Author
Michael S Sabel, MD Section Editor
Anees B Chagpar, MD, MSc, MPH Deputy Editor
Susan E Pories, MD, FACS
Last literature review version 17.1: January 2009 | This topic last updated: November 14,
2008 (More)
terms such as fibrocystic changes, fibrocystic disease, chronic cystic mastitis, and
mammary dysplasia refer to nonproliferative lesions and are less useful clinically, as they
encompass a heterogeneous group of diagnoses [5,13] . The most common
nonproliferative breast lesions are breast cysts.
Breast cysts Cysts are fluid filled, round or ovoid masses derived from the terminal duct
lobular unit. Cysts are found in as many as one third of women between 35 and 50 years
old. Acute enlargement of cysts may cause severe, localized pain of sudden onset. Simple
cysts and complicated cysts are discussed here. Complex masses have a cystic
component, but are considered more suspicious for malignancy and are discussed
separately [14] . (See "Complex masses" below).
Simple cysts On ultrasound evaluation, simple cysts are circumscribed, anechoic, with
posterior acoustic enhancement, lack of Doppler signal, and absence of solid components.
Simple cysts are benign by definition and no intervention is necessary, although aspiration
is often performed to relieve pain; simple non-painful cysts identified on ultrasonography
need not be aspirated. The cyst should disappear with removal of the fluid and the patient
can be reassured. If the cyst does recur, a second attempt at aspiration is reasonable. If a
breast cyst recurs a third time, the patient should be evaluated by a surgeon for
consideration of excision [7] . If clear fluid is obtained on aspiration of a cyst, this can be
discarded, however if the fluid is bloody it should be sent for cytologic analysis. (See
"Primary care evaluation of breast lumps", section on Fine needle aspiration biopsy).
Complicated cysts Complicated cysts are defined as those meeting most, but not all,
criteria for simple cysts on ultrasound examination. This includes lesions with internal
echoes, fluid or debris levels, thin septations, a perceptible wall, or lack of posterior
acoustic enhancement. These lesions are rarely malignant (0.4 percent) but should be
aspirated to confirm diagnosis or followed with imaging [15] .
Complex cysts Complex cysts, also referred to as complex masses, contain mixed
cystic and solid components or an intracystic solid mass. Complex masses do require
biopsy. Core needle biopsy is utilized, if possible, and a clip must be placed to ensure that
the lesion can be localized to allow excision if the core biopsy is positive. These lesions
have a relatively high rate of cancer, ranging from 20 to 43 percent [14] .
epithelial hyperplasia, epithelial calcification, or papillary apocrine changes [29] . They are
associated with a slightly increased risk of cancer when multicentric proliferative changes
are present in the surrounding glandular tissue.
Appropriate management of complex fibroadenomas is controversial. While some believe
that complex fibroadenomas warrant complete removal for histological examination, others
suggest that they can be managed conservatively following core biopsy [29] . In one series
of 401 fibroadenomas, 63 (15.7 percent) were considered complex. At a mean follow-up of
two years, invasive carcinoma was found in only one of the 63 patients with complex
fibroadenomas; her initial core biopsy had shown atypical lobular hyperplasia.
Radial scars Radial scars are usually discovered incidentally when a breast mass is
removed for other reasons; occasionally they are large enough to be detected by
mammography, which cannot reliably differentiate between these lesions and spiculated
carcinoma [40-43] . Radial scars are characterized microscopically by a fibroelastic core
with radiating ducts and lobules.
When radial scars are found on core biopsy, the entire lesion must be excised. In addition
to the possibility of finding an unrecognized in situ or invasive component, there is some
evidence that radial scars are premalignant lesions that can slowly progress from scar to
hyperplasia to carcinoma over time [44] . No additional treatment is needed for radial scars.
The risk of subsequent breast cancer in this population is modest and chemoprevention is
not indicated.
Risk reduction strategies Women with AH are counseled regarding risk reduction
strategies. Ongoing surveillance with yearly mammography and twice yearly breast exams
is appropriate [2,8,11,16-19] . Women with AH should stop taking birth control pills and
avoid hormone replacement therapy. Tamoxifen or raloxifene may be considered in women
with AH for breast cancer risk reduction, although the risks and side effects must be
discussed thoroughly [52-54] . The Gail breast model incorporates atypical proliferative
disease into a risk calculation that can be used to identify women who are appropriate
candidates for breast chemoprevention. (See "Selective estrogen receptor modulators for
the prevention of breast cancer" and see "Epidemiology and risk factors for breast cancer"
and see "Patient information: Tamoxifen and raloxifene for the prevention of breast
cancer").
Flat epithelial atypia Flat epithelial atypia, also referred to as columnar cell change with
atypia, columnar cell hyperplasia with atypia, or clinging carcinoma, is usually diagnosed on
breast biopsies done for calcifications. When diagnosed on a core needle biopsy specimen,
excision should be performed as about one-third of cases will show a more advanced
lesion. The relationship between flat epithelial atypia and cancer is still being defined, but
the available data suggest that the risk of local recurrence or progression to invasive
cancer is low [55] .
Lobular carcinoma in situ Women with lobular carcinoma in situ (LCIS) have a
significantly increased risk of breast cancer and require referral to a specialist for a full
discussion of treatment options. This topic is discussed separately. (See "Lobular
carcinoma in situ").
Fat necrosis Fat necrosis of the breast is a benign condition that most commonly
occurs as the result of breast trauma or surgical intervention. Fat necrosis can be confused
with a malignancy on physical exam and may also mimic malignancy on radiologic studies.
