Fibroadenoma

Fibroadenoma is the most common benign breast neoplasm and accounts for about 12% of all palpable breast lumps. They are particularly frequent in women aged 15-30 years. Fibroadenomas commonly present as a painless breast lump and some 20% are multiple. Clinical breast examination reveals a firm, mobile, smooth or lobulated non-tender mass. The impression of a benign tumor is confirmed by imaging and fine-needle cytology. The natural history of a fibroadenoma is that approximately 5% grow progressively, the majority remain the same size and about 20% regress. In women under 40 years of age, small (less than 2 cm) fibroadenomas do not need to be removed. If the lump starts to grow, however, removal is indicated. Many surgeons recommend excision of any lump in women over 40 years of age.

Breast cyst(s)

Benign breast cysts are common and most frequent in the 40-50 year age group. In one study of 725 patients who died from causes other than breast cancer, microcysts (< 1 mm) were found in 37% of women and larger cysts were detected in 21%. Breast cysts are frequently multiple, often asymptomatic and are often discovered by chance by the patient. A solitary cyst is smooth and spherical. In consistency it can vary from soft to firm to hard. Usually it is not possible to demonstrate fluctuation, fluid thrill or transillumination. The clinical diagnostic feature is its smooth round shape. When subjected to triple evaluation, they exhibit specific X-ray features and fine-needle aspiration usually obtains green to bluish-black fluid. Provided that no residual lump remains after aspiration and the fluid is not blood-stained, cytology is not necessary. If there is a residual lump, it needs to be subjected to biopsy, unless cytology suggests otherwise. Recurrence of cysts is infrequent, but if the patient is known to have recurrent cysts and presents with another lump, it is generally safe to perform aspiration without a new triple evaluation.

Breast pain

Breast pain is the third commonest presenting symptom of breast disease. Breast pain is either cyclical, non-cyclical or does not originate from the breast. A careful history and clinical examination usually can help distinguish between these categories. Sometimes it is helpful to ask the patient to keep a pain diary so that the nature and cyclicity of the pain can be established. Cyclical pain can become continuous as it becomes more severe. If the pain is clearly cyclical and the breast examination does not reveal a discrete lump, no further investigation is needed. If the pain is of recent onset, non-cyclical and located in one breast only, investigation with imaging is necessary. If the results of the examination and the imaging are negative, the patient has to be reassured. If the imaging gives cause for concern, a biopsy is indicated.

Non-cyclical breast pain has inflammation as the underlying pathology. It is difficult to treat, but stopping smoking and a trial of non-steroidal anti-inflammatory drug may help. If the pain is localized to a single tender spot within the breast, infiltration with local anesthetic and a corticosteroid may help. Gamolenic acid is taken by many women, but it is not usually effective.

Cyclical mastalgia

This is a condition which presents with pain lasting typically for about a week in the second half of the luteal phase. The pain is due to the effect of cyclical hormonal changes in the breast, which may increase some 10-15% in size premenstrually. Common strategies to help women with cyclical mastalgia are: properly fitting brassieres, danazol, tamoxifen and prolactin treatments, normally tried in that order. Treatment of 8-12 weeks is recommended before assessing the result and deciding to change. Diuretic therapy and supplementation with vitamins B, B6 and E have not been proven to be effective. Dietary manipulations (excluding coffee, tea and chocolate) can also be tried. Until recently, gamolenic acid was commonly prescribed for breast pain. However, because of lack of effectiveness it is no longer available on the UK National Health Service (NHS).

Nipple discharge

Nipple discharge occurs in over 10% of women with benign breast disease and in 2-3% of women with cancer. In 5% of women consulting their physician for a breast problem, spontaneous nipple discharge is the primary complaint. The discharge can be clear, milky, bloody or of green/dark color. Bilateral nipple discharge, clear or milky, in the absence of breast lump(s), excludes breast cancer and indicates systemic cause, such as a prolactinoma or medication. Unilateral clear or bloody discharge is commonly caused by duct papilloma or duct ectasia. Pressing with one finger around the periphery of the areola will reveal the culprit duct. Excision of a single duct is the recommended treatment, so intraduct carcinoma can be excluded. Some practitioners evaluate clear discharge with mammography and cytology, reserving duct excision for patients with bloody discharge. Multiduct discharge due to duct ectasia does not require treatment except for symptomatic relief. The patient should be advised to wear a properly fitting brassiere and be discouraged from aspirating the discharge or manipulating her breasts.

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