Though any disease related to breast sounds scary due to fear of cancer, in reality only a few of those are cancerous while others are found to be benign breast diseases (BBDs). BBDs are estimated to be present in almost 70-80 per cent of Indian women in variable severity — from mild to severe. But women rarely seek medical advice due to lack of awareness and social stigma. To know more about BBDs and its treatments, ARCHANA JYOTI reached out to AIIMS-Delhi Surgical Disciplines Department Head Prof (Dr) Sunil Chumber and his team of medicos
Causes for BBDs
Dr Ankita Singh and Dr Piyush Ranjan shared that BBDs are usually due to minor aberrations of a) the normal process of development of breast occurring between 15-25 years of age, b) cyclical hormone-related changes occurring between 15-50 years of age, and c) involution of the breast occurring between 35-55 years of age; the processes that occurs in a life span starting from birth, first menstruation to menopause and post-menopause (i.e. cessation of menstruation). These diseases are also seen during pregnancy as well as lactation (breast feeding).
Though most of the clinical breast changes in women are benign, it is only 3-6% of cases that are due to breast cancer. Thus any breast related changes and problems should be reported to a doctor to ensure adequate treatment, says Dr Singh.
The presence of usually painless, single to multiple lumps in one or both breasts in young females, which are diagnosed as Fibroadenomas on biopsy or fine needle aspiration of lump, are the commonest benign tumors of the breast. They usually do not require any treatment in most cases and occur in 25% of women.
Pain in one or both breasts without lump or nodularity called Mastalgia and with lump or nodularity is called fibrocystic change of breast. They are common and reported in around 50% of all women over the age of 30 years and up to 70% of women overall, explains Dr Ranjan.
Breast inflammation called Mastitis is a condition when a women complaint of painful swelling in breast with redness, painful and hot to touch, with or without pus discharge, nipple retraction or inversion and may be accompanied by fever. This condition is usually found in females during breastfeeding but can occur otherwise. If there is a delay in treatment it can progress to breast abscess which is collection of pus inside breast and has to be drained.
Breast cysts are fluid filled lumps that are common in 35-55 years of age and confirmed on ultrasound of breast. Nipple discharge is usually found in reproductive age groups. It can be watery, greenish, milky, pus like and even bloody. If nipple discharge is bloody accompanied with breast lumps, it needs further evaluation to rule out cancer, informs Dr Singh. Other disorders like duct papilloma, atypical duct hyperplasia (ADH), atypical lobular hyperplasia (ALH), and ductal carcinoma in situ (DCIS) are relatively less common and picked up on ultrasound, mammography and confirmed on biopsy. They are associated with a higher risk of breast cancers and thus needs adequate management.
Classification, Consequences and Treatment of BBDs
Sensation of a lump can be scary, and always builds a thought of malignancy. Mastalgia makes the patient worrisome and hampers with routine daily activities and the sexual well-being of the individual. Nipple discharge causes frequent soakage of inner dressing and social discomfort, adds Dr Ravi Chandra.
Fibroadenomas: They are solid, firm masses that are usually benign and most common in young women. They usually cause concern in many young women, as breast cancer also presents with painless breast lump. The size of lump may remain static or increase and might be associated with pain.
Every fibroadenoma need not be surgically removed, because they tend to remain unchanged or decrease in size approaching menopause and usually become nonpalpable after the menopause. The doctor might recommend regular monitoring by monthly breast self-examination and follow-up visits for clinical examinations. However, If the fibroadenoma is large, causing disfigurement or discomfort, surgical removal might be considered. This can be performed electively as a day-care or outpatient procedure in the form of lumpectomy or percutaneous vacuum-assisted core excision under local/regional anaesthesia and, if large under general anaesthesia. The role of medical treatment in the form of hormonal therapy has also been proven in limited settings.
Fibrocystic breast changes: This is a rubbery firm feel of the breast. Sometimes the breast may feel dense and painful to touch. If mastalgia develops, it is an aberration in the normal development of the breast(ANDI) and is most times managed with supportive treatment.
Inflammatory conditions: Conditions like mastitis or granulomatous mastitis fall under this category. They are painful breast masses. They also include lactational mastitis and breast abscess which are mostly found in breast-feeding mothers. These may vary from mild requiring supportive treatment to severe needing urgent surgical removal of pus and infected material. Breast abscess can cause skin maceration or breast architecture distortion, pus discharge from the nipple, or may even form a sinus tract.
