CLINICAL OBSTETRICS AND GYNECOLOGY Volume 54, Number 1, 110–124 r 2011, Lippincott Williams & Wilkins

Benign Breast Diseases: Epidemiology, Evaluation, and Management
BUNJA RUNGRUANG, MD, and JOSEPH L. KELLEY, III, MD Department of Gynecologic Oncology, Magee-Womens Hospital, Pittsburgh, Pennsylvania
Abstract: Benign breast diseases are common and encompass a spectrum of disorders. The majority of diagnoses will stem from a patient presenting with symptoms such as a mass or discomfort, or as a result of breast imaging which shows abnormalities leading to percutaneous biopsy. When mammographic and pathologic findings are disconcordant or when a highrisk lesion that can be associated with a preinvasive or invasive malignancy is found, formal excisional biopsy is recommended. Key words: benign breast disease, palpable masses, radiographic abnormalities, fibrocystic change, benign neoplasms, mastalgia

Benign breast diseases are common and include presentations involving palpable masses, radiographic abnormalities, and mastalgia. The incidence of benign breast lesions begins to rise during the second decade and peaks in the fourth to fifth decades, as opposed to malignant disCorrespondence: Joseph L. Kelley, III, MD, Division of Gynecologic Oncology, Magee-Womens Hospital, 300 Halket Street, Suite 2130 Pittsburgh, PA 15228. E-mail: jkelley@mail.magee.edu
CLINICAL OBSTETRICS AND GYNECOLOGY /

eases, where the incidence continues to increase after menopause with a peak incidence at the age of 70 years.1–12 The majority of patients presenting with breast complaints will be found to have benign conditions.1–8 With the breast imaging and percutaneous needle biopsy, a diagnosis can be accomplished rapidly and without requiring additional surgical management in the majority of these lesions. After establishment of a nonmalignant diagnosis, treatment is generally aimed at symptomatic relief and patient education.

Fibrocystic Change
The most frequent benign disorder of the breast is fibrocystic changes, affecting premenopausal women aged 20 to 50 years.1–8 Fibrocystic changes are generally multifocal and bilateral. Patients present with breast pain and tender nodules. Although the exact pathogenesis
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round or ovoid masses derived from the terminal duct lobular unit. but about 20% to 25% of women will have a palpable mass. the patient should be evaluated by a surgeon for consideration of excision. These are common and are seen in as many as one-third of women aged 35 to 50 years. ductal epithelial hyperplasia. As gross cysts are not associated with an increased risk of carcinoma development. adenosis (increased number or size of glandular components).9 to 13. ranging from relative risks of 1. the current consensus on the management is routine follow-up without further therapy.13 Fibrocystic changes are observed clinically in up to 50% and histologically in 90% of women.9 and 3. These cysts are benign by definition and if asymptomatic. If the cyst recurs. The subsequent risk for breast cancer for each of these lesions is classified based on the histologic appearance of the lesion.21 If clear fluid is obtained on aspiration of a cyst.5% of www. however. On account of the importance of determining whether these lesions are a risk factor for the subsequent development of breast cancer. when compared with the general population. however.17 There is no elevated breast cancer risk in women with biopsy-proven nonproliferative lesions. Simple cysts are circumscribed and anechoic. respectively.22 Incidence is reported in approximately 5% to 5. as cysts cannot be distinguished from solid masses by clinical examination or mammography. ductal ectasia.16 as nonproliferative lesions and proliferative lesions without and with atypia [atypical hyperplasia (AH)].com Nonproliferative lesions include cysts. Nonproliferative breast lesions are not . Sonographic characteristics include internal echoes. severe.3 to 1.18. whereas proliferative disease without atypia and with atypical ductal or lobular hyperplasia have an increased breast cancer risk.16. a hormonal imbalance with estrogen predominance seems to be a factor in its development. a thickened or irregular wall.17 Acute enlargement of cysts may cause sudden. papillary apocrine change.16. and the patient can be reassured. no further investigation is required. fluid or debris levels. a fineneedle aspiration (FNA) can be performed to establish the diagnosis. If a breast cyst recurs a third time. they are evaluated under a classification system proposed by Dupont and Page. Ultrasound evaluation provides rapid and accurate evaluation and is the preferred imaging test. with posterior acoustic enhancement and absence of solid components on ultrasound. no intervention is necessary.19 Absolute