Benign Breast Conditions

A benign breast condition is any non-cancerous breast abnormality. According to the American Cancer Society, when breast tissue is examined under a microscope some type of abnormality is common in nine out of every ten women. Though not life-threatening, benign conditions may cause pain or discomfort for some patients. Some (not all) benign conditions can signal an increased risk for breast cancer. The most common benign breast conditions include fibrocystic breast condition, benign breast tumors, and breast inflammation. Depending on the type of benign breast condition and the patient's medical situation, treatment may or may not be necessary.

Main menu:

• Overview: Breast Tissue Changes
• How Are Benign Breast Conditions Detected?
• Nipple Discharge
• Lobular Carcinoma in Situ (LCIS)
• Fibrocystic Breast Condition
• Simple Cysts
• Galactoceles
• Fibroadenomas
• Phyllodes Tumors
• Intraductal Papillomas
• Granular Cell Tumors
• Duct Ectasia
• Fat Necrosis
• Breast Inflammation: Mastitis
• Conclusion
• Additional Resources and References

Overview: Breast Tissue Changes

The breast is composed of two main types of tissues: glandular tissues and stromal (supporting) tissues. The glandular tissues house the milk-producing lobules and the ducts (the milk passages). The stromal tissues include fatty and fibrous connective tissue. Any changes in the glandular or stromal areas may cause symptoms of benign breast conditions.

Some women experience changes to their breast tissue over their lifetime. These changes can include an increase in the number of breast cells (hyperplasia) or the emergence of atypical breast cells (atypical hyperplasia). In some instances, a portion of breast tissue that exhibits abnormal characteristics can eventually develop into a cancerous tumor. That is why physicians carefully monitor patients with abnormal breast cells, to ensure that if cancer develops at a later date, it is detected and treated early. Some patients with atypical hyperplasia may also be recommended to take the drug tamoxifen to help prevent breast cancer. While the appearance of atypical hyperplasia increases the risk of breast cancer, not all women with abnormal breast cells go on to develop breast cancer.

The following chart summarizes the typical progression of breast tissue from "normal" to "cancer:"

Courtesy of the American Medical Association.

While many cases of breast cancer arise from the above sequence some breast tumors may skip one or more intermediate steps (for example, cells may proceed from "normal" directly to "carcinoma in situ"). In general, anything farther along than atypical hyperplasia is usually classified as a cancer. Abnormalities beginning with ductal carcinoma in situ (DCIS), usually require treatment as cancers. The treatment of benign breast conditions varies depending on a number of factors including the exact diagnosis, potential for developing breast cancer, and a woman’s discomfort.

How Are Benign Breast Conditions Detected?

Benign breast lumps are often first detected by physicians during clinical breast examination, routine mammogram or by patients practicing breast self-examination (BSE). Focal pain (pain confined to one spot in the breast) or nipple discharge (other than milk) may also alert a woman to have her condition checked by a doctor. Benign breast lumps are usually confirmed by imaging tests (mammogram, ultrasound/sonogram), observing the lump over a period of time, or doing fine needle aspiration biopsy (FNAB), core needle biopsy (CNB) or surgical biopsy.

Nipple Discharge

Nipple discharge, fluid coming from the nipple(s), is the third most common breast complaint for which women seek medical attention, after lumps and breast pain. The majority of nipple discharges are associated with non-cancerous changes in the breast such as hormonal imbalances or papillomas (see section below on intraductal papilloma for more information). However, because a small percentage of nipple discharges can indicate breast/nipple cancer, any persistent discharge from the nipple(s) should be evaluated by a physician.

Up to 20% of women may experience spontaneous milky, opalescent, or clear fluid nipple discharge. During breast self-exam, fluid may normally be expressed from the breasts of 50% to 60% of Caucasian (White) and African-American women and 40% of Asian-American women. Usually, a discharge that is clear, milky, yellow, or green, and is noted from both nipples, is not associated with breast cancer. Bloody or watery nipple discharge, especially if limited to one side and/or a single breast duct, is considered abnormal; however, only around 10% of abnormal discharges are found to be cancerous.

Nipple discharge may be a concern if it is:

• Bloody or watery (serous) with a red, pink, or brown color
• Sticky and clear in color or brown to black in color (opalescent)
• Appears spontaneously without squeezing the nipple
• Persistent
• On one side only (unilateral)
• A fluid other than breast milk

Women should report persistent nipple discharge to their doctors for analysis. To examine nipple discharge, a small amount of the fluid is placed on glass slides under a microscope to determine if cancer cells are present.

