Understanding Breast Changes, Part II

About Breast Lumps and Other Changes

Over her lifetime, a woman can encounter a broad variety of breast conditions. These include normal changes that occur during the menstrual cycle as well as several types of benign lumps. What they have in common is that they are not cancer. Even for breast lumps that require a biopsy, some 80 percent prove to be benign.

Each breast has 15 to 20 sections, called lobes, each with many smaller lobules. The lobules end in dozens of tiny bulbs that can produce milk. Lobes, lobules, and bulbs are all linked by thin tubes called ducts. These ducts lead to the nipple, which is centered in a dark area of skin called the areola. The spaces between the lobules and ducts are filled with fat. There are no muscles in the breast, but muscles lie under each breast and cover the ribs.

These normal features can sometimes make the breasts feel lumpy, especially in women who are thin or who have small breasts.

In addition, from the time a girl begins to menstruate, her breasts undergo regular changes each month. Many doctors believe that nearly all breasts develop some lasting changes, beginning when the woman is about 30 years old. Eventually, about half of all women will experience symptoms such as lumps, pain, or nipple discharge. Generally these disappear with menopause.

Some studies show that the chances of developing benign breast changes are higher for a woman who has never had children, has irregular menstrual cycles, or has a family history of breast cancer. Benign breast conditions are less common among women who take birth control pills or who are overweight. Because they generally involve the glandular tissues of the breast, benign breast conditions are more of a problem for women of child-bearing age, who have more glandular breasts.

Types of Benign Breast Changes 

Common benign breast changes fall into several broad categories. These include generalized breast changes, solitary lumps, nipple discharge, and infection and/or inflammation.

Generalized Breast Changes
Generalized breast lumpiness is known by several names, including fibrocystic disease changes and benign breast disease. Such lumpiness, which is sometimes described as "ropy" or "granular," can often be felt in the area around the nipple and areola and in the upper-outer part of the breast. Such lumpiness may become more obvious as a woman approaches middle age and the milk-producing glandular tissue of her breasts increasingly gives way to soft, fatty tissue. Unless she is taking replacement hormones, this type of lumpiness generally disappears for good after menopause.

The menstrual cycle also brings cyclic breast changes. Many women experience swelling, tenderness, and pain before and sometimes during their periods. At the same time, one or more lumps or a feeling of increased lumpiness may develop because of extra fluid collecting in the breast tissue. These lumps normally go away by the end of the period.

During pregnancy, the milk-producing glands become swollen and the breasts may feel lumpier than usual. Although very uncommon, breast cancer has been diagnosed during pregnancy. If you have any questions about how your breasts feel or look, talk to your doctor.

Solitary Lumps
Benign breast conditions also include several types of distinct, solitary lumps. Such lumps, which can appear at any time, may be large or small, soft or rubbery, fluid-filled or solid.

Cysts are fluid-filled sacs. They occur most often in women ages 35 to 50, and they often enlarge and become tender and painful just before the menstrual period. They are usually found in both breasts. Some cysts are so small they cannot be felt; rarely, cysts may be several inches across. Cysts are usually treated by observation or by fine needle aspiration. They show up clearly on ultrasound.

Fibroadenomas are solid and round benign tumors that are made up of both structural (fibro) and glandular (adenoma) tissues. Usually, these lumps are painless and found by the woman herself. They feel rubbery and can easily be moved around. Fibroadenomas are the most common type of tumors in women in their late teens and early twenties, and they occur twice as often in African-American women as in other American women.

Fibroadenomas have a typically benign appearance on mammography (smooth, round masses with a clearly defined edge), and they can sometimes be diagnosed with fine needle aspiration. Although fibroadenomas do not become malignant, they can enlarge with pregnancy and breast-feeding. Most surgeons believe that it is a good idea to remove fibroadenomas to make sure they are benign.

Fat necrosis is the name given to painless, round, and firm lumps formed by damaged and disintegrating fatty tissues. This condition typically occurs in obese women with very large breasts. It often develops in response to a bruise or blow to the breast, even though the woman may not remember the specific injury. Sometimes the skin around the lumps looks red or bruised. Fat necrosis can easily be mistaken for cancer, so such lumps are removed in a surgical biopsy. (See Biopsy, page 29.)

Sclerosing adenosis is a benign condition involving the excessive growth of tissues in the breast's lobules. It frequently causes breast pain. Usually the changes are microscopic, but adenosis can produce lumps, and it can show up on a mammogram, often as calcifications. Short of biopsy, adenosis can be difficult to distinguish from cancer. The usual approach is surgical biopsy, which furnishes both diagnosis and treatment.

