About Breast Lumps
And Other Changes
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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.
(See Aspirating a Cyst, page 28.)
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.
~ A word of caution: If you
find a lump or
other change in your breast, don't use this site
to try to diagnose it yourself. There is no
substitute for
a doctor's evaluation.~
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.
~ In general, doctors feel it
is wise to biopsy
any distinct and persistent lump. ~
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.
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