Evaluation of breast lumps is one our greatest challenges at our center. Breasts are by nature lumpy, and this lumpiness is accentuated with hormonal stimulation, as occurs with the menstrual cycle and with hormone replacement therapy.
Most lumps are not cancer, but if a lump is a cancer, it is imperative to make the diagnosis as soon as possible. Thus, when it comes to lumps, we have a dual challenge: First, to diagnosis cancer early; and second, to reassure the patient when the lump is benign.
Over the past 30 years we have treated tens of thousands of women with breast lumps. In fact, of the thousands of breast cancers which I have personally diagnosed at our center, many presented as breast lumps. The vast majority of malignant breasts lumps tend to be first detected by the women themselves. Only 5% of breast lumps that eventually prove to be cancers were found first by the health care professional.
Unfortunately, the majority of breast cancers that are first found by the women are found incidentally, or “by accident”. A typical story would be that the woman receives minor trauma to the chest, and in checking herself she finds a breast lump. Lumps that are found “by accident” tend to be large, and usually require aggressive treatment.
However, a new trend seems to be emerging. Recently we have been seeing a growing number of women finding small lumps on breast self-examination (BSE). These small lumps found on self-examination typically have an excellent prognosis. The women who tended to find these potentially curable breast cancers on self-examination had become proficient in BSE, and had made the long-term commitment to do a careful monthly self-examination.
I have seen numerous examples in which a woman doing BSE found a subtle change six months after I performed a normal clinical breast examination. When such a woman brought the change in her breast to my attention, I was often unable to feel a definite lump. However, an ultrasound of the area of concern would reveal a small, yet potentially curable breast cancer.
Some of these women caught the cancer so early that chemotherapy was not needed, and their chances for cure (even without chemotherapy) were excellent. If these women had not discovered the subtle changes in their breasts on self-exam, the tumor could have evolved from curable to non-curable by the time that the next scheduled visit was due.
Thus, despite the current controversy about the benefits of BSE, we are convinced that when taught properly, it can be life saving. When done right, BSE provides a woman with one more layer of protection in avoiding a delay in diagnosis of breast cancer. We find that when women make the commitment to learn BSE, they typically experience that they are in control of their breast health. This leads to improved self-confidence and a sense of empowerment.
Types of Breast Lumps
Fibrocystic Condition :
Women commonly tell us that that they have fibrocystic breasts, when in fact they just have normal breasts. The glandular tissue in the breast (the milk producing portions) are sensitive to hormonal stimulation. Menstruating women typically note that both breasts feel engorged, swollen, and tender just before the onset of the menstrual period, when the effects of peak hormone levels are intensified. Post-menopausal women on hormone replacement often experience similar breast pain.
Oftentimes, as part of this cyclic-hormonal process, a lump will form that can be readily distinguished from the surrounding breast tissue. These lumps are typically of two types: cystic (fluid-filled), or solid. Both types are completely benign and are not associated with a future increased risk of breast cancer.
Breast Cysts :
Cysts are fluid-filled capsules in the breast that can vary in size from microscopic to more than an inch in diameter. Most cysts do not cause symptoms, and can be ignored. For those cysts that do cause a problem, the treatment of choice is aspiration. A small needle is inserted into the cyst and the fluid is suctioned out; in most cases, this fluid is discarded without further testing (unless there is evidence of gross blood in it). The procedure is done in the office under local anesthesia, and usually with ultrasound guidance to help locate the cyst(s) in the breast.
There are three indications for aspirating a cyst. The first indication for aspiration is the presence of a distinct lump.
We often also aspirate cysts when they cause focal breast pain. Finally, we also aspirate a cyst when it produces an obscuring density on the mammogram that causes difficulty in accurate interpretation.
Our policy after successfully aspirating breast cysts is to see the patient back in 3 months. If the cyst continues to reform in the same spot, we will consider open surgical biopsy or a core biopsy. If the cyst does not disappear after the initial aspiration, we would also consider biopsy. If the cyst fluid is bloody on aspiration, we send it for cytology analysis to check for any occult cancer cells.
Fibrocystic breast lumps :
As mentioned before, we typically divide breast lumps into two categories: cystic and solid. The cystic lumps are easily identified on ultrasound, and are easily treated with aspiration. The most common cause of both solid and cystic breast lumps is hormonal stimulation. Solid lumps caused by hormonal stimulation are called fibrocystic lumps. The name is confusing since these lumps tend to be solid, but on microscopic examination they do show microcystic changes related to hormonal stimulation.
