Management of Benign Breast Disease

MANAGEMENT OF BENIGN BREAST DISEASE

 

Jerry K. Myers, M.D.

 

 

     Benign breast disease is one of the most common of all medical entities evaluated and followed in a woman. The reason for this is the relative high incidence of breast cancer, and the difficulty distinguishing benign disease from malignant disease.

     Fibrocystic disease (cystic mastitis, fibrocystic change, etc.)is a common term denoting the entire realm of benign breast problems. This includes all variants of problems in the breast whether they are cystic (fluid filled masses) or fibrous (solid masses) or more commonly a combination of both.

     Benign breast problems can present in many ways: 1) a tender fullness in a segment of the breast, 2) diffuse tenderness of the entire breast, 3) diffuse or local firmness with little or no tenderness, 4) a firm or soft nodule (lump) with or without tenderness, 5) skin tenderness and redness (mastitis, infection, abscess, etc.) and/or 6) nipple problems (drainage, tenderness, etc.).

     Breast nodules (lumps felt within the breast) usually present the largest diagnostic dilemma. These breast changes may mimic breast cancer, or even more seriously, a breast cancer may mimic them. Because of this dilemma, this area in benign breast disease is where most of the attention is concentrated, both medically and surgically. These abnormalities are sometimes found by the patient (in the very important self breast exam), by the physician in a routine exam,by mammogram (either screening or in follow-up)or other breast imaging test.

     Some abnormalities are noted only by the palpable exam (either self exam or physician exam), while others are noted only by the mammogram, ultrasound or other imaging test. Some nodules that can be felt may have a tissue density of such that will not visualize on a mammogram or by other imaging techniques. Ten to fifteen percent of breast cancers that are palpable cannot be visualized on the mammogram for the same reason. Other abnormalities are too small to be felt, but can be readily seen on the mammogram. In some dense breasts, neither the mammogram or palpable exam may reveal an abnormality while an ultrasound or other test may. Also, calcium deposits that cannot be felt may be detected only by the mammogram denoting the need for further evaluation, since some early cancers present with calcium deposits only.

     Evaluating a breast lesion can be done in several ways; close follow-up with frequent examinations (either by imaging techniques and/or by palpation),needle aspirate or core biopsies, or by completely removing the nodule or disease surgically. Of these the only method that gives a definite and immediate diagnosis is the surgical biopsy.

     When a breast abnormality is noted and felt to be benign by examination, close follow-up may be elected. During this period, continual follow-up may be elected if no significant change in the breast area occurs or a decision to biopsy may be decided if the area changes accordingly. When done carefully, this method of evaluating breast problems can be done safely and avert a surgical procedure.

     When a breast cyst drains completely with no residual nodule remaining, the area is considered benign and careful follow-up of the area can be done. If the nodule does not fully resolve after aspiration, the remaining area must be followed closely or biopsied as one would any other breast nodule.

     Nipple drainage or discharge is not an uncommon problem. It may be associated and caused by hormonal changes (galactorrhea) which may simply be from medication stimulus, changes from an ongoing or previous pregnancy, rarely from a pituitary tumor, or the reason being completely unknown. This discharge is usually clear or milky. More commonly the discharge is associated with breast ductal hyperplasia or a small benign ductal papilloma tumor that usually secretes a greenish discharge and less commonly a bloody discharge. All of these conditions must be carefully evaluated to assess the etiology and obviously rule out an underlying breast cancer that may also be associated with the discharge. It is uncommon to have a cancer associated with a nipple discharge without an associated mass on exam or mammogram; however, it is still possible and because of this either careful follow-up or biopsy is recommended.

     Needle aspirate biopsies are great tools to aid in the careful follow-up of lesions thought to be benign. These tests are 95% accurate in most experienced surgeons’ and pathologists’ hands, and can present meaningful objective data in following breast problems. This test is done easily and quickly in the doctor’s office with results obtained in 2-3 days.

     Although the above methods to evaluate breast problems can be accomplished safely and accurately, the only 100% reliable and immediate answer is the open surgical excisional biopsy (complete removal of the abnormal area and evaluation of the specimen pathologically). This requires an outpatient surgical procedure either under local or general anesthesia at a hospital or surgicenter.

     An open biopsy may be elected of a palpated abnormality. This simply requires making a small incision over the abnormal area, removing the tissue, and having a pathologist further evaluate it. The biopsy may also be done on an area seen only on the mammogram and not felt at all. This will require a needle localization (insertion of a guide wire into the abnormality via mammographic control in the radiology department just prior to surgery by the radiologist) at the time of surgery for the surgeon to actually find the lesion. The surgeon then dissects down the needle guide wire to the exact area localized by the radiologist, removes the tissue, and immediately sends it to the radiologist and pathologist to confirm that the localized tissue is removed. The pathologist then microscopically evaluates the tissue. If the biopsy result of the needle localization is benign, I always do a follow-up mammogram 1 month later to completely confirm that the abnormal breast tissue is indeed gone.

     Complications of the surgical biopsy are possible, but relatively uncommon. The most common problems are associated with the surgical wound and include bleeding, hematomas, and wound infections. These can usually be handled without difficulty, but occasionally require further surgery to correct the problem. Scarring is usually minimal, but impossible to prevent. The other possible reason for further surgery is if the follow-up mammogram after needle localization reveals continual presence of abnormal tissue. This would then require further excision.