Nipple Discharge
Nipple discharge accompanies some benign breast conditions. Since the breast is a gland, secretions from the nipple of a mature woman are not unusual, nor even necessarily a sign of disease. For example, small amounts of discharge commonly occur in women taking birth control pills or certain other medications, including sedatives and tranquilizers. If the discharge is being caused by a disease, the disease is more likely to be benign than cancerous.

Nipple discharges come in a variety of colors and textures. A milky discharge can be traced to many causes, including thyroid malfunction and oral contraceptives or other drugs. Women with generalized breast lumpiness may have a sticky discharge that is brown or green.

The doctor will take a sample of the discharge and send it to a
laboratory to be analyzed. Benign sticky discharges are treated chiefly by keeping the nipple clean. A discharge caused by infection may require antibiotics.

One of the most common sources of a bloody or sticky discharge is an intraductal papilloma, a small, wartlike growth that projects into breast ducts near the nipple. Any slight bump or bruise in the area of the nipple can cause the papilloma to bleed. Single (solitary) intraductal papillomas usually affect women nearing menopause. If the discharge becomes bothersome, the diseased duct can be removed surgically without damaging the appearance of the breast. Multiple intraductal papillomas, in contrast, are more common in younger women. They often occur in both breasts and are more likely to be associated with a lump than with nipple discharge. Multiple intraductal papillomas, or any papillomas associated with a lump, need to be removed.

Infection and/or Inflammation
Infection and/or inflammation, including mastitis and mammary duct ectasia, are characteristic of some benign breast conditions.

Mastitis (sometimes called "postpartum mastitis") is an infection most often seen in women who are breast-feeding. A duct may become blocked, allowing milk to pool, causing inflammation, and setting the stage for infection by bacteria. The breast appears red and feels warm, tender, and lumpy.

In its earlier stages, mastitis can be cured by antibiotics. If a pus-containing abscess forms, it will need to be drained or surgically removed.

Mammary duct ectasia is a disease of women nearing menopause. Ducts beneath the nipple become inflamed and can become clogged. Mammary duct ectasia can become painful, and it can produce a thick and sticky discharge that is grey to green in color. Treatment consists of warm compresses, antibiotics, and, if necessary, surgery to remove the duct.

Benign Breast Conditions and the Risk for Breast Cancer

Most benign breast changes do not increase a woman's risk for getting cancer. Recent studies show that only certain very specific types of microscopic changes put a woman at higher risk. These changes feature excessive cell growth, or hyperplasia.

About 70 percent of the women who have a biopsy showing a benign condition have no evidence of hyperplasia. These women are at no increased risk for breast cancer.

About 25 percent of benign breast biopsies show signs of hyperplasia, including conditions such as intraductal papilloma and sclerosing adenosis. Hyperplasia slightly increases the risk of developing breast cancer.

The remaining 5 percent of benign breast biopsies reveal both excessive cell growth--hyperplasia--and cells that are abnormal--atypia. A diagnosis of atypical hyperplasia, as it is called, moderately increases breast cancer risk.

If You Find a Lump  

If you discover a lump in one breast, check the other breast. If both breasts feel the same, the lumpiness is probably normal. You should, however, mention it to your doctor at your next visit.

But if the lump is something new or unusual and does not go away after your next menstrual period, it is time to call your doctor. The same is true if you discover a discharge from the nipple or skin changes such as dimpling or puckering. If you do not have a doctor, your local medical society may be able to help you find one in your area.

You should not let fear delay you. It is natural to be concerned if you find a lump in your breast. But remember that four-fifths of all breast lumps are not cancer. The sooner any problem is diagnosed, the sooner you can have it treated.

Clinical Evaluation
No matter how your breast lump was discovered, the doctor will want to begin with your medical history. What symptoms do you have and how long have you had them? What is your age, menstrual status, general health? Are you pregnant? Are you taking any medications? How many children do you have? Do you have any relatives with benign breast conditions or breast cancer? Have you previously been diagnosed with benign breast changes?

The doctor will then carefully examine your breasts and will probably schedule you for a diagnostic mammogram, to obtain as much information as possible about the changes in your breast. This may be either a lump that can be felt or an abnormality discovered on a screening mammogram. Diagnostic mammography may include additional views or use special techniques to magnify a suspicious area or to eliminate shadows produced by overlapping layers of normal breast tissue. The doctor will want to compare the diagnostic mammograms with any previous mammograms. If the lump appears to be a cyst, your doctor may ask you to have a sonogram (ultrasound study).

Aspirating a Cyst
When a cyst is suspected, some doctors proceed directly with
aspiration. This procedure, which uses a very thin needle and a syringe, takes only a few minutes and can be done in the doctor's office. The procedure is not usually very uncomfortable, since most of the nerves in the breast are in the skin.

