructed duct. The epithelium of these cells is usually two-layered as seen in normal breast ducts and lobules. The stroma surrounding these cysts is variably fibrotic and often shows clusters of chronic inflammatory cells.

Clinically, gross cysts may be silent or painful and may cause palpable lumps and may be seen only on ultrasonography. The consistency of these cysts depends on the pressure of fluid within them and the amount of normal breast tissue surrounding them. With a low amount of pressure they will appear soft and fluctuant, however when the cyst is tense or deep it may feel like a solid tumor. These cysts are often solitary but may be multiple, feeling somewhat like a cluster of grapes on palpation. They may develop almost overnight or more gradually and may resolve as rapidly. The presenting symptom of a rapidly developing cyst is often localized pain, thought to result from the distention of the surrounding tissue or possibly from escape of cystic fluid into the surrounding breast tissue evoking a sterile inflammatory reaction.

Gross cysts are often demonstrated by mammography or ultrasonography in a palpably normal breast. These asymptomatic, radiographic, and ultrasonographic lesions probably do not require treatment. The main significance of gross cysts is that they often form dominant masses and therefore must be differentiated from cancerous masses. Aspiration is both diagnostic and therapeutic with modern high definition ultrasonography.

The relationship of gross cysts to cancer has been controversial. Recent studies suggested that the incidence of breast cancer in patients with gross cysts and a family history of breast cancer (mother, sister, or daughter premenopausal) may be increased, whereas gross cysts alone did not confer any significant increased risk.

GALACTOCELE
A galactocele is a simple milk-filled cyst probably formed by overdistention of a lactiferous duct. Usually it presents as a firm, nontender mass in the breast tissue, commonly in the upper outer quadrants beyond the areolar border. Diagnostic aspiration is almost always curative.

LIPOMAS AND ADENOLIPOMAS
Lipomas consist of encapsulated nodules of mature adipose tissue. Although true lipomas do occur in the breast, the lesion that commonly presents as a lipoma is often merely a fatty area of breast tissue without a true capsule. Adenolipoma is a name applied to a benign fatty tumor of the breast that contains entrapped lobular and epithelial elements.

INTRADUCTAL PAPILLOMAS
Solitary intraductal papillomas are tumors of the major lactiferous ducts most frequently observed in women 30 to 40 years of age. The most frequent presenting symptom of intraductal papilloma is nipple discharge which may be serous or bloody. Bloody discharge is present in approximately 50% of cases.

Intraductal papillomas are generally less than 1.0 cm in diameter usually measuring 3.0 mm to 4.0 mm. Occasionally these lesions may be as large as 4.0 cm to 5.0 cm. Current evidence suggests that these lesions rarely undergo malignant transformation.

Multiple intraductal papillomas tend to occur in younger patients, are less often associated with nipple discharge, are more frequently peripheral, and are more often bilateral. Most important, multiple lesions appear to be more susceptible to the development of carcinoma.

MAMMARY DUCT ECTASIA (peri-ductal mastitis)
Mammary duct ectasia occurs primarily in perimenopausal and postmenopausal women and is characterized by dilatation of the subareolar ducts. This disorder is most often unilateral but bilateral involvement may be seen. Patients most frequently present with a mass which may be tender and painful or which may be accompanied by skin retraction. Nipple inversion results from traction on the nipple by ducts that have undergone fibrosis and shortening and is seen in about 30% to 40% of cases. Nipple discharge which may be serous, pasty or bloody is apparent in approximately 20% of cases. The finding of a mass associated with skin or nipple retraction may be mistaken for a carcinoma. A pathogenic cause of this condition has not been fully established. Available evidence suggests however, that the primary event is periductal inflammation and that duct ectasia is the ultimate outcome of this disorder.