Mastitis may occur more frequently during breastfeeding as compared to non-lactating females, and rarely after menopause. Treatment involves supportive care in the form of, antibiotics to clear the infection, analgesics for pain, adequate breast support, and, continuation of breast feeds or expression of breast milk (if infant is not able to latch) from the affected side to prevent further congestion of the breast and early recovery if the patient is breastfeeding. Frequent breastfeeding or pumping, along with proper positioning and latching, can help drain the infected milk ducts. Mastitis if not diagnosed or treated earlier can become an abscess which is a localized collection of pus that, if large, requires drainage by needle aspiration, tube drainage, or even surgical drainage in selected patients.
Periductal mastitis: This is another subset of mastitis that causes nipple discharge. The condition is self-limited and usually subsides over time, responds to medical treatment and, particularly resolves after menopause. If the patient's symptoms are non-responsive to medical treatment, surgical excision of all the milk ducts known as "Radical Duct excision" or tying off all the ducts is the only effective treatment.
Dr Rituja Aphle informs that most women presenting with cyclic mastalgia have an intense variant of physiologic breast changes that are associated with pain in the breasts usually before the start of the menstrual cycle. However, in non-cyclical mastalgia, the breast pain is unrelated to menstruation. Simple measures such as the use of a well-fitted brassier, avoidance of caffeine, and regular exercise can improve mastalgia in milder symptoms. Topical non-steroidal anti-inflammatory (NSAIDS) preparations over the breasts along with oral NSAIDS are very effective. The use of flax seeds ameliorates pain. A breast pain chart for daily monitoring of the occurrence and intensity of the mastalgia before, during, and after treatment is useful in documenting the results of therapy. Appropriate hormonal pharmaceutical drugs prescribed by the doctor after ruling out underlying breast cancers are effective therapies for mastalgia.
Cysts: Fluid-filled sacs that can be simple or complex. They are very common in middle-aged women. Most of the cysts do not require any treatment. It can increase in size and often need needle aspiration to drain fluid-filled cysts. Small cysts are usually diagnosed incidentally, are asymptomatic and usually require no treatment, but larger, painful, or suspicious complex cysts require management in the form of supportive care with diagnostic as well therapeutic needle drainage. They may require evaluation if a solid component is present to rule out cancers for adequate treatment.
Fat necrosis: This occurs due to trauma or injury to the breast and results in the death of fat cells. They may be confused with cancer-like tumors but usually do not require any treatment. Fat necrosis doesn't raise your cancer risk and Treatment might be required to prevent breast abscess.
Papilloma: Growth within the ducts that can sometimes cause bloody nipple discharge. This growth is usually not felt by the patient. Intraductal papillomas may cause nipple discharge. The risk of cancer goes up if you have five or more papillomas at one time. Surgery can remove these growths and reduce cancer risk.
Hyperplasia: It is overgrowth of the breast ductal or lobular cells. Usual hyperplasia doesn't increase cancer risk and doesn't require treatment. If there is atypical hyperplasia, it is more prone to breast cancer.
ANDI and Symptoms of BBDs
The non-cancerous lesions of breast or what is known as benign lesions consists of many conditions which are understood to be deviation from normal process happening in our body and are together known as Aberrations of Normal Development and Involution (ANDI). The degree of aberration determines whether they are normal processes, aberrations or diseases. Dr Sunil Chumber explains that changes in breast is a continuous process happening with increasing age under different hormonal effects, each of these categories are further understood in three phases:
"Early reproductive or development phase" (15-25 years) - includes nipple retraction (inwardly turned nipples) - normal process, fibroadenoma (non-cancerous tumours in breast) - an aberration, Gigantomastia (overly large breasts) which is a disease state
"Mature reproductive or cyclical change phase" (25-40 years) - includes normal changes with menstrual cycle, mastalgia (breast pain) and nodularity (lumpiness) which are aberrations whereas if the pain becomes incapacitating it is becomes disease state
"Involution or shrinking" (35 -55 years) - includes normal processes of milk duct dilation, duct ectasia (dilated ducts filled with thick fluid) and cysts (fluid filled small sacs) as aberrations and periductal mastitis which is a disease where there is possible infection and body reaction in ducts around the nipple.
The concept of ANDI implies that most BBDs can be regarded as aberrations of normal processes and do not require active specific treatment. Management is based on accurate diagnosis, patient concern, and quality of life.