Lobular Carcinoma in Situ (LCIS)

Though technically a Stage 0 cancer, lobular carcinoma in situ (LCIS, also called lobular neoplasia) is not usually classified as a cancer. Instead, LCIS is considered a pre-cancerous condition. It signals a significantly increased risk of cancer anywhere in the breast. LCIS begins in the lobules (the milk-producing glands of the breast) but does not penetrate the lobular walls. Many times, physicians encounter LCIS serendipitously (by chance) on breast biopsy while investigating an area of concern.

While the microscopic features of LCIS are abnormal and are similar to malignancy, LCIS does not behave as a cancer (and therefore is not treated as a cancer). However, a mastectomy (breast removal) may be occasionally performed if LCIS patients have a strong family history of breast cancer. More likely, LCIS patients are closely monitored with physician performed clinical breast examinations and mammograms.

Some LCIS patients are eligible to take the drug tamoxifen to help prevent breast cancer. In 1998, the Food and Drug Administration approved the drug tamoxifen to prevent breast cancer in high risk patients. Tamoxifen is an "anti-estrogen" and works by binding to estrogen receptors. Research has shown that tamoxifen can reduce breast cancer risk in some women.

Click here to learn more about tamoxifen.

Fibrocystic Breast Condition

Fibrocystic breast condition (sometimes referred to as fibrocystic disease, fibrocystic change, cystic disease, chronic cystic mastitis or mammary dysphasia) is not a disease, but rather, it describes a variety of changes in the glandular and stromal tissues of the breast. Symptoms of fibrocystic breasts in the breast include cysts (accumulated packets of fluid), fibrosis (formation of scar-like connective tissue), lumpiness, areas of thickening, tenderness, or breast pain. Though sometimes painful, fibrocystic breast condition is not cancer. However, fibrocystic breasts can sometimes make breast cancer more difficult to detect with mammography. Therefore, ultrasound may be necessary in some cases if a breast abnormality is detected in a woman with fibrocystic breasts. According to the American Cancer Society, fibrocystic breasts affect at least half of all women at some point in their lives. Fibrocystic changes are the most common cause of breast lumps in women between 30 and 50 years old.

Symptoms of fibrocystic changes in the breast include:

• cysts (packets of fluid)
• fibrosis (formation of scar-like connective tissue)
• lumpiness
• areas of thickening
• tenderness
• pain

Women who suffer from fibrocystic changes typically have cyclic breast pain since the cause of the condition is related to the way breast tissue responds to monthly changes in the body’s levels of the hormones estrogen and progesterone. During each menstrual cycle, breast tissue sometimes swells because hormonal stimulation causes the breast’s milk glands and ducts to enlarge, and in turn, the breasts retain water. During menstruation, breasts may feel swollen, painful, tender, or lumpy. Breast swelling usually ends when menstruation is over. Symptoms of fibrocystic change usually stop after menopause but may be prolonged if a woman undergoes hormone replacement therapy.

Fibrocystic breast condition is often first noticed by the woman and further investigated with clinical breast exam, mammogram, or in some instances, biopsy. Fibrocystic changes are typically discovered in both breasts in the upper outer quadrant and the underside of the breast where a ridge may sometimes be felt.

Often, physicians may recommend that the symptoms of fibrocystic breasts be treated with self-care. Depending on the individual situation, several measures may be recommended to relieve the symptoms of fibrocystic breasts. The following chart summarizes treatment options for fibrocystic breasts:

Occasionally, doctors may surgically remove non-cancerous breast lumps. For women with painful cysts, draining the fluid by fine needle aspiration biopsy may help relieve symptoms of fibrocystic breasts.

Click here to learn more about fibrocystic breasts.

Simple Cysts

Simple breast cysts are accumulations of fluid in the breast. Simple cysts are non-cancerous and typically present themselves in the form of smooth, rounded lumps. They are often moveable within the breast, although they can also appear deep within the breast tissue. While the cause of simple cysts is unknown, experts do know that such cysts respond to the body's hormone levels. For instance, simple cysts may appear a week or two before a woman's menstrual period and disappear afterwards. These cysts are most common in pre-menopausal women, especially when they are approaching menopause. However, simple cysts can occur in women after menopause as well, especially if they are taking hormone replacement therapy (HRT). Existing simple cysts may also persist or enlarge in women on HRT. Some research has suggested that caffeine can cause simple breast cysts, although this is controversial among members of the medical community. Nevertheless, some women find that reducing caffeine consumption decreases breast discomfort.