Holding the lump steady, the doctor inserts the needle and attempts to draw out any fluid. If the lump is indeed a cyst, removing the fluid will cause the cyst to collapse and the lump to disappear. Unless the cyst reappears in the next week or two, no other treatment is needed. If the cyst reappears at a later date, it can simply be drained again.

If the lump turns out to be solid, it may be possible to use the needle to withdraw a clump of cells, which can then be sent to a laboratory for further testing. (Cysts are so rarely associated with cancer that the fluid removed from a cyst is not usually tested unless it is bloody or the woman is older than 55 years of age.)

Biopsy  

The only certain way to learn whether a breast lump or mammographic abnormality is cancerous is by having a biopsy, a procedure in which tissue is removed by a surgeon or other specialist and examined under a microscope by a pathologist. A pathologist is a doctor who specializes in identifying tissue changes that are characteristic of disease, including cancer.

Tissue samples for biopsy can be obtained by either surgery or needle. The doctor's choice of biopsy technique depends on such things as the nature and location of the lump, as well as the woman's general health.

Surgical biopsies can be either excisional or incisional. An excisional biopsy removes the entire lump or suspicious area. Excisional biopsy is currently the standard procedure for lumps that are smaller than an inch or so in diameter. In effect, it is similar to a lumpectomy, surgery to remove the lump and a margin of surrounding tissue. Lumpectomy is usually used in combination with radiation therapy as the basic treatment for early breast cancer.

An excisional biopsy is typically performed in the outpatient department of a hospital. A local anesthetic is injected into the woman's breast. Sometimes she is given a tranquilizer before the procedure. The surgeon makes an incision along the contour of the breast and removes the lump along with a small margin of normal tissue. Because no skin is removed, the biopsy scar is usually small. The procedure typically takes less than an hour. After spending an hour or two in the recovery room, the woman goes home the same day.

An incisional biopsy removes only a portion of the tumor (by slicing into it) for the pathologist to examine. Incisional biopsies are generally reserved for tumors that are larger. They too are usually performed under local anesthesia, with the woman going home the same day.

Whether or not a surgical biopsy will change the shape of your breast depends partly on the size of the lump and where it is located in the breast, as well as how much of a margin of healthy tissue the surgeon decides to remove. You should talk with your doctor beforehand, so you understand just how extensive the surgery will be and what the cosmetic result will be.

Needle biopsies can be performed with either a very fine needle or a cutting needle large enough to remove a small nugget of tissue.

• Fine needle aspiration uses a very thin needle and syringe to remove either fluid from a cyst or clusters of cells from a solid mass. Accurate fine needle aspiration biopsy of a solid mass takes great skill, gained through experience with numerous cases.
  

• Core needle biopsy uses a somewhat larger needle with a special cutting edge. The needle is inserted, under local anesthesia, through a small incision in the skin, and a small core of tissue is removed. This technique may not work well for lumps that are very hard or very small. Core needle biopsy may cause some bruising, but rarely leaves an external scar, and the procedure is over in a matter of minutes.

At some institutions with extensive experience, aspiration biopsy is considered as reliable as surgical biopsy; it is trusted to confirm the malignancy of a clinically suspicious mass or to confirm a diagnosis that a lump is not cancerous. Should the needle biopsy results be uncertain, the diagnosis is pursued with a surgical biopsy. Some doctors prefer to verify all aspiration biopsy results with a surgical biopsy before proceeding with treatment.

Localization biopsy (also known as needle localization) is a procedure that uses mammography to locate and a needle to biopsy breast abnormalities that can be seen on a mammogram but cannot be felt (nonpalpable abnormalities). Localization can be used with surgical biopsy, fine needle aspiration, or core needle biopsy.

For a surgical biopsy, the radiologist locates the abnormality on a mammogram (or a sonogram) just prior to surgery. Using the mammogram as a guide, the radiologist inserts a fine needle or wire so the tip rests in the suspicious area -- typically, an area of microcalcifications. The needle is anchored with a gauze bandage, and a second mammogram is taken to confirm that the needle is on target.

The woman, along with her mammograms, goes to the operating room, where the surgeon locates and cuts out the needle-targeted area. The more precisely the needle is placed, the less tissue needs to be removed.

Sometimes the surgeon will be able to feel the lump during surgery. In other cases, especially where the mammogram showed only microcalcifications, the abnormality can be neither seen nor felt. To make sure the surgical specimen in fact contains the abnormality, it is x-rayed on the spot. If this specimen x-ray fails to show the mass or the calcifications, the surgeon is able to remove additional tissue.