risk. NONPROLIFERATIVE BREAST LESIONS 111 associated with an increased risk of breast cancer.17 Complicated cysts do not meet all criteria for simple cysts on ultrasound examination. reaspiration is reasonable.Benign Breast Diseases is unclear. Alternatively. and focal pain. nonsclerosing adenosis. epithelial-related calcifications. The cyst should resolve with removal of the fluid. it should be sent for cytologic analysis.clinicalobgyn. if the fluid is bloody.14. Most are found incidentally.20 Breast Cysts Cysts are fluid-filled.0. The indistinct clinical and pathologic findings call into question the validity of referring to it as a disease. More than 80% of patients with a diagnosis of AH do not develop invasive cancer during their lifetimes. radial scar. Aspiration can be performed to relieve pain. and papillomas. and lack of posterior acoustic enhancement. apocrine metaplasia. and periductal fibrosis. for both proliferative diseases with and without atypia is quite low.15 Pathologic correlates include the presence of cysts (macro and micro). thin septations. The majority of breast biopsies (up to 70%) show nonproliferative lesions.

It can present as a palpable mass or as a suspicious finding at mammography.3 to 1. myoepithelial. Usual ductal hyperplasia or simple hyperplasia denotes an increased number of cells that may vary in cell size and shape but retain the cytologic features of benign cells without architectural distortion. They are characterized microscopically by a fibroelastic core with radiating ducts and lobules displaying variable epithelial hyperplasia.22. In mild hyperplasia. Further classification is based on the degree of architectural and cytologic features of the proliferating cells. sclerosing adenosis. as the risk of subsequent breast cancer in this population is small. increased surveillance and chemoprevention are not indicated.32 Histologically. myoepithelial cells. proliferating epithelial cells are a 3 to 4-cell layer. Normally.26–29 However. approximately 1 to 2 times that of the general population with a relative risk of 1.34 Sclerosing adenosis has been shown to be a risk factor for invasive breast cancer independent of its association with other proliferative lesions of the breast but the risk is small (RR 1.16. intraductal or sclerosing papilloma. duct ectasia. or florid epithelial hyperplasia are an admixture of cell types (epithelial cells.4%) but should be aspirated to confirm diagnosis. and intraductal papilloma or papillomatosis. Sclerosing adenosis of the breast is defined as a lobular lesion of disordered acinar.35 Radial Scars Radial scars are pseudoproliferative lesions of uncertain significance. usually an incidental finding on either percutaneous or excisional biopsy. In addition.com . moderate.18. which can mimic infiltrating carcinoma both grossly and microscopically.10. often with accompanying bridging of the luminal space. including epithelial hyperplasia. and connective tissue elements. Sclerosing Adenosis Adenosis is characterized by an increased number or size of glandular components involving the lobular units. radial scar.32. it is characterized by increased fibrous tissue and interspersed glandular cells.112 Rungruang and Kelley is distended and may be obliterated. complex sclerosing lesion. Radial all breast ultrasound examinations. The most important cytologic features of mild.33 Sclerosing adenosis is strongly associated with other proliferative lesions. and metaplastic apocrine cells) and variation in the appearances of epithelial cells and their nuclei.19. and apocrine changes.25 PROLIFERATIVE BREAST LESIONS WITHOUT ATYPIA Proliferative lesions without atypia include ductal hyperplasia. the lumen www. if the lesion also includes an intracystic mass.9. breast ducts are lined by 2 layers of low cuboidal cells with specialized luminal borders and basal contractile myoepithelial cells.32.7) and chemoprevention is not indicated. These lesions are associated with a slightly increased risk of developing breast cancer. whereas moderate hyperplasia describes epithelial proliferation more than 4 cells thick.30 This entity can be stratified into 3 types. These lesions are rarely malignant (0. Any increase in cell number within the ductal space is regarded as ductal epithelial hyperplasia.31 No additional treatment is needed for this pathologic entity and it is not associated with an increased risk of breast cancer. it should be regarded as ‘‘suspicious for neoplasm’’ and managed as solid lesions. with either a core needle biopsy or surgical excision. it can coexist with both invasive and in-situ cancers. adenosis. Ductal Hyperplasia The most common proliferative breast lesion without atypia is epithelial hyperplasia.clinicalobgyn. Radial scars are a histopathologic diagnosis. and papillomatosis. In florid hyperplasia.22–24 However.