Dr Suneha chips in saying that young girls and adult women with benign changes in the breast can present with a lump in the breast, breast pain which may or may not be associated with menstrual cycles, nipple discharge, changes in breast size and shape, changes over nipple like nipple getting inverted, creased or scaling, and dimpled or puckered breasts. It is important to note that not all breast lumps or nipple discharges are indicative of cancer, however, it is recommended to visit a doctor for further check-up in case any of these features develop. Some causes like simple cysts can remain without any symptoms and get picked up during a breast screening programme.
How BBD is diagnosed?
BBD encompasses various diseases with chief complaints of the patients being pain, lumps, and nipple discharge. To establish the diagnosis, there are various modalities of investigation. History and examination is usually followed by an ultrasound of both the breasts and the axilla. In patients above 40 years of age, a mammogram is preferred over an ultrasound as an initial modality. MRI of the breasts is required when the ultrasound or mammogram is not satisfactory in establishing the diagnosis and the treating clinician determines the need and usefulness on individual cases basis. Other modalities to aid in diagnosis are the pain chart has been modified as per Indian setting by department of Surgery at AIIMS New Delhi. It helps the doctor to understand the severity of the pain and its variation over the menstrual cycle. It also helps them to assess the response to the treatment prescribed for the pain. We also send the nipple discharge or the pus for bacterial culture to rule out any infection, says Dr Kamal Kataria and Dr Gopal Puri.
BBDs and cancer
BBDs have a wide range of entities. When a patient goes to the doctor with breast-related complaints, based on her presentation she might be advised to
get a breast imaging and biopsy to confirm the diagnosis but also to rule
out breast cancers based on clinical suspicion.
Once the biopsy report is available, we can mostly understand the nature of the disease, whether malignant (cancerous) or benign and the possible future risk of breast cancer.
As per the literature, the following are some BBDs and their risk for breast cancer.
BBDs Relative risk of breast cancer.
Non-proliferative lesions No increased risk
of the breast
Sclerosing adenosis No increased risk
Intraductal papilloma No increased risk
Florid hyperplasia 1.5-2 fold
Atypical lobular hyperplasia 4 fold
Atypical ducal hyperplasia 4 fold
Ductal involvement by cells 7 fold
of atypical ductal hyperplasia
The Non-proliferative disorders of the breast which cause no increased risk are as follows:
Simple cysts and apocrine metaplasia
Duct ectasia
Mild ductal epithelial hyperplasia
Calcifications
Fibroadenoma and related lesions
Ignore BBDs at your peril
Giant Fibroadenoma: Giant Fibroadenoma are fibroadenomas greater than 5cm in size. They are less common and faster growing compared to simple Fibroadenomas. Complex fibroadenomas can become cancerous. It can have cell overgrowth (hyperplasia) and calcium deposits.
Gigantomastia: They may occur in males or females, where their breast tissue enlarges. It is almost always benign (non-cancerous)
Subareolar abscess: This abscess is located underneath the nipple-areola complex and may be associated with breastfeeding or TB. Abscess usually doesn't cause cancer but it may be associated with breast cancer. Rarely breast cancer presents as an abscess.
Mammary duct fistula: It is an abnormal connection between a breast duct and skin. There are rare chances of cancer.
Incapacitating mastalgia: Mastalgia is breast pain. Breast pain is rarely related to breast cancer. However, an underlying asymptomatic, unrelated breast cancer is always ruled out clinically in women >35 years of age.
Periductal mastitis: It is inflammation in and around the nipple. It doesn't increase the risk of developing breast cancer, says Dr Catherine Halam.
At the same time, Dr Richa Garg and Dr Ankita Singh warn that epithelial hyperplasia with atypia: There is a high risk of developing breast cancer in the future.
What surgeries can we do?
Most breast-related conditions are benign, but it is imperative to rule out malignancy.. While they are not life-threatening, these conditions can cause discomfort, pain, infection, or aesthetic concerns. While some benign breast conditions may only require monitoring and non-surgical interventions, others might necessitate surgical treatment.
There are various surgical options depending on the type of condition.
Lumpectomy: A lumpectomy involves the removal of a lump. This procedure is commonly used for fibroadenomas, which are benign tumors that can cause discomfort or concerns related to cosmesis. Lumpectomy is directed towards the preservation of breast tissue as much as possible while ensuring complete removal of the lump. Sometimes the lump may be so large, as in the case of phyllodes disease, that it may require a mastectomy (removal of the entire breast). These tumors are notorious for recurrence if not removed completely with a clear margin.