Most women only develop one or two simple cysts at a time, but in some cases, multiple simple cysts may appear throughout the breast. These cysts are usually confirmed with mammography and ultrasound (sonogram). In particular, ultrasound is excellent at quickly identifying whether a breast abnormality is in fact a simple cyst or a solid mass. After the abnormality is found to be a simple cyst with ultrasound, it is usually left alone unless:

• The diagnosis is uncertain. Most simple cysts are well-defined, have distinct borders, and ultrasound signals are able to easily pass through them. If radiologists detect an area with fluid that does not meet the criteria of a simple cyst, they may term the area "a complex cyst." Complex cysts can be cancerous because they are actually not cysts but tumors that have necrosed, or bled into themselves.
• The simple cyst is causing discomfort. In some instances, simple cysts can be painful. Draining the cysts with a thin needle (fine needle aspiration) collapses them and reduces discomfort. Some radiologists inject air into the area after drainage to help minimize the chances that the cyst will return.

When cysts are drained, the fluid is usually discarded unless it is bloody or looks suspicious. In these cases, it is sent to a pathology laboratory for analysis under a microscope. Normal cystic fluid can be a number of colors including yellow, brown, green, black, amber, or milky.

Galactoceles

Galactoceles are milk-filled cysts that can occur in women who are pregnant or lactating. As with other cysts, galactoceles are always non-cancerous. They often appear as smooth, moveable lumps, although they can also be hard or unmoveable. Galactoceles are treated the same way as cysts: usually by leaving them alone. If the diagnosis is uncertain or the galactocele is causing discomfort, it can be drained with a thin needle (fine needle aspiration).

Fibroadenomas

Fibroadenomas are common benign breast tumors often too small to feel by hand, though occasionally, they may grow to be several inches in diameter. Fibroadenomas are made up of both glandular and stromal (connective) breast tissue and usually occur in women between 20-30 years of age. According to the American Cancer Society, African-American women are affected with fibroadenomas more often than women of other racial or ethnic groups. The tumors tend to be round and have borders that are distinct from the surrounding breast tissue, so they often feel like a marble within the breast. Some women have only one fibroadenoma while others may have multiple tumors. Fibroadenoma are usually diagnosed by fine needle aspiration or core needle biopsy.

Fibroadenomas often stop growing or even shrink on their own without any treatment. In these cases, doctors may recommend not having the tumors removed. Fibroadenoma surgery may involve removing a margin of surrounding breast tissue. The risk of surgery is that scarring could occur that could distort the shape and texture of the breast and make future physical examination and mammography more difficult to interpret. On the other hand, if fibroadenomas do not stop growing, they usually need to be surgically removed. Sometimes one or more new fibroadenomas will grow after one is removed.

Phyllodes Tumors

Phyllodes tumors (also spelled as phylloides) are also benign breast tumors in the glandular and stroma (connective) breast tissues but are far less common than fibroadenomas. The difference between phyllodes tumors and fibroadenomas is that there is an overgrowth of the fibro-connective tissue in phyllodes tumors. Phyllodes tumors are usually benign but on very rare occasions, they may be malignant (cancerous) and could metastasize (spread).

Treatment of phyllodes tumors involves removing the mass and a one-inch margin of surrounding breast tissue. Cancerous phyllodes tumors are also surgically removed by either lumpectomy or mastectomy, but do not typically respond well to chemotherapy or radiation therapy.

Intraductal Papillomas

Intraductal papillomas are non-cancerous wart-like growths with a branching or stalk that has grown inside the breast. A papilloma often involves the large milk ducts near the nipple, causing bloody nipple discharge. Occasionally, multiple papillomas may be found further from the nipple.

Papillomas are usually diagnosed by imaging the breast duct with a galactogram (also called ductogram) or removing a portion of the affected duct (duct excision). Typically, surgeons remove the papilloma and a segment of the duct where the papilloma is found, usually through an incision at the edge of the areola (the pigmented region surrounding the nipple).

Of the benign conditions that cause suspicious nipple discharge, approximately half are due to papillomas, and the other half are a mixture of fibrocystic conditions or duct ectasia, the widening and hardening of the duct due to age or damage (See the section on duct ectasia for more information).

Granular Cell Tumors

Granular cell tumors are usually found in the mouth or skin but may rarely be detected in the breast. Most granular cell tumors of the breast are identified as movable, firm lumps, measuring between one-half and one inch in diameter. Doctors typically diagnose grandular cell tumors by a fine needle or needle core biopsy and then surgically remove the tumors along with a surrounding margin of breast tissue. Granular cell tumors do not indicate higher risk for developing breast cancer.

