BENIGN BREAST CONDITIONS

Fibroadenoma is a benign growth in the breast. It is best though of as similar to a birthmark. It develops as the breast changes. Growth should stop before age 30. Treatment can be either surgery or active observation. 

It is vital to remember that new, non-cystic lumps after age 30 are unlikely to be fibroadenomas.

PATIENT CASE:

Zainab, aged 17 years: 

Zainab found a lump in the left breast. She visited her GP who organised to do an ultrasound of the breast which showed a solitary 4cm lump with no suspicious features. A further needle biopsy diagnosed the lump as a fibroadenoma. 

Zainab’s grandmother (her mother’s mother) had been diagnosed with breast cancer aged 50 and both Zainab and her mother were keen to have the lump removed, especially as Zainab felt it was getting larger. 

No problems! Zainab was admitted to hospital a few weeks later and the lump was removed. There were no complications. The diagnosis was confirmed as a simple fibroadenoma, and Zainab had a pleasing cosmetic result. No further follow up was required. 

Discussion:

Zainab was the correct age for fibroadenoma diagnosis. We could have just observed, but Zainab and her family were keen to have the lump removed and I was happy to operate as this was already a large lump and was going to continue to grow for several more years. 

PATIENT CASE: 

Leanne, aged 23 years:

Leanne had breast pain after starting the oral contraceptive pill. Her GP promptly organised an ultrasound where several lumps were found in both breasts, none of which looked alarming. 

None of these lumps could be felt in the breast. For more information, we organised a biopsy of the largest lump which, revealing the lump as a fibroadenoma. Leanne had no family history of breast disease and wasn’t keen on a surgery. After discussing her options, we decided to actively observe the lumps for the moment. 

I asked Leanne to return for review with a repeat ultrasound in six months. The repeat ultrasound showed some of the lumps had slightly increased in size however the breast examination was normal. 

Leanne returned for a final visit 12 months later. The breast pain she had been experiencing had stopped and a new ultrasound showed that the lumps were stable. Similarly, the physical breast examination was fine. Leanne required no further ultrasounds or visits. 

Discussion: 

Again, Leanne is within the correct age category for the diagnosis of fibroadenoma and, in fact, multiple fibroadenomas are common. The presence of multiple lumps in multiple sites makes surgery a poor choice, especially if the lumps can not be felt in the breast. In this situation, we generally biopsy the largest lump then follow with active observation. 

Fibroadenomas will often slowly continue to increase in size until about age 25 so I wasn’t too alarmed by a slight size increase with the first follow up ultrasound. If the size was continuing to increase with the second ultrasound I would have seen Leanne again twelve months later. Active observation requires re-assessment at every visit but once things are stable then it is safe to stop. 

Regarding the breast pain, the Oral Contraceptive pill (OCP) works by fooling your body into thinking you are pregnant. Similar to breast pain in early pregnancy, the OCP quite often causes breast pain that gradually settles. 

 Breast cysts are a common cause of benign lumps, particularly in the older patient, and management can require complex decision making.

A cyst is loosely defined as a fluid-filled lump.

General Guidelines:

Breast cysts in the woman who has never been pregnant are usually due to an abnormality of milk duct development. They often present as cystic lumps during the teenage years, or early twenties. They are usually solitary and quite frequently require surgery as they tend to recur even with multiple aspirations (drainings).

Between ages 30 – 50, breast cysts are often small and multiple, and they are milky in origin. They may be described as “complex” on ultrasound as they contain milk debris (curdled milk). They are usually found when an ultrasound is done for some other reason such as breast pain. They rarely require surgery, drainage or even biopsy. 

Heading towards menopause, new cysts are often larger and are degenerative or inflammatory in nature. They often present as a lump. They are rarely solitary; there are usually a few cysts in each breast. Cysts over 2cm are routinely drained with a needle aspiration (sometimes several times), but rarely require surgery.  