It is sometimes necessary to biopsy these lesions to confirm the diagnosis, although
experienced radiologists can usually determine that a lesion represents fat necrosis on the
basis of mammographic and ultrasound findings such as oil cysts [6,56] . Once diagnosis is
established, excision is not necessary and there is no increased risk of subsequent breast
cancer.
Galactocele Galactoceles (milk retention cysts) are cystic collections of fluid, usually
caused by an obstructed milk duct. At mammography, galactoceles may appear as an
indeterminate mass, unless the classic fat-fluid level is seen. Ultrasound may show a
complex mass. Diagnosis can be made on the basis of the clinical history and aspiration,
which yields a milky substance [60] . Once diagnosis is established, excision is not
necessary and there is no increased risk of subsequent breast cancer. (See "Common
problems of breastfeeding in the postpartum period").
Adenoma Adenomas are pure epithelial neoplasms of the breast. They are
distinguished from fibroadenomas by their sparse stromal elements. Adenomas are divided
into two main groups; tubular and lactating adenomas. Lactating adenomas occur
commonly in pregnancy. They are well circumscribed and lobulated. Although they may
require excision because of their size, they do not have malignant potential [5,6] .
PASH is benign, but should be distinguished from a malignancy and is often confused with
mammary angiosarcoma [6,70] . If there are any suspicious features on imaging, the
diagnosis of PASH on a core biopsy should not be accepted as a final diagnosis and
excisional biopsy should be performed. However, in the absence of suspicious imaging
characteristics, a diagnosis of PASH at core biopsy is considered sufficient, and surgical
excision is not always necessary [71] . There is no increased risk of subsequent breast
cancer associated with PASH.
COMPLEX MASSES Complex masses with mixed cystic and solid components or an
intracystic solid mass require biopsy. Core needle biopsy is utilized, if possible, and a clip is
placed to ensure that the lesion can be localized to allow excision if the core biopsy is
positive. These lesions have a relatively high rate of cancer, ranging from 20 to 43 percent
[15] .
BREAST PAIN Breast pain is classified as cyclical (ie, related to the menstrual cycle),
noncyclical, or extramammary. Breast cancer may present as breast pain, thus a breast
examination is indicated. Younger women (< 30 years 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 two to three months to
confirm the initial impression of normalcy. For women who have localized breast pain, an
increased risk of breast cancer or an abnormal breast exam, further evaluation with a
targeted breast ultrasound and mammography is indicated. In general however,
mammography is not effective or useful for women under the age of 30 as breast tissue in
this age group is normally very dense. This topic is discussed in detail separately. (See
"Breast pain").
Cyclical breast pain occurs in about 60 percent of premenopausal women, and historically
had been attributed to "fibrocystic breast changes," a term that is no longer considered
helpful as it encompasses normal and benign breast conditions (see "Classification of
benign breast lesions" above). Symptomatic relief may be achieved with the use of a soft
brassiere with good support, acetaminophen, and/or a nonsteroidal antiinflammatory drug.
The role of diet and lifestyle in relieving cyclical breast pain is unclear, with a strong
likelihood of a placebo response for many interventions. A low fat (15 percent of calories),
high complex carbohydrate diet has been effective in some observational studies [73,74] .
Elimination of caffeine has not been effective in controlleld trials [75-78] , although it seems
to be helpful in some women. Inconclusive evidence exists for the role of vitamin E [79] and
evening primrose oil [80] in reducing pain. Hormone replacement therapy can cause breast
pain and this should be discontinued if at all possible [81] .
For patients with more severe mastalgia, tamoxifen 10 mg can provide breast pain relief
[82] , although this medication is associated with side effects including include menopauselike symptoms such as hot flashes, vaginal dryness, joint pain, and leg cramps. Tamoxifen
also increases the risk of blood clots, strokes, uterine cancer, and cataracts. (see "Use of
selective estrogen receptor modulators in postmenopausal women"). Tamoxifen has not
been approved by the US Food and Drug Administration for treatment of breast pain and is
infrequently used for this indication. Several other drugs that affect estrogen or prolactin
secretion (including danazol, bromocriptine, and GNRH agonists) have been studied [8385] , but are not advocated for use in patients with severe mastalgia because of significant
side effect profiles.
SUMMARY AND RECOMMENDATIONS Benign breast lesions can be classified into three
categories on the basis of histologic findings: non-proliferative, proliferative without atypia,
and atypical hyperplasias. (See "Classification of benign breast lesions" above).
Nonproliferative lesions are not generally associated with an increased risk of breast
cancer. Management is directed at making a definitive diagnosis and providing relief of
symptoms. (See "Nonproliferative breast lesions" above). Proliferative disease without
atypia is associated with a slightly increased risk of subsequent breast cancer. Once the
diagnosis is established, no additional treatment is indicated. (See "Proliferative breast
lesions without atypia" above). Atypical hyperplasia is associated with a moderate increase
in risk of subsequent breast cancer. These women should be monitored closely and
counseled regarding risk reduction strategies. (See "Atypical hyperplasia" above).
Papillomas, radial scars, atypical hyperplasia or flat epithelial atypia when diagnosed on
core biopsy should be excised to ensure accuracy of diagnosis. (See "Papilloma" above
and see "Radial scars" above and see "Atypical hyperplasia" above and see "Flat epithelial
atypia" above). Core biopsy, rather than fine needle aspiration, should be performed on
complex cystic masses to ensure accurate diagnosis. We recommend clip placement to
mark the biopsy site. (See "Complex masses" above).
ACKNOWLEDGEMENT The authors and editorial staff at UpToDate, Inc. would like to
acknowledge Richard J Santen, MD for his contributions to previous versions of this topic.
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