Duct Ectasia

Duct ectasia, widening and hardening of the duct, is characterized by a thick green or black nipple discharge, typically affecting women in their forties and fifties. The nipple and surrounding tissue may be red and tender. Duct ectasia is a benign condition but can sometimes be mistaken as cancer if a hard lump develops around the abnormal duct. Opalescent (clear) nipple discharge is often due to duct ectasia or cyst.

Often, duct ectasia does not need treatment, or improves with the application of heat or antibiotic drugs. Occasionally, the affected duct is surgically removed by an incision at the border of the areola (the pigmented region around the nipple).

Fat Necrosis

Fat necrosis, a benign condition where fatty breast tissue swells or becomes tender, can occur spontaneously or as the result of an injury to the breast. When the body attempts to repair damaged breast tissue, the affected area may sometimes be replaced with firm scar tissue. Fat necrosis may be mistaken as cancer on a mammogram; however symptoms of fat necrosis usually subside within a month. Biopsy can confirm fat necrosis.

According to the American Cancer Society, some areas of fat necrosis can have a different response to injury. Instead of forming scar tissue, the fat cells die and release their contents, forming a sac-like collection of greasy fluid called an oil cyst. Oil cysts can be diagnosed by fine needle aspiration, which also serves as a treatment. While fat necrosis itself is a non-cancerous condition, its appearance can sometimes draw attention to another suspicious area of the breast that had not previously been discovered.

Breast Inflammation: Mastitis

Mastitis, another non-cancerous condition, most commonly affects women while they are breast-feeding. Cracking of the skin around the nipple allows bacteria from the skin surface to enter the breast duct where it grows and attracts inflammatory cells. Inflammatory cells release substances to fight the infection, but also cause breast tissue swelling and increased blood flow. Breasts infected with mastitis often swell, become red in color, and feel warm to the touch. Most of the time, mastitis is treated with antibiotics. However, if a collection of pus (an abscess) from inflammatory cells and fluid results, the pus may have to be drained.

Click here for information about mastitis as a result of breast-feeding.

Click here for information about malignant (cancerous) breast inflammation, called inflammatory breast cancer.

Conclusion

This article describes a variety of benign breast conditions and typical treatments. Women should discuss all breast concerns with their physicians. Treatments will vary depending on specific cases, family history, and other factors.

The American Cancer Society recommends the following guidelines for the detection of breast cancer in women who are asymptomatic (show no symptoms of breast cancer):

• Women 20 years of age and older should perform breast self-examination (BSE) every month.
• Women 20-39 should have a physical examination of the breast (CBE or clinical breast exam) at least every three years, performed by health care professional such as a physician, physician assistant, nurse or nurse practitioner. CBE may often be received in the same appointment as a Pap smear.
• Women 20-39 should also perform monthly BSE.
• Women 40 and older should have a physical examination of the breast (CBE or clinical breast exam) every year, performed by a health care professional, such as a physician, physician assistant, nurse or nurse practitioner. CBE can often be performed in the same visit as a mammogram. Monthly BSE should also be performed.
• Women 40 years of age and older should have a screening mammogram every year in addition to annual CBE and monthly BSE.

Women at high risk of breast cancer such as those with a strong family history of breast cancer, should ask their physician whether annual mammography should begin before age 40. For example, some physicians recommend women begin screening mammography at an age ten years earlier than the age her mother was diagnosed with breast cancer.

Additional Resources and References

• The Breast Book: The Essential Guide to Breast Care and Breast Health for Women of All Ages (1996) by Miriam Stoppard, MD and Rache Simmons. This book covers a variety of topics and breast health concerns, including benign and malignant conditions.
• For more information on both benign and malignant nipple discharge, please visit http://www.imaginis.com/breasthealth/nipple.asp.
• http://www.cancer.org/. The American Cancer Society provides detailed information on benign breast conditions.
• O’Grady, Lois et al, A Practical Approach to Breast Disease, Boston: Little Brown and Company, 1995, 186-187. A good source of information on breast pain, nipple discharge, and benign breast conditions.
• The American Medical Association Encyclopedia of Medicine, Charles Clayman, Ed, New York, Random House, 1989, 666.
• For more information on high risk factors for breast cancer, please visit http://www.imaginis.com/breasthealth/bc_risks.asp.

Updated: July 17, 2009