Needle Aspiration/ Incision and Drainage: Cysts, which are fluid-filled sacs, are a common benign breast condition. In cases of symptomatic or large cysts, needle aspiration may be performed. A thin needle is inserted into the cyst to drain its contents, relieving pain and reducing the size of the cyst. In the case of breast abscess (quite common in lactating women), ultrasound-guided drainage should be attempted. Incision & drainage is performed in selected cases.
Removal of milk ducts: Ductal ectasia is a condition where the milk ducts beneath the nipple become dilated and inflamed, causing nipple discharge and pain. Microdochectomy involves the removal of the affected duct whereas radical duct excision involves the removal of all milk ducts. Both the procedures can be done with a periareolar incision hence the scar gets hidden. It is done when there is persistent nipple discharge from multiple ducts, or for intraductal papillomas. Sometimes nipple discharge can be due to underlying malignancy.
Dr Prasanna R. Arumugaswamy and Dr Yashwant Rathore tell that these procedures not only address discomfort and aesthetic concerns but also aid in diagnosis, thus enabling appropriate treatment decisions. It is important to consult a surgeon to determine the most suitable treatment approach. Early diagnosis, proper evaluation, and informed decision-making contribute to effective management and improved well-being for individuals with benign breast diseases.
For cosmetic indications, the breast may be augmented using silicone implants and in large ptotic breasts, symmetrical reduction can be done.
When do we operate?
According to Dr Devender Singh, surgery for BBDs is recommended if there's :
Suspicion of cancer: In females with progressing age, benign breast lumps which may appear suspicious for cancer, can be removed, and sent for examination.
Breast infections: Patients developing pus in the breast that are not amenable to drainage by a wide-bore needle may be considered for surgery.
Persistent nipple discharge: Persistent discharge from the nipple, where cancer has been ruled out, can still be very discomforting for the patient. In this condition, the duct causing the nipple discharge can be removed surgically.
Large or growing breast lumps: If the breast lump continues to grow and causes discomfort or pain, it can be removed surgically.
Cosmetic reasons: If a breast lump is causing deformity or asymmetry of the breast, it may be removed surgically.
Non-operative management Option
Dr Jyoti Sharma says that non-operative management, also known as conservative or non-surgical management, involves treating a condition without resorting to surgery. For BBDs, this approach focuses on relieving symptoms, reducing discomfort, and improving overall breast health through various methods. Let's explore some of the key non-operative approaches:
Lifestyle Modifications: Making changes in your daily routine can have a positive impact on benign breast diseases. Maintaining a healthy weight, wearing well supported brassier, and managing stress can help manage symptoms of breast pain.
Pain Management: If pain is a prominent symptom, over-the-counter pain relievers like ibuprofen or acetaminophen can provide relief. Your doctor might recommend specific medications based on your condition and medical history.
Hormonal Therapy: Some benign breast conditions are influenced by hormonal fluctuations. Hormonal therapies, such as birth control pills or hormonal replacement therapy, can help regulate hormone levels and manage symptoms.
Hot and Cold Compresses: Applying hot or cold compresses to the affected area can help reduce pain and inflammation. These simple remedies can be easily done at home.
Counselling and Education: Sometimes, anxiety and worry about breast conditions can worsen symptoms. counselling about the nature of benign breast diseases can help alleviate stress and improve overall well-being.
Regular Monitoring: For certain conditions, like fibroadenomas, your doctor might recommend regular monitoring with imaging tests (like mammograms or ultrasounds) to track any changes over time.
Dietary Adjustments: Although research is ongoing, some studies suggest that dietary changes, such as reducing caffeine (in the form of tea, coffee & aerated drinks) and consuming a balanced diet rich in fruits and vegetables, could be beneficial. Intake of flax seeds (rich in alpha linolenic acid) helps in breast pain.
When to Seek Medical Attention?
Non-operative approaches can be effective for many BBDs, it's essential to seek medical attention if you experience any concerning symptoms, suggest Dr Ajay Mohan and Dr Sakshi Dholpuria. These include sudden changes in breast appearance, unusual lumps, persistent pain, or any discharge from the nipples. Your doctor will be able to diagnose the condition accurately and recommend the most appropriate treatment plan for your specific case, they add.