Very, VERY rarely an unusual form of breast cancer can present as a cyst. These rare cancers present in the older patient (usually after menopause),  are often solitary and are larger that 2cm. They may present a complex appearance on ultrasound, but are not to be confused with small “complex” milky cysts seen before menopause. Investigation always starts with aspiration for assessment of the fluid. If there are papillary elements, atypical features, or the fluid is bloodstained then surgery is recommended. 

PATIENT CASE: 

Youssra, aged 15 years: 

 About six months ago, Youssra noticed a lump close to the right nipple and an ultrasound revealed it to be a cyst. The fluid was aspirated but fairly rapidly recurred. I saw her with her parents to discuss the possible options for her. 

Youssra was not keen for more aspirations and we went ahead and removed the lump with surgery. A “blind” milk duct that didn’t open to the nipple had caused fluid to build up behind it. The wound healed well in this young patient with a nice cosmetic outcome. 

Discussion: 

I always attempt to avoid creating a scar on the breast of a young woman. However I completely understood Youssra’s desire to avoid further aspirations, and was happy to support her and her parents’ decision for surgery. These cysts are due to developmental abnormalities and will almost always recur so  I have a low threshold to recommend surgery in this situation. 

PATIENT CASE: 

Ibtisam, aged 37 years: 

Ibtisam came to see me with breast pain. She had a one year old baby and a four year old pre-schooler. Both children were breastfed with no problems for nine months. Ultrasound showed multiple cysts in both breasts, up to 12mm in size. The 12mm cyst was described as “complex”.

I reassured Ibtisam that the breast pain and ultrasound findings were not alarming and probably breast-feeding related. We commenced active observation. Ultrasounds at 6 and 12 months were stable. Ibtisam fell pregnant with her next child before the 12 months ultrasound and is planning to breastfeed. I will review her after she has finished breast feeding the next baby and we will repeated the ultrasound. 

Discussion: 

In the pre-menopasual woman, description of a cyst as “complex” is not really alarming, but the ultrasound report will often recommend biopsy, which can be hard to resist. 

As a general rule, cysts under 1cm do not need a biopsy, even if they look complex on the ultrasound. I usually recommend biopsy of any complex cyst larger than 15mm, although I have never yet had one turn out to be a cancer in this setting of multiple cysts in a pre-menopausal woman. For cysts between 10 – 15mm I take other factors into account such a family history. 

Some Final Thoughts: 

With cysts I occasionally find myself doing biopsies that I don’t really think are necessary, mainly because the ultrasound report recommends a biopsy and the patient is understandably anxious. A benign biopsy does help the patient to accept the plan for active observation rather than surgery. I find that anxiety levels decrease with ongoing review and I often see these patients a few times more than strictly necessary, just to give them confidence in the observation process. 

I tend to be reluctant to go on to surgery for benign cystic disease. There is often some inflammation of the breast tissue around the cysts and the healing is lumpy and often not cosmetic. Of course, if the patient is really insistent, then we will go ahead with surgery. However I have never had an unexpected cancer diagnosis in this situation. 

Breast pain is the most common reason women see a doctor about their breasts. Most GPs will do a breast examination then organise an ultrasound, maybe with a mammogram if the patient is older than forty. If the imaging is normal then the patient is usually reassured and nothing further is done. 

However, if the breast pain is severe, or the mammogram or ultrasound are abnormal, or there are complicating factors such as family history then the patient might be referred to a breast specialist.

I generally feel that my job is to make sure there is nothing to worry about. We will investigate any abnormality on the mammogram/ultrasound and follow up on a regular basis to make sure nothing is missed.

However, investigation and reassurance don’t actually treat the pain! When looking at treatment options, we try to establish if the pain is related to the menstrual cycle or not (“cyclical” or “non-cyclical”). 

Cyclical pain is by far the most common. Fortunately, episodes tend to resolve within about six months although pain may recur on and off until menopause. It is very rarely related to breast cancer. Initially I tend to recommend simple analgesia. With reassurance and a strategy for managing bad days, this is generally enough.