SCLEROSING ADENOSIS
Sclerosing adenosis most commonly occurs in multiple microscopic foci. Occasionally it presents as a palpable mass. It is formed by a proliferation of both stromal and epithelial elements of the TDLU. The hallmark of sclerosing adenosis is a cellular proliferation which, at low-power magnification, is limited to a discrete area, and in fact, is lobular in configuration. It is often difficult to identify the normal double-layered epithelium and solid proliferations of myoid or epithelial cells may occur. The prime significance of sclerosing adenosis is its ability to mimic carcinoma. Adenosis very commonly contains microcalcifications which on mammography may raise the suspicion of carcinoma. Since adenosis may occur as a palpable mass and because of its pseudoinfiltrative appearance, it may create difficulties in differential diagnosis.

RADIAL SCAR
Radial sclerosing lesions are a form of sclerosing papillary proliferation. Its importance lies in the fact that it may on mammographic gross and microscopic examinations simulate carcinoma. These lesions are generally detected by mammography on which they appear as soft tissue densities with irregular, spiculated edges similar in appearance of carcinomas. These lesions are typically less than 1.0 cm in diameter. Most often it is impossible to differentiate these from carcinoma on mammography and local excision of these lesions is the treatment of choice.

NIPPLE DISCHARGE

When nipple discharge is grossly bloody or persistently guaiac-positive, or when the secretion has a sticky, clear character, further evaluation is indicated. Cytologic studies obtained with frosted or albumin-coated glass slides may help to distinguish between benign and malignant causes of abnormal secretion. The presence of erythrocytes and papillary clusters of 30 ductal cells or more suggest a malignant process. A contrast ductogram mammography will help image and localize the area from which the discharge originates. This can only be done when there is an active discharge and is done only when the discharge occurs from a single duct. The most common causes of occult blood in nipple discharge are, in order of frequency, intraductal papilloma, duct ectasia, "fibrocystic change," and carcinoma.

Clinically important nipple discharges are usually spontaneous and persistent. There are seven basic types, each which presents a characteristic clinical picture. The type of discharge can often by determined by observing its color and consistency (eg., is it sticky?), testing for blood with a Hemostix, or testing for pus with a slide stained with Wright's stain. The types which are generally not related to breast cancer are those which have the appearance of skim milk and are usually bilateral and originate from multiple ducts. This type of nipple discharge called galactorrhea is caused by an increased production of prolactin by the pituitary gland. It is most commonly seen after pregnancy but may also occur in patients with endocrine anovulatory syndromes, and in those taking tranquilizers, Rauwolfia alkaloid, methyldopa, and oral contraceptives. Pituitary adenomas are a fairly common cause of galactorrhea.

Multicolored discharges are sticky or grumous to palpation and predominately green in color. The discharge leaves a characteristic green stain on a white gauze pad. These discharges may also have a brown or reddish color that mimics blood but tests negative for blood and makes a brownish rather than red stain on the gauze pad. Multicolored, sticky discharges are usually bilateral and originate from multiple ducts. An increase in prolactin that leads to duct ectasia may be the cause, and this condition is often accompanied by periductal mastitis and inflammation.

Purulent discharges have the characteristic appearance of pus, which can be confirmed with the Wright's stain. These discharges, which are unilateral and usually from multiple ducts are accompanied by pain, tenderness, and signs of underlying infection.

The types that may indicate breast cancer are serous (yellow), serosanguineous (pink), sanguineous (bloody), and watery discharges, although watery discharges are usually due to benign lesions (especially intraductal papillomas), and may be caused by cancer or precancerous lesions. These discharges are usually unilateral and from a single duct.

The serous type has the color of weak tea and makes a yellow, tealike stain on a white background such as a gauze pad, handkerchief, bra, or nightgown. The serosanguineous type appears pink and makes a pink stain. The sanguineous discharge gives the appearance of blood. When fresh it makes a bright red color on a white background with lighter shadings of red extending toward the periphery. When old, the discharge may appear dark or red/brown and leave a brown stain. The presence of blood can be easily determined with a Hemostix. The watery type of discharge is clear and usually does not leave any stain.

Galactography (also called ductography) -- contrast mammograms obtained by injecting a radio-opaque dye into the discharging duct -- is the diagnostic procedure of choice in patients with a suspicious nipple discharge. This technique allows the clinician to visualize and localize the involved duct and lesion.  

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