In general, when a lump in the breast is found, a tissue diagnosis must be made. Fortunately, fibrocystic breasts lumps are completely benign, and are not associated with any risk for the future development of breast cancer.
Fibroadenomas are the most common benign breast lumps found in women in their teens and 20’s. They are typically firm, smooth, round and mobile. They usually are not tender. On ultrasound, they are typically oval, with smooth borders. Although the diagnosis is usually quite obvious on initial evaluation, we believe that tissue confirmation with either a core biopsy or surgical removal is indicated in most cases. If a diagnosis of a fibroadenoma can be established on a core biopsy, clinical observation is appropriate. However, if the fibroadenoma shows signs of progressive or rapid growth over time, it should be surgically removed.
Multiple fibroadenomas :
In approximately 10% of women who get fibroadenomas, they will occur in multiples within the breast. In some rare cases, a dozen or more can be detected on ultrasound in each breast. In general, our policy is to core biopsy the largest lesion(s) in each breast. If a diagnosis of fibroadenoma can be established, we simply follow the patient at regular intervals. In older patients, we consider obtaining a base-line MRI.
Cystosarcoma phylloides (CSP) :
CSP is an unusual condition that usually presents and a hard, round mass which resembles a typical fibroadenoma. Rapid growth is one clinical clue that a lump that feels like a fibroadenoma is actually a CSP. Rapid growth is an indication for excisional biopsy . Usually, the diagnosis is first made on a core biopsy. This allows us to plan a surgery that will remove the lump, plus a surrounding margin of normal tissue.
When we remove what we think is a simple fibroadenoma and it actually proves to be a CSP, we usually go back and remove the surrounding tissue. If the clearance of surrounding tissue is done properly, later recurrence is rare.
Other Benign Lumps :
There is a long list of condition in the breast that will cause a lump. In general, there are some simple rules that can be followed to make certain a lump is benign. The concern with any lump is that it may represent a breast cancer. Any new lump requires an examination by an experienced healthcare provider who is familiar with breast health and anatomy. We always perform an ultrasound examination during the initial workup, and typically add a diagnostic mammogram in most cases (depending on the patient’s age, status of the previous mammogram, and the level of our clinical suspicion).
The only way a lump can be definitively proved to be benign is by tissue sampling. In most cases, a simple core biopsy will establish a definitive diagnosis. In some cases, the tissue obtained on the core biopsy is insufficient to make a definitive diagnosis; thus, either a repeat core biopsy or (usually) open surgical removal of the lump is required.
If after complete assessment and adequate tissue sampling the lump is determined to be benign, only routine follow-up is indicated and the woman is at no increased risk for the future development of breast cancer. However, there are some benign lumps which signify an increased risk of developing future breast cancer, and more aggressive follow-up is indicated. These high-risk lesions will be discussed in the next section.
High risk lumps :
Whenever a woman has a breast biopsy, it is essential that she has a clear understanding of the nature of the lump. Basically, the results are divided into three categories: Benign (as described in the sections above); high-risk; and malignant.
Benign biopsies are considered to confer a normal risk for the future development of breast cancer. Routine follow-up is all that is required. We do suggest that women keep a personal heath care file that includes all biopsy results/reports. Of course, if a biopsy proves to be malignant, appropriate follow-up with a breast care specialist is mandatory.
In the event that a breast biopsy demonstrates high-risk changes (i.e. atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in-situ, radial scar), the risk for the development of a future breast cancer is increased beyond normal. Such women should be followed in a center staffed by breast care specialists when possible. Estrogen replacement or other hormone use should be avoided or minimized. These women should be given the option of hormonal blockade with agents such as tamoxifen or Evista. Regular physical examination and BSE are important. In women with dense breast tissue, adjunct ultrasound and MRI screening (in addition to annual mammography) is indicated.
A family history of breast cancer increases the risk of future cancer in patients with atypia (the presence of atypical cells in a breast biopsy). Women with a strong family history should strongly consider hormonal blockade therapy, and in select circumstances they should also consider the option of prophylactic mastectomy.
When a breast biopsy comes back as cancer, there is an urgent need for the doctor to meet face-to-face with the patient and provide a detailed explanation of the situation. It is important for the patient to realize that there is always hope. When breast cancer is caught early, there is a high probability for cure. However, even more advanced cancers can be highly responsive to modern therapy.