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Benign Breast Disease in Women Angrit Stachs, Johannes Stubert, Toralf Reimer, Steffi Hartmann

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Benign Breast Disease in Women Angrit Stachs, Johannes Stubert, Toralf Reimer, Steffi Hartmann MEDICINE Continuing Medical Education Benign Breast Disease in Women Angrit Stachs, Johannes Stubert, Toralf Reimer, Steffi Hartmann Summary Background: Most clinical breast changes in women are benign; in only 3% to 6% of cases are they due to breast cancer. How- ever, there is a lack of up-to-date, evidence-based treatment recommendations for the various benign differential diagnoses. Methods: Selective literature search of PubMed from 1985 to May 2019, including current national (AWMF, Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften [Association of Scientific Medical Societies in Germany]) and inter- national guidelines. Results: Mastalgia and fibrocystic changes are common (around 50% of all women over the age of 30). Fibroadenomas occur in 25% of women; they are the most common benign tumors of the breast and do not require treatment. With most benign breast changes the risk of dedifferentiation is very low. However, it is important in the differential diagnosis to distinguish between such benign changes and breast cancer or changes that carry a risk of malignancy. Complex cysts, for example, carry a risk of malig- nancy of 23% to 31%, papillary lesions 16% , and radial scars 7%. Where there is doubt, histological confirmation should be sought by means of percutaneous biopsy. Conclusion: Benign breast changes can be definitively distinguished from malignant lesions through the selective use of avail- able diagnostic investigations and interdisciplinary collaboration. When lesions of uncertain malignant potential are found (B3 in the biopsy classification), complete excision is indicated. Prospective studies on the early diagnosis of breast cancer in lesions carrying a risk of malignancy are desirable. Cite this as: Stachs A, Stubert J, Reimer T, Hartmann S: Benign breast disease in women. Dtsch Arztebl Int 2019; 116: 565–74. DOI: 10.3238/arztebl.2019.0565 Department of ccording to data from the Netherlands and the USA, breast cancer peaks during the postmenopause (e2, e3). Obstetrics and Gynecology, Univer- around 3% of women’s consultations with their The management of benign breast changes includes clini- sity of Rostock: PD A general practitioners (GPs) are about breast symp- cal, radiological, and if necessary histological diagnostic Dr. med. Angrit toms (1, e1). At around 70 000 new cases a year, breast investigations to rule out malignancy; palliation of Stachs, Johannes Stubert, Ph.D., Prof. cancer is the most common form of cancer in women in symptoms; and counseling and monitoring of patients at Dr. med. Toralf Germany, occurring in approximately one in eight women increased risk of breast cancer. Typical presenting symp- Reimer, Dr. med. Steffi Hartmann at some time during their lives. For this reason, breast toms such as pain, a palpable mass, and nipple discharge changes are a cause of anxiety in patients and require a can be caused by a wide array of benign differential diag- carefully targeted diagnostic process (2). Although breast noses (Table 1) and require targeted diagnostic imaging in cancer is detected in only 3% to 6 % of women with clini- addition to a comprehensive history and clinical examina - cal symptoms, and in most cases the cause of the symp- tion (e4). The BI-RADS (“breast imaging reporting and toms is benign, no evidence-based recommendations for data system”) classification—the standardized descrip- the management of benign disease have been produced tion of radiological findings—offers the clinician recom- because the focus has been on the diagnosis and treatment mendations for action (Table 2) (4). Today’s minimally of breast cancer (1, 3) (e1). Benign breast changes are invasive techniques for achieving a confirmed histologi- more common in women of child-bearing age, peaking cal diagnosis mean that surgical excision, previously between the ages of 30 and 50, whereas the incidence of common, can now be avoided in most cases. Prevalence Diagnosis Benign breast changes are more common in women of In addition to a comprehensive history and clinical examina - child-bearing age, peaking between the ages of 30 and 50, tion, diagnostic imaging (ultrasonography, mammography as whereas the incidence of breast cancer peaks during the indicated) is important for ruling out breast cancer. postmenopause. Deutsches Ärzteblatt International | Dtsch Arztebl Int 2019; 116: 565–74 565 MEDICINE TABLE 1 Differential diagnoses of benign breast changes, classified by main symptom Symptom Benign causes Incidence of breast cancer Pain – Cysts 2% to 7% (7) (unilateral) – Fibrocystic breast disease – Hyperplasia of the breast – Mastitis – Postoperative changes