Breast Lumps in Women

Picture of the anatomy of the breast

• Breast lumps can be caused by infections, injuries, non-cancerous growths, and cancer.
• Breast cancer usually causes no pain in the breast. The symptoms of breast cancer include painless breast lumps, nipple discharge, and inflammation of the skin of the breast.
• The chances that a particular breast lump could be cancerous depend on many factors, including past medical history, physical examination, as well as genetic and other risk factors.
• The only way to be certain that a lump is not cancerous is to have a tissue sampling (biopsy). There are several ways to do the biopsy. The treatment of a breast lump depends on its cause.

There are many causes of breast lumps. Some of these causes are harmless, while others can be painful and/or dangerous. Causes of breast lumps include infections, injuries, non-cancerous growths, and cancer.

Breast cancer is the second leading cause of cancer-related deaths in women in the United States. Currently, death rates from breast cancer are declining. The decline in death rates may be due to a combination of earlier detection and better screening as well as improved treatments. While most breast lumps are harmless (benign), every breast lump should be evaluated by a doctor to exclude or establish a diagnosis of cancer.

Inflammation of the breast tissue is known as mastitis. Mastitis may occur in women who are breastfeeding a baby (lactating). When the skin of the nipple (areola) is injured or cracked, which may occur with nursing, bacteria can enter the damaged area and cause infections. In a breastfeeding woman, a hard area commonly thought of as a "clogged milk duct" can form.

Sometimes, certain treatments (see below) can prevent the painful, hard area from developing into an actual breast infection. Infections can either be a deep pocket of pus, in which the infection looks like it is growing down into the breast (an abscess), or a wider area of skin redness that spreads out (cellulitis). Body piercing in the nipple area increases the risk of breast infections, and these may be particularly difficult to treat.

If a breast is injured by trauma, tiny blood vessels can rupture to cause an area of localized bleeding (hematoma) that can be felt as a lump. Trauma to the breast can damage the fat cells in the breast tissue, a condition called fat necrosis. The injury can also form a lump in the breast.

These types of lumps that follow a significant trauma are not cancerous. Fat necrosis can also occur at the site of a previous breast biopsy.

• Fibroadenomas are benign (not cancerous) growths and are very common. These growths most commonly occur in women 30 to 35 years old, but can also occur in women under 30 years of age. Fibroadenomas are solid, firm tumors that are usually painless or only slightly tender. They sometimes grow quickly in teenagers or during pregnancy.
• Breast cysts are fluid-filled sacs within the breast tissue and are benign. They are very common, especially over the age of 35. These cysts often vary in size during the menstrual cycle and may be tender.
• Fibrocystic changes are characterized by breasts that are lumpy with many irregularities in the breast tissue itself. Fibrocystic breasts seem to occur when a woman's breasts are overly sensitive to fluctuating hormone levels. Women with fibrocystic changes may have pain and/or lumps.

Sometimes breast cancer causes no symptoms or signs; but when they do occur, they may include:

• Nipple discharge that occurs without the nipple being touched can be caused by benign (non-cancerous) growths. Examples of these growths are intraductal papillomas (non-cancerous growths that protrude into the milk ducts) and dilated areas of milk ducts (ductal ectasia). Nipple discharge also can be caused by cancer of the breast tissue. Because nipple discharge can be a sign of cancer, it needs to be evaluated by a doctor.
• Skin changes on the breast, including redness and warmth, can sometimes be a sign of breast cancer.
• Inflammation: A form of breast cancer that commonly causes symptoms and signs of inflammation is Paget's disease of the breast. However, most inflammation or rashes on the breast are not due to cancer. They may be caused by benign problems such as nipple eczema or fungal infection. Still, a doctor should evaluate any rashes. Areas that are especially scaly and red, particularly if they are persistent, or if there is also nipple discharge, are often sampled (biopsied) to rule out cancer.

Breast cancer frequently causes no pain in the breast. Although women often worry about breast pain, most women with breast pain do not have breast cancer.