42 The central papillomas tend to be solitary.44 Central single papillomas have not been considered premalignant or markers of risk when they are not associated with atypia. and their probability of having an in-situ or invasive carcinoma is higher than with the central papilloma.46 The standard recommendation for management of papillomas is that excisional biopsy be performed when diagnosed by percutaneous needle biopsy. The risk represented by the occurrence of such abnormalities in an otherwise benign papilloma is currently debated. www.Benign Breast Diseases scars are occasionally large enough to be detected by mammography. the lactiferous sinuses and the terminal ductules. when radial scars are found on core biopsy. it is termed juvenile papillomatosis and is associated with a heightened risk for breast cancer. with 5 or more papillomas representing papillomatosis. and ductal carcinoma in situ. no additional treatment is needed.45.44 Papillomatosis is defined as a minimum of 5 clearly separate papillomas within a localized segment of breast tissue. and lobular neoplasia) in the surrounding breast tissue. the entire lesion must be excised.29. In addition to the possibility of finding an unrecognized in situ or invasive component. benign duct papilloma does not carry any increased risk for subsequent breast cancer.36–39 Radial scars may serve as a milieu for the development of atypical epithelial proliferations. including atypical ductal hyperplasia (ADH). In particular. atypical lobular hyperplasia (ALH). lobular carcinoma in situ. Multiple papillomas tend to occur bilaterally. Solitary or multiple intraductal papillomas may present as a palpable mass. and in-situ carcinoma. ADH. It can arise at any point in the ductal system and shows a predilection for the extreme ends of the ductal system.51 Available data suggest that the finding of a solitary. whereas multiple papillomas may indicate a slightly elevated risk for subsequent breast cancer but no additional treatment is advised. nodule on mammographic or ultrasonographic evaluation. there is some evidence that the radial scars may be premalignant lesions. The epithelial component can be subjected to a spectrum of morphologic changes. Intraductal Papilloma and Papillomatosis Intraductal papilloma is a discrete tumor of the epithelium of mammary ducts. usually in a peripheral or subareolar location.com . but the radiographic features are nonspecific and cannot reliably be differentiated from carcinoma. atypical intraductal hyperplasia. In patients with multiple papillomas on excisional biopsy. they are characterized by the formation of epithelial fronds that have both the luminal epithelial and the outer myoepithelial cell layers.40 For this reason. central. a spontaneous serous or serosanguinous discharge.52–54 When severe ductal papillomatosis occurs below the age of 30 years.43 A solitary papilloma consists of a monotonous array of papillary cells that grow from the wall of a cyst into its lumen.41 The risk of subsequent breast cancer in this population is small and no additional treatment beyond excision is recommended. ranging 113 from metaplasia to hyperplasia.47–50 Once the diagnosis of solitary papilloma is confirmed by excisional biopsy. or as a filling defect on ductography. It has been suggested that the recurrence of papillomas is related to the presence of proliferative breast lesions (including usual ductal hyperplasia.clinicalobgyn. supported by a fibrovascular stroma. thorough sampling of the specimen and diagnostic radiographic imaging of contralateral breast tissue is suggested to rule out malignancy. There is a significant correlation between the presence of ADH in papillary lesions on core biopsies and the presence of invasive or preinvasive carcinoma of the breast in excisional biopsies. whereas the peripheral ones are usually multiple.