Stereotactic localization biopsy is a newer approach that relies on a three-dimensional x-ray to guide the needle biopsy of a nonpalpable mass. With one type of equipment, the patient lies face down on an examining table with a hole in it that allows the breast to hang through; the x-ray machine and the maneuverable needle "gun" are set up underneath. Alternatively, specialized stereotactic equipment can be attached to a standard mammography machine.

The breast is x-rayed from two different angles, and a computer plots the exact position of the suspicious area. (Because only a small area of the breast is exposed to the radiation, the doses are similar to those from standard mammography.) Once the target is clearly identified, the radiologist positions the gun and advances the biopsy needle into the lesion.

Tissue Studies
The cells or tissue removed through needle or surgical biopsy are promptly sent (along with the x-ray of the specimen, if one was made) to the pathology lab. If the excised lump is large enough, the pathologist can take a preliminary look by quick-freezing a small portion of the tissue sample. This makes the sample firm enough to slice into razor-thin sections that can be examined under the microscope. A "frozen section" provides an immediate, if provisional, diagnosis, and the surgeon may be able to give you the results before you go home.

The results of a frozen section are not 100 percent certain, however. A more thorough assessment takes several days, while the pathologist processes "permanent sections" of tissue that can be examined in greater detail.

When the biopsy specimen is small--as is often the case when the abnormality consists of mammographic calcifications only--many doctors prefer to bypass a frozen section so the tiny specimen can be analyzed in its entirety.

The pathologist looks for abnormal cell shapes and unusual growth patterns. In many cases the diagnosis will be clear-cut. However, the distinctions between benign and cancerous can be subtle, and even experts don't always agree. When in doubt, pathologists readily consult their colleagues. If there is any question about the results of your biopsy, you will want to make sure your biopsy slides have been reviewed by more than one pathologist.

Deciding To Biopsy
Not every lump or mammographic change merits a biopsy. Nearly all mammographic masses that look smooth and clearly outlined, for instance, are benign. Your doctor needs to thoughtfully weigh the findings from your physical exam and mammogram along with your background and your medical history when making a recommendation about a biopsy.

Although benign lumps rarely, if ever, turn into cancer, cancerous lumps can develop near benign lumps and can be hidden on a mammogram. Even if you have had a benign lump removed in the past, you cannot be sure any new lump is also benign.

In some cases, the doctor may suggest watching the suspicious area for a month or two. Because many lumps are caused by normal hormonal changes, this waiting period may provide additional information.

Similarly, if the changes on your mammogram show all the signs of benign disease, your doctor may advise waiting several months and then taking another mammogram. This would be followed by more diagnostic mammograms over the next 3 years. If you choose this option, however, you must be strongly committed to regularly scheduled followups.

If you feel uncomfortable about waiting, express your concerns to your doctor. You may also want to get a second opinion, perhaps from a breast specialist or surgeon. Many cities have breast clinics where you can get a second opinion.

Biopsy: One Step or Two?
Not too many years ago, all women undergoing surgery for breast symptoms had a one-step procedure: If the surgical biopsy showed cancer, the surgeon performed a mastectomy immediately. The woman went into surgery not knowing if she had cancer or if her breast would be removed.

Today a woman facing biopsy has a broader range of options. In most cases, biopsy and diagnosis will be separated from any further treatment by an interval of several days or weeks. Such a two-step procedure does not harm the patient, and it has several benefits. It allows time for the tissue sample to be examined in detail and, if cancer is found, it gives the woman time to adjust to the diagnosis. She can review her treatment options, seek a second opinion, receive counseling, and arrange her schedule.

Some women, nonetheless, prefer a one-step procedure. They have decided beforehand that, if the surgical biopsy and frozen section show cancer, they want to go ahead with surgery, either mastectomy or lumpectomy and axillary dissection (removal of the underarm lymph nodes). If, on the other hand, the lump proves to be benign, the incision will be closed. The procedure will have taken less than an hour, and the woman may go home the same day or the next day.

A one-step procedure avoids the physical and psychological stress, as well as the costs in time and money, of two rounds of surgery and anesthesia--a particularly important consideration for women who are ill or frail. Women who have symptoms of breast cancer can find the wait between biopsy and surgery emotionally draining, and they may be relieved to have a one-step procedure to take care of the problem as quickly as possible.

No single solution is right for everyone. Each woman should consult with her doctors and her family, weigh the alternatives, and decide what approach is appropriate. Being involved in the decision-making process can give a woman a sense of control over her body and her life.

Continue to Part III

Source:  National Cancer Institute, National Institutes of Health, Bethesda, MD  20892