Benign Breast Lumps
The majority (80%) of breast lumps detected are benign, i.e. are not cancerous. Benign breast lumps represent alterations in normal breast development; they are essentially harmless and often disappear with time. Sometimes, however, they can be difficult to distinguish from a malignant (cancerous) lump and an incorrect diagnosis can have serious consequences.
Fibroadenoma (Breast ‘Mouse’)
A fibroadenoma usually appears as a well-defined, firm lump in the breast. They are often very mobile, hence the name breast ‘mouse’. These benign lumps represent an alteration in the normal development of the breast and are dependent on the sex hormone oestrogen. Fibroadenomas can occur as a single lump, as multiple lumps, and can even occur in both breasts. They can grow rapidly, especially in adolescent girls, and if they reach a size greater than 5 cm in diameter they are known as giant fibroadenomas.
Fibroadenomas can occur at any age but are most commonly found in younger women, usually between 15 and 30 years of age. They are also seen more often in African women than Caucasians.
If you are aged 15–30 years and discover a well-defined, smooth, firm and mobile lump in your breast, the most likely diagnosis will be fibroadenoma. However, you must see your family doctor, who should refer you to a breast specialist. The specialist will examine the breasts, arrange a mammogram and/or an ultrasound scan of the breast and perform a needle biopsy to confirm the diagnosis.
Once the diagnosis has been confirmed, the specialist will offer you the option of having the lump removed under general or local anaesthesia or being followed-up in the clinic once more in 6 months’ time. If there is any doubt regarding the diagnosis, then a larger biopsy (core biopsy) or removal of the lump will be recommended.
What Happens if I Have a Fibroadenoma?
If the three tests (physical examination, ultrasound scan and/or mammogram, and needle biopsy) confirm the diagnosis of fibroadenoma, then you may find yourself in a dilemma regarding what to do about it. Studies have shown that one in three fibroadenomas shrinks or disappears completely within two years of diagnosis, about one in two stays the same size, and only around 15 in every 100 actually get bigger.
For women under the age of 30 years, the best option is to leave the lump alone and have a follow-up assessment (via ultrasound scan) in 6 months’ time. Provided the diagnosis is confidently made with needle biopsy and ultrasound scan and the lump has not grown larger after this time, the patient can be reassured and discharged from the clinic. Women with a strong family history of breast cancer may be advised to have any breast lump removed. For women aged over 30 years, the lump can be left alone if the diagnosis is confirmed with ultrasound-guided core biopsy. Alternatively the lump can be removed surgically. This is a relatively minor operation that is usually performed as a day case through a cut around the nipple. It can even be done under a local anaesthetic. There is usually minimal breast distortion and scarring and does not increase your chance of developing breast cancer.
Surgical removal will avoid missing the occasional breast cancer that may occur, although the chance of having breast cancer here is very small. Innocent lumps like fibroadenomas can be also removed through key-hole surgery using a vacuum-assisted device under local anaesthesia in the clinic. This facility requires expertise and is not widely available. If the patient is not keen on having open or key-hole breast surgery, an ultrasound scan can be performed in 6 months’ time in order to monitor the lump’s size and provide further reassurance.
Patients with lumps larger than 3 cm are advised to have the lump surgically removed, especially if they are over 40 years of age. This is because, in some cases, it can be extremely difficult to distinguish between fibroadenoma and a type of breast tumour called a phyllodes tumour. However, there is no evidence to suggest that breast cancer develops from fibroadenomas.
In the author’s opinion, if the diagnosis of a simple fibroadenoma is confirmed with ultrasound-guided core biopsy then it can be safely left alone if it is smaller than 3 cm in size. The key-hole approach using a tiny scar ( 2mm ) should be used if the patient requests removal of a fibroadenoma smaller than 3 cm.
The Principle of key-hole removal of benign breast lumps
The fibroadenoma seems to have disappeared after removal by the key-hole approach (ultrasound images)
This is a rare cause of breast lumps. The tumour resembles a fibroadenoma (breast mouse) but tends to occur in older women (of 35–50 years). Phyllodes tumours can be benign, borderline malignant or frankly malignant (cancerous). Benign phyllodes tumours are more frequent than either the borderline or malignant types.
Phyllodes tumour is treated by surgical removal of the lump together with a rim of the surrounding normal breast tissue. This is called a wide local excision. The lymph glands in the armpit are not usually removed for this tumour. An interesting feature of phyllodes tumour however is the fact that it may recur even if it is benign and has been removed surgically. Overall, the chances of this rare tumour spreading to other parts of the body are very small indeed, and patients with this condition can be reassured and followed up in the breast clinic with yearly visits. Neither radiotherapy nor chemotherapy plays a significant role in the management phyllodes tumours.
A breast cyst is a just 'bag' containing fluid. Breast cysts are most common in women aged 40-50 years and seem to be related to the sex hormone oestrogen. They are found in both breasts in one third of cases. Approximately 7% of all women develop a breast cyst at some time during their life.
Any woman who discovers a lump in her breast should visit her family doctor immediately. He/she will arrange a referral to a local breast specialist. The specialist will perform the usual tests to make a diagnosis - physical examination of the breast and an ultrasound scan and/or a mammogram. Investigations will often reveal the presence of multiple cysts in both breasts. If a solid (non-cystic) lump is detected, it should be appropriately investigated.
What Happens if I Have a Breast Cyst?
Small cysts do not usually require treatment. Cysts that are large or painful can easily be treated using a needle and syringe to remove the cyst fluid. Any lump that remains after this should be investigated with biopsy and mammography. The fluid obtained from the cyst is usually discarded, unless it is blood-stained or there is a residual lump. Blood-stained fluid can sometimes be associated with breast cancer, especially if there is a residual lump. In such cases it will be sent for further tests.
Nodularity refers to the presence of multiple, small lumps in the breast. It can occur in one area of the breast (localised) or throughout the breast (generalised). Nodularity is one of the most frequent reasons for referring a woman to the breast clinic. In fact, pre-menstrual nodularity is normal.
Generalised Nodularity (Lumpiness)
Women with generalised nodularity are examined by the breast specialist who usually arranges a mammogram if the woman is over 35 years old. If no discrete lump is detected and the mammogram does not reveal any suspicious abnormalities, the patient can be reassured and discharged. The condition is entirely harmless and has no relationship to breast cancer.
It can be very difficult to distinguish localised nodularity from a discrete breast lump. So in such cases, an ultrasound examination is often required to exclude a discrete lump. If no discrete lump is found by ultrasound scan or if the mammogram (for women over 35 years) does not reveal any significant abnormalities, the patient can be reassured and discharged. Any discrete lumps detected should be investigated and treated appropriately.
Localised nodularity may be related to hormones and it usually becomes less prominent with age or upon stopping HRT.