and the risk declines after 15 years.114 Rungruang and Kelley AH is associated with an increased risk of developing both ipsilateral and contralateral breast cancer. With the increasing use of mammography and detection of microcalcifications. The etiology is unknown but a hormonal relationship is likely as they persist during the reproductive years.58.57.73 Clinically.18. absolute risk is low and the majority of patients do not develop invasive cancer during their lifetime. but synchronous breast cancer has been reported in up to 15% of cases55 and long-term radiographic follow-up is recommended. and nontender mass.com Benign Neoplasms of the Breast FIBROADENOMA Fibroadenoma is a common lesion of the breast.63 Women with ADH develop cancer usually within 10 to 15 years of the diagnosis. Macroscopically. reported in up to 25% of asymptomatic women.19 Various risk reduction strategies exist including the use of selective estrogen receptors modifiers depending on the individuals Gail Model risk assessment. Fibroadenomas are solid tumors containing glandular and fibrous tissue. a fibroadenoma is a well-circumscribed.17.60 Patients who also have a first-degree relative with breast cancer have nearly a 10-fold increased risk as well.62. The relative risk of invasive breast cancer associated with AH ranges from 3 to 6-fold. ADH is being diagnosed in 30% of patients undergoing percutaneous biopsy. a fibroadenoma can present as a palpable.61 www. firm. and together they are referred to as AH.58 Similarly. less than 3 cm in diameter. and regress after menopause.71. In contrast.62. but the contralateral breast is also at risk. mobile. ALH is usually detected on percutaneous biopsy for microcalcifications. These lesions have an increased breast cancer risk.64 Patients with this diagnosis on core biopsy require excisional biopsy to confirm the diagnosis.70 The peak incidence is between the ages of 15 and 35 years. PROLIFERATIVE BREAST LESIONS WITH ATYPIA Proliferative lesions with atypia include atypical ductal and lobular hyperplasia and atypical papilloma or papillomatosis.16.9 to 13.56.16.68 Patients with these conditions should be counseled regarding long-term surveillance and consideration for chemoprevention with tamoxifen or raloxifene.16.56.69 The actual risk of breast cancer is unknown for this rare entity. increase the risk to 10-fold. when compared with the general population. and this results in an upgrade in diagnosis to ductal carcinoma in situ in 15% to 50% of cases. Classifications include ADH and ALH. Histologic appearance of these lesions includes ductal or lobular elements with uniform cells and loss of apical-basal cellular orientation.clinicalobgyn. can increase in size during pregnancy or with estrogen therapy.0.65–67 ALH has a 4-fold increased risk of breast cancer and is 3 times more likely to arise in the ipsilateral breast than the contralateral side. ranging from relative risks of 3. However.59. and the cut surface of is both lobulated and bulging. especially those associated with calcifications.19. firm mass. . Microscopic appearance consists of a proliferation of epithelial and mesenchymal elements.17 The risk for breast cancer is higher in the affected breast.72 A direct association had been noted between oral contraceptive use before the age of 20 years and the risk of fibroadenoma.60 Multifocal lesions.57 AH AH is an incidental finding on percutaneous biopsy of mammographic abnormalities or palpable breast masses. this diagnosis is rare (4%) among patients having biopsies for a palpable mass.