For those with persistent or severe pain, specific treatments have been investigated. Unfortunately treatments for breast pain are not very effective – or have significant side effects! Here is a quick overview of some treatment strategies:

Treatments that probably do work

Non-cyclical Pain: 

• Goserelin suppresses ovarian function. It does work well but has a lot of side effects (menopausal symptoms) and the pain tends to recur after treatment stops. 
• Danazol is a bit like testosterone and has a complex action not completely understood. It seems to be our best treatment for severe, non-cyclical pain but not recommended for more than six months and symptoms recur after the treatment stops. Side effects are “masculinising” such as acne, hirsutism and deep voice (which may not resolve). Cyclical pain:

Cyclical Pain: 

• Bromocriptine decreases prolactin levels. Prolactin is the milk stimulating hormone that is produced in the brain, being very high during breast-feeding. Levels also normally rise slightly in the second half of the menstrual cycle and some studies found levels are unexpectedly high in patients with cyclical breast pain. Bromocriptine actually works quite well (30% reduction in pain). However, side effects include severe nausea, vomiting and dizziness
• Tamoxifen is an anti-oestrogen drug used in breast cancer management. Studies have shown it significantly improves mild to moderate cyclical breast pain. Side effects include hot flushes and a (low) risk of blood clots. It can cause birth defects if taken while pregnant. Not recommended for more than six months and only under expert supervision.
• Evening Primrose Oil (taken by mouth) possibly replaces fatty acid deficiencies which one theory suggests may be a cause of cyclical mastalgia. It may have a benefit in mild cases. The good thing is it has virtually no side effects.
• Simple analgesics (paracetamol, anti-inflammatories), including anti-inflammatory creams.

Treatments that might work

Stop or change the Contraceptive Pill, Implanon implant, Mirena IUD

Vitamin B6

Quitting caffeine

Stop smoking

Strong support bra

Treatments that don’t work

Diuretics (fluid tablets)

Surgery 

PATIENT CASE:

Bijayata, aged 38 years: 

Bijayata had generalised breast pain for about six months, related to her menstrual cycle. This was gradually getting worse, so she saw her own doctor who did an ultrasound that showed a lump in the right breast. She was referred to me for further assessment.

Biopsy showed this lump was a fibroadenoma. This is a benign lump and was unlikely to be related to the pain. Repeat ultrasound six months later showed the lump was stable and I reassured Bijayata there was no suspicion of breast cancer. The pain had completely settled when I saw her for the six month follow up.

Discussion:

The fibroadenoma was an incidental finding and not the cause of the breast pain, but it was a huge relief for Bijayata to be told it was benign. Since the pain had settled, Bijayata didn’t need any further follow up other than regular mammograms from age 50.

PATIENT CASE:

Necla, aged 50 years: 

Necla was invited to her first screening mammogram by the BreastScreen program. She was entering menopause, still having the occasional period. She had never had a mammogram, however she had a family history of breast cancer with her mother developing breast cancer in her 70s. While filling out the standard BreastScreen questionnaire she answered she had noticed some pain in the left breast. 

While the mammogram was fine, BreastScreen sent Necla a letter recommending she see her doctor about the breast pain. Her doctor sent her for an ultrasound which showed a small  lump in the left breast. Biopsy showed a cancer which hadn’t been seen on the mammogram, and Theresa commenced appropriate treatment.

Discussion: 

Necla wasn’t too worried about the breast pain – which she had for a few months – she was just answering the BreastScreen questions. It had never occurred to her to see a doctor about the pain. But there were actually a few worrying features – it was a new symptom, not cyclical, and very localised.

It is really important that patients and their doctors realise that breast pain – although common – is not normal, and should be investigated. It is essential to see your doctor so tests can be done, just in case. Theresa reporting the breast pain prompted the ultrasound which detected the cancer. Good result.