Palpable mass – Cysts 8% (1, e1) – Fibrocystic breast disease – Fibroadenoma – Lipoma – Hamartoma – Pseudoangiomatous stromal hyperplasia (PASH) – Intramammary lymph nodes Nipple discharge – Hypothyreoidism 5% to 21% (29, e26) – Galactorrhea – Intraductal papilloma – Periductal mastitis – Ductal ectasia Method classified as cyclic and noncyclic. Differential diag- The literature review performed for this article was noses to rule out are chest pain of extramammary origin based on a selective literature search of PubMed from such as intercostal neuralgia and pain from cardiac or 1985 to May 2019 including current national (AWMF, vertebrogenic causes. Association of Scientific Medical Societies in Ger- Surveys have shown that more than half of all many) and international guidelines (EUSOMA, WHO, women report significant breast pain, which in 30% to American College of Obstetricians and Gynecologists, 40% of cases impairs their everyday and sexual life American College of Radiology). This article discusses (e5). In two-thirds of cases, the pain is cyclic and is selected benign breast changes according to their inci- worst a week premenstrually and perimenstrually. dence and significance in everyday clinical routine, Cyclic mastalgia manifests at around 30 years of age; grouping them by their main presenting symptoms. the onset of noncyclic mastalgia is notably later, at a mean age of 41. What causes mastalgia is unknown. Learning goals The fact that cyclic mastalgia improves in association After reading this article, readers should: with hormonal changes such as when the menopause ● Be familiar with the symptoms, diagnosis, and is reached, and during pregnancy and lactation, management of the most common benign breast suggest a hormonal cause (e5). In a woman with non- diseases of women (mastalgia, fibrocystic cyclic mastalgia, inflammatory, neoplastic, and changes, benign tumors, mammary duct ectasia, vascular breast disease needs to be ruled out (e6). In mastitis); cases with no underlying pathology, rates of sponta- ● Be able to distinguish benign breast changes from neous remission within a few months to up to 3 years malignant findings; are high (5). After breast cancer treatment, 30% of ● Know the breast cancer risk associated with cer- women have persistent noncyclic mastalgia, tain benign breast conditions. especially those who are premenopausal, have a high body mass index, or have a concomitant psychologi- Mastalgia cal condition (6, e7). Mastalgia (also called mastodynia) is the name given to Diagnostic investigations include obtaining a com- pain related to the mammary gland occurring either prehensive history and clinical exam. Palpation will spontaneously or in response to touch. Mastalgia is reveal the localization of the pain, any mass or Mastalgia Fibrocystic changes and risk of breast cancer In two-thirds of cases, mastaliga is cyclic. Differential diag- Of the common fibrocystic breast changes, only proliferating noses for noncyclic mastalgia include inflammatory, neoplastic, lesions with atypia are associated with a clearly increased risk and vascular breast disease. of breast cancer. These include flat epithelial atypia, atypical ductal hyperplasia, and atypical lobular hyperplasia. 566 Deutsches Ärzteblatt International | Dtsch Arztebl Int 2019; 116: 565–74 MEDICINE masses, and any swollen lymph glands. In women TABLE 2 from the age of 40 onward, or those with additional risk factors such as any abnormal clinical findings or BI-RADS assessment categories for the classification of radiological findings a family history of breast cancer, unilateral noncyclic in the breast and resulting recommendations for management, adapted from (4) mastalgia should prompt mammography (supple- BI-RADS category BI-RADS code Recommendation mented by ultrasonography) to rule out breast cancer, Assessment incomplete 0 Comparison with previous images or which is the underlying cause in 2% to 7% of cases further diagnostic investigations may be (7). Once malignancy has been excluded, most necessary women do not require treatment for alleviation of the Negative 1 Refer for breast cancer screening painful symptoms (e8). Benign 2 Refer for breast cancer screening The range of options for relieving symptoms in Probably benign 3 Shortened-interval follow-up cyclic mastalgia includes wearing a well-fitting bra (in 6 months) (in 85% of patients this reduces the pain within 3 months), intermittent analgesics, relaxation tech- Suspect 4 Histological study recommended niques (autogenic training, progressive muscle Highly suggestive of 5 Histological diagnostic confirmation and relaxation), and regular physical exercise such as malignancy initiation of therapy required swimming, walking, or gymnastics (8, e9). Among BI-RADS, „breast imaging reporting and data system“ herbal preparations, flaxseed (also called linseed; 25 g ground flaxseed
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