30. Often both types of growth are seen in the same lesion. both mammography and ultrasound imaging are unrevealing unless the tumor is large. They www. damage to the breast’s duct system. Ultrasound-guided cryoablation is an excellent treatment option for small (<3 cm) fibroadenomas in women who wish to avoid surgery. These present as soft. it is important to recognize phylloides tumor because it should be excised completely with clear margins to reduce local recurrence. Although phylloides tumors may appear similar to fibroadenoma on ultrasound.76. Ultrasound alone or FNA cannot differentiate between a fibroadenoma and a phylloides tumor.77. Hypercellular stroma with cytologic ayptia. Adenomas are pure epithelial neoplasms of the breast. These lesions grow rapidly and can reach up to 15 or 20 cm in dimension.85 FNA biopsy shows fat cells with or without epithelial cells. Juvenile fibroadenomas are distinguished from adult fibroadenomas by exhibiting more glandularity and greater stromal cellularity. usually as a painless.81 Juvenile fibroadenoma is a variant of fibroadenoma that presents between 10 and 18 years of age.73 When the tumor is larger than 10 cm.com .85 There is no increased risk of subsequent breast cancer associated with lipomas. and infiltrative margins of the lesion are the most reliable discriminators to separate lesions with recurrence and malignant behavior.76–80 In the clinical scenario where the fibroadenoma increases in size or becomes symptomatic.75 Disadvantages of excisional surgery include cosmetic change. the patient can be followed with clinical examinations.74. it is termed a giant fibroadenoma and is seen commonly in adolescents. However.84 LIPOMA Breast lipomas are benign solitary tumors composed of mature fat cells. The most common types are lactating and tubular adenomas. In terms of surgical treatment of these tumors. Both lactating and tubular adenomas occur during the reproductive ages. If the clinical diagnosis of lipoma is confirmed by either FNA biopsy or core biopsy and the mammogram and ultrasound are concordant. ADENOMA Phylloides tumor is a fibroepithelial tumor of the breast with a spectrum of changes. core needle biopsy is mandatory. Usually. solitary. increased mitoses. nontender. surgical excision is recommended. clinical characteristics. skin thickening. They are distinguished from fibroadenomas by their sparse stromal elements. The diagnosis is confirmed with a core or excisional biopsy.83. if the diagnosis is not certain or the lesion grows rapidly. Excision is recommended to exclude the presence of atypia or a phylloides tumor and to restore cosmesis to the affected breast. Patient and physician preference often determines long-term management of this condition. well-circumscribed masses that can be smooth or lobulated. and confounding future mammographic imaging because of architectural distortion. and pathologic findings on percutaneous core needle biopsy. The diagnosis of fibroadenoma is confirmed by percutaneous core biopsy. greater than 5 cm in size. the tumor should be surgically removed.Benign Breast Diseases with stroma proliferating around tubular glands (pericanalicular growth) or compressed cleft-like ducts (intracanalicular growth).clinicalobgyn. they are characterized by rapid growth and local recurrence if excised without adequate margins. concordant imaging. Surgical removal is recommended to restore breast symmetry.82 PHYLLOIDES TUMOR 115 Benign phylloides tumor is difficult to differentiate from fibroadenoma. with lactating adenomas occurring during pregnancy. unilateral mass. Excision or observation are options depending on the age of the patient. If a phylloides tumor is suspected. and increased focal density.

