Gynecology Topic 41. Breast diseases

I. General Approach

Benign Breast Disease

• Benign breast diseases: Non-malignant breast conditions presenting with pain, lump, nipple discharge, inflammation, or skin change.
• Exam aim: Distinguish benign disease from breast cancer and identify lesions with increased future cancer risk.
• Common benign exam topics: Fibrocystic change, fibroadenoma, intraductal papilloma.
• Triple assessment of a suspicious breast problem: Clinical examination + imaging + tissue diagnosis when indicated.

Initial Assessment of a Breast Lump

1. History: Age, cyclicity, pain, pregnancy/lactation, nipple discharge, hormone therapy, family history.
2. Inspection: Asymmetry, erythema, edema, peau d'orange, ulceration, nipple retraction, discharge.
3. Palpation: Size, site, mobility, borders, consistency, tenderness, fixation, axillary/supraclavicular nodes.
4. Imaging:

• Age <30 years / pregnant / lactating: Breast ultrasound first.
• Age >=30 years or suspicious finding: Diagnostic mammography/tomosynthesis ± ultrasound.

5. Biopsy: Core needle biopsy for solid, suspicious, discordant, persistent or growing lesions.

Red Flags

• Hard irregular fixed mass.
• Skin dimpling, ulceration, peau d'orange, persistent focal erythema.
• Bloody or clear spontaneous unilateral nipple discharge.
• New nipple inversion/retraction.
• Palpable axillary nodes.

II. Fibrocystic Change and Hyperplasia

Fibrocystic Breast Changes

• Fibrocystic changes: Cysts, stromal fibrosis and epithelial changes in the breast.
• Most common benign breast condition in premenopausal women.
• Pathomechanism: Repeated estrogen/progesterone stimulation → Ductal/lobular change → Cysts + stromal fibrosis + nodularity.
• Risk factors/associations: Hormone replacement therapy, family tendency; caffeine may worsen mastalgia in some patients.

Histologic Classification and Cancer Risk

1. Non-proliferative lesions: Simple cysts, papillary apocrine metaplasia, stromal fibrosis.
2. Proliferative lesions without atypia: Usual ductal hyperplasia, sclerosing adenosis, papilloma without atypia.
3. Atypical hyperplasia: Atypical ductal or lobular hyperplasia → Clearly increased future breast cancer risk.

• Key correction: Fibrocystic change overall is common and usually benign; cancer risk depends mainly on proliferation and atypia.

Clinical Features

• Cyclic mastalgia: Breast pain/tenderness worsens premenstrually.
• Lumps: Often multiple, bilateral, mobile, tender, fluctuating with cycle.
• Symptoms often improve after menstruation.

Diagnosis and Treatment

1. Physical examination.
2. Ultrasound: Cystic vs solid lesion, especially in young women.
3. Mammography: Especially age >=30-40 years or suspicious features.
4. FNAB / aspiration: Symptomatic simple cyst or diagnostic uncertainty.
5. Core needle biopsy: Suspicion of cancer, solid lesion, atypical imaging, bloody aspirate, recurrent/persistent mass.

• Conservative treatment: Reassurance after adequate evaluation, supportive bra, NSAIDs, heat/local measures.
• Hormonal options: Combined oral contraceptives or progestin strategy may help cyclic symptoms in selected patients.
• Cyst aspiration: Large, painful or tense cyst.
• Surgical excision: Suspicious, atypical, recurrent, bloody, or imaging-pathology discordant lesion.

III. Benign Breast Tumors

Fibroadenoma

• Fibroadenoma: Benign fibroepithelial tumor composed of stromal/fibrous tissue and glands.
• Most common benign breast tumor; typical age 15-35 years.
• Etiology: Estrogen-sensitive growth → May enlarge before menstruation, during pregnancy or hormone therapy.
• Clinical feature: Smooth, rounded, well-circumscribed, mobile, firm, usually painless mass.
• Risk of malignant transformation is very rare; simple fibroadenoma usually does not meaningfully increase cancer risk.

Fibroadenoma: Diagnosis and Treatment

1. Physical examination.
2. Ultrasound: Well-defined hypoechoic solid lesion.
3. Mammography: Less sensitive in young dense breasts; used by age/risk/suspicion.
4. Core needle biopsy: If diagnosis uncertain, lesion is growing, patient is older, or imaging is not classic.

• Observation: Small, classic, biopsy-confirmed fibroadenoma with concordant imaging.
• Follow-up: Clinical ± ultrasound surveillance.
• Excision indications: Rapid growth, size >3-4 cm, symptoms, atypia, discordance or cancer suspicion.

Intraductal Papilloma

• Intraductal papilloma: Benign epithelial breast tumor growing within lactiferous ducts, often subareolar.
• Histology: Ductal epithelial + myoepithelial proliferation with fibrovascular core.
• Typical patient: Premenopausal/perimenopausal woman.
• Clinical feature: Spontaneous unilateral bloody or serous nipple discharge; palpable mass if large.
• Cancer risk: Slightly increased, especially with atypia or multiple/peripheral papillomas.

Intraductal Papilloma: Diagnosis and Treatment

1. Clinical examination: Identify single-duct vs multiduct discharge.
2. Ultrasound: Intraductal mass ± duct dilatation.
3. Mammography: May show mass or calcifications.
4. Galactography/ductogram: Intraluminal filling defect in selected cases.
5. Core needle biopsy: If lesion is visible and large enough.

• Surgical duct excision: Symptomatic discharge, atypia, multiple papillomas, imaging-pathology discordance, or malignancy concern.
• Observation: Selected asymptomatic, biopsy-proven papilloma without atypia and concordant imaging.