89. or have had prior surgery or radiation to the breast.86 Tubular adenoma of the breast presents as a solitary.88 These lesions may require excision only because of mass effect. Risk factors include improper nursing technique.90 Clinically. such as with dicloxacillin or other broad spectrum penicillin. such as the axilla. palpable. seems to be the most appropriate approach. breast emptying with frequent nursing or manual pumping and beginning empiric antibiotic therapy. well-circumscribed. and are classified as idiopathic. It presents as a solitary or multiple. As lactation mastitis is a process of subcutaneous cellulitis.com Acute mastitis usually occurs during the first 3 months postpartum in the setting of breast feeding. As the duration of symptoms before starting treatment is found to be the only independent risk factor for abscess development. and erythematous breast and is often associated with a febrile reaction. and irregular microcalcifications in dilated acini may be prominent on mammography and ultrasonography. When an abscess occurs. Imaging and biopsies are helpful in distinguishing this cancer from an infectious etiology. therefore. tightly packed acinar structures are seen in a sparsely cellular stroma. freely movable breast mass that tends to be small (<3 cm). this results in a diffusely painful. swollen. Although some of these changes are a result of infectious agents.91 There is little consensus on the type or duration of antibiotic therapy and when to begin antibiotics. Although they may require excision because of their size. but they do not have malignant potential.30 Lactating adenoma is the most prevalent breast mass during pregnancy and puerperium. In addition. surgical removal or medical therapy to shrink the tumor may be necessary because of its mass effect.86. and sleep deprivation. firm mass.87 Although the tumor may spontaneously involute. Lactating adenoma may also develop in ectopic locations. Most patients with inflammatory breast cancer are www. MASTITIS are well circumscribed and lobulated. stress. detection of pathogens in breast milk may not always be possible. The diagnosis is based on clinical symptoms. they do not have malignant potential. It is important to recognize that inflammatory breast cancer can mimic an infectious or inflammatory condition. others do not have a well-understood etiology and may represent local reaction to a systemic disease or a localized antigen-antibody reaction.116 Rungruang and Kelley diagnosed after an initial treatment with antibiotics failed to show clinical improvement. The lesion is well circumscribed and lobulated and is characterized by hyperplastic lobules lined by actively secreting cells. nipple cracks or fissures.92 This is usually seen in the lower half of . Cellulitis of the breast with or without an abscess is common in women who are overweight. have large breasts.30 Inflammatory Conditions of the Breast A variety of inflammatory and reactive changes can be observed in the breast. incision and drainage or percutaneous drainage are options for management. early diagnosis and early management of mastitis is of value. This tumor may resemble a noncalcified fibroadenoma radiographically. Microorganisms can then enter through the open skin and populate within areas of milk stasis.91 Mastitis can also be seen in women who are not lactating but evaluation for inflammatory breast cancer is mandatory. chest wall. or vulva. tiny. It is a cellulitis of the interlobular connective tissue within the mammary gland and can result in abscess formation and septicemia. punctuate.clinicalobgyn. discrete. Histologically.

These present as soft cystic masses on physical examination. HAMARTOMA Fat necrosis of the breast is a benign condition that most commonly occurs as Hamartomas are uncommon benign tumor-like nodules that have varying amounts of glandular.96 There is no evidence that mammary duct ectasia is associated with increased risk for breast cancer. Histologically.98 Even the macroscopic appearance of the benign lesion can suggest a malignant tumor. These ducts contain eosinophilic. The most important histologic feature of this disorder is the dilatation of major ducts in the subareolar region. Usually. which yields a milky substance. and ultrasound may show a complex mass. nipple retraction. excision is not necessary. noncyclical mastalgia. the skin should be kept clean and dry. The classic mammographic appearance is a circumscribed area consisting of both soft tissue and lipomatous elements.99 Once the diagnosis is established. and Staphylococcus aureus is the most common responsible organism.92 117 Miscellaneous Benign Lesions of the Breast MAMMARY DUCT ECTASIA Mammary duct ectasia is a disease of middle-aged to elderly parous women. creams and powders should be avoided.102 Although the pathogenesis of the lesion is not clear.101. excision is not necessary. The etiology is not well known. encapsulated. surrounded by a thin translucent zone. adipose. Fat necrosis can be confused with a malignancy on physical examination and radiologic studies. For patients with recurrent infections of the lower breast area. and there is no increased risk of subsequent breast cancer. who can present with nipple discharge.com . and these luminal secretions may undergo calcifications that may be the presenting sign in many patients. this is an asymptomatic lesion and is detected by mammogram with a finding of microcalcifications.100 Once the diagnosis is established. although experienced radiologists can usually determine that a lesion represents fat necrosis on the basis of mammographic and ultrasound findings such as oil cysts. appearing as a spiculated dense mass with skin retraction.30.97 It is sometimes necessary to biopsy these lesions to confirm the diagnosis. acute episodes of infection should be treated with appropriate antibiotics.Benign Breast Diseases the breast. Similar to lactational mastitis. or with a nonpuerperal infection which may manifest without fever. On mammographic imaging. unless the classic fatfluid level is seen.93–96 Mammary duct ectasia generally does not require surgery and should be managed conservatively. and cotton bras should be worn.93 The clinical presentation of nipple inversion can mimic invasive carcinoma. a palpable subareolar mass. They either present as discrete. galactoceles may appear as an indeterminate mass. where sweat accumulates. and skin thickening. erythema. it is thought to result from a www. granular secretions and foamy histiocytes both within the duct epithelium and the lumen. painless masses or are found incidentally on screening mammography. the diagnosis of fat necrosis is characterized by anuclear fat cells. but smoking is an associated factor. Diagnosis is made by clinical history and aspiration. with precutaneous or incisional drainage of the abscess if present. and fibrous tissue. GALACTOCELE Galactoceles are cystic collections of fluid.clinicalobgyn. FAT NECROSIS the result of breast trauma or surgery. usually caused by an obstructed milk duct. often surrounded by histiocytic giant cells and foamy phagocytic histiocytes. ecchymosis.

noncyclical.102. www. microscopic foci to clinically and mammographically evident breast masses.30 PSEUDOANGIOMATOUS STROMAL HYPERPLASIA Mastalgia Breast pain is classified as cyclical. the most characteristic appearance is an otherwise normal breast and fat tissue distributed in a nodular fashion within fibrotic stroma surrounding and extending to individual lobules.118 Rungruang and Kelley dysgenesis rather than a true tumorous process. Cyclical mastalgia is more severe and persistent than normal cyclical pain. reassurance can be given after normal mammography to exclude other findings. In addition.101. If moderate or severe breast pain has been present for less than 6 months.107 Fibrocystic breast changes can also be painful in response to hormonal stimulation during ovulation. On gross examination. and the cut surface consists of homogeneous white and rubbery tissue. which may present as a mass on physical examination or radiologic imaging. symptomatic treatment may be offered. Breast cancer may present as breast pain. The histologic appearance is characterized by anastomosing slit-like empty spaces lined by spindle cells. surgical excision is recommended. as hamartomas do not have specific diagnostic features.com Cyclical breast pain is caused by normal hormonal changes associated with ovulation that stimulate the proliferation of normal breast tissue.30. Histologically. which is associated with multiple hamartomas and increased risk of early onset breast and thyroid cancer.109. Minor discomfort is normal and is usually bilateral and diffuse in nature. hamartomas are typically well-circumscribed lesions with smooth contours.110 Danazol has also been shown to be effective. which obliterates the usual interlobular-specialized loose stroma. thus a breast examination is indicated. an increased risk of breast cancer or an abnormal breast examination.106 If there are any suspicious features on imaging.108 A 3month course of 10 mg tamoxifen can reduce pain in 71% to 75% of women with few side effects. PASH is usually a well-demarcated mass with a smooth external surface. it should be distinguished from a malignancy. Younger women (less than 30 y of age) with complaints of cyclical diffuse breast pain who are at no increased risk for breast cancer and have a normal breast examination should have a follow-up examination scheduled in 2 to 3 months to confirm the initial impression of normalcy. For women who have localized breast pain.105 In fact. CYCLICAL BREAST PAIN Pseudoangiomatous stromal hyperplasia (PASH) is a benign stromal proliferation. but . the most common being hot flashes. In women above 35 years of age without imaging in the last year. further evaluation with a targeted breast ultrasound and mammography is indicated. Although PASH is benign. On macroscopic examination. Some cases have been reported to be related to a genetic defect called Cowden syndrome. PASH is found as an incidental microscopic finding in as many of 25% of breast biopsy specimens. There is no increased risk of subsequent breast cancer associated with PASH. the diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis and excisional biopsy should be performed. or extramammary.103 The diagnosis can be difficult to make with limited tissue. cyclical breast pain can be associated with pharmacologic hormonal agents such as oral contraceptives.clinicalobgyn. Its clinicopathologic spectrum ranges from incidental. there is a high probability of spontaneous remission and the patient should be reassured without further treatment. If the pain is present for more than 6 months or more than 6 weeks with persistent and very severe pain. such as mammary angiosarcoma.104 As coincidental malignancy can occur.

It is most frequently because of the pectoralis major muscle. Chest wall pain is usually lateral and burning in quality. Kelsey JL. 2. Additional symptoms include neck and shoulder pain. Bartow SA. Pooled information from epidemiologic studies. J Natl Cancer Inst. Large pendulous breasts may be painful secondary to stretching of Cooper’s ligaments.60: 2751–2760. Black WC. Trauma or trauma-in- www. Gammon MD. headaches.146:1–15. Parazzini F.108 SUMMARY Noncyclical breast pain is not related to hormonal changes associated with the menstrual cycle and may occur in both premenopausal and postmenopausal women.111–113 Danazol should only be considered if there is no response to tamoxifen. therefore accurate diagnosis is important. These lesions tend to be unilateral and variable in the location in the breast. 4. 1985.115. Nonsteroidal anti-inflammatory drugs may relieve pain due to Mondor disease. The pathoepidemiology of benign proliferative epithelial disorders of the female breast. Gallbladder disease and ischemic heart disease may also present as extramammary pain. Cook MG.65:13–20.clinicalobgyn.114 Hormone replacement therapy may cause noncyclical breast pain in up to one-third of women. and this pain can be reproduced by asking the patient to place her hand flat on the iliac wing and push inward. When a patient presents with a breast mass. Cancer. Rohan TE. Mark Elwood J. and malignant breast lesions in populations at different risk for breast cancer.108:112–120.12:228–240. Risk factors for benign breast disease and their relation with breast cancer risk. Excisional biopsy should be recommended for mass lesions that cause breast distortion or for high-risk lesions found on percutaneous sampling. Most patients will have a benign condition. Am J Epidemiol. Epidemiol Rev.108 NONCYCLICAL BREAST PAIN 119 duced fat necrosis can also be a source of extramammary pain. Prevalence of benign. 71:167–178. spine problems. but this usually resolves spontaneously over time. depression. J Pathol. 1987. and indicated imaging and biopsies are key to diagnosis. et al. La Vecchia C. et al. pregnancy. 1978. Epidemiology of breast cancer. 1985. such as nausea. et al. and medications.117 Many of these conditions resolve spontaneously.Benign Breast Diseases with more side effects. atypical. 6. References 1. These patients may have up to 85% relief in their symptoms from wearing a more supportive bra.com .116 Other causes of noncyclical breast pain include inflammatory breast cancer. but some of these conditions confer increased risk of subsequent breast cancer. 1990. Risk of breast cancer in women with benign breast lesion. Incidence rates and risk factors of benign breast neoplasms. Extramammary pain is referred pain from sources outside the breast. and menstrual irregularity. headache. careful history. physical examination. Thomas DB. Treatment is generally aimed at the underlying cause of pain. thrombophlebitis (Mondor disease). 3. Cole P. but symptomatic treatments can be offered for persistent or severe pain. Tumori. 5. This can include chest wall pain. A forensic autopsy study.108 EXTRAMAMMARY PAIN Benign breast diseases are common and encompass a spectrum of disorders. prior breast surgery. 1980. trauma. Hutchinson WB. Spinal problems typically occur in older women because of the accumulation of spinal disease in the neck and upper thorax with age. Hamlin WB. Pathak DR. Franceschi S. or scarring from a previous biopsy. and a rash under the breasts. with either localized or diffuse pain. Kaplan SD.

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