Physical examination

A manual examination of the breast is an important screening method for detecting cancer, and it is the first step in the evaluation of a breast lump. Unfortunately, the manual examination of the breast is not precise. However, if a mass can be felt manually, it is important to estimate the location of the mass so that the mammogram and/or other diagnostic examinations can focus on that particular area. A doctor also inspects any suspicious skin changes that may be a sign of breast cancer. Since manual examination can miss breast cancer, mammography is also an important screening tool.

Mammogram

Women with a breast lump need to have a mammogram of both breasts. A mammogram is estimated to be able to detect about 90% of breast cancers. This means that about 10% of breast cancers are missed by mammography. Therefore, if a woman or her physician feels a lump and the mammogram is normal, further studies or biopsies are carried out to rule out cancer. Sometimes, a certain pattern of calcium deposits appears on the mammogram that makes the doctor suspicious of cancer. In these cases, it is often recommended that a biopsy be taken that is guided by mammogram images to be sure the correct area is sampled.

Ultrasound

Ultrasound is useful in the evaluation of breast lumps. It can distinguish between a cyst, which is filled with fluid, and a solid lump (which may or may not be cancerous). The first step in the evaluation of a breast lump is to determine whether it is a cyst or solid mass. This is best accomplished by performing an ultrasound examination. In a young woman, where a benign cyst is anticipated and, the ultrasound is confirmatory, she may not require any procedures or biopsies. If it is unclear on the ultrasound whether the lump is entirely cystic in nature, a further evaluation is usually recommended.

MRI

Magnetic resonance imaging (MRI) is becoming more widely used in the evaluation of breast lumps because it is particularly sensitive to small abnormalities in breast tissue. MRI is a special radiology technique designed to image internal structures of the body using magnetism, radio waves, and a computer to produce images of body structures. Cancers generally have a greater blood supply than non-cancerous growths. The images obtained from an MRI may help determine whether a particular area is cancerous as the MRI exhibits greater contrast in those areas with an increased blood supply. In most cases, MRI is performed if the results of mammography and ultrasound evaluations are not conclusive.

MRI also has limitations. For example, MRI cannot detect the presence of calcium deposits, which can be identified by mammography and may be a sign of cancer.

Treatment for breast lumps varies depending on the underlying cause:

1. Breast pain (mastodynia) is a common problem. As long as the doctor or patient can feel no mass, and no breast lump is seen on a mammogram or ultrasound, breast pain is often concluded to be a normal condition. It is often thought that this pain is caused by natural hormonal fluctuations. If the discomfort is particularly acute and interferes excessively with a woman's life, oral contraceptives or other medications can be helpful, especially if the pain is worse around the time of the menstrual cycles.
2. Fibrocystic changes do not require medication or surgery. Often, a baseline mammogram is done. Then, no further treatment is needed unless a new lump arises, in which case an evaluation with a mammogram and possibly ultrasound is necessary.
3. Fibroadenomas are usually removed because they may otherwise be difficult to distinguish from cancer.
4. Breast cancer requires urgent treatment. Treatment depends on the type of cancer detected, its size, and its location.
5. Breast abscesses often need to be drained by a doctor because antibiotics alone cannot adequately treat an abscess.
6. Breast infection (mastitis) in a woman who is breastfeeding is treated with warm compresses and antibiotics. Heat treatment is convenient and effective and can be done by wetting some washcloths and putting them in the microwave briefly to warm them before placing them on the breast and massaging. Heat treatment helps open up the milk ducts. Nursing your baby or using a breast pump can also help relieve the swelling and pain. Contrary to common myth, nursing the baby or using a breast pump is a critical part of the treatment because it helps decrease the chance of the infection progressing.

If the area actually looks red or fails to get better with heat, massage, and nursing, a doctor should be consulted for consideration of antibiotics. If untreated, mastitis can quickly progress and develop into a severe infection. Whether a woman is pregnant or not, she needs to see a doctor if the area does not return completely to normal with treatment in order to rule out more unusual types of infections. Cellulitis needs to be treated with antibiotics and frequent follow-ups with the doctor.

The chances that a particular breast lump could be cancerous depend on many factors, including a woman's past medical history, her physical examination, and results of radiological tests (e.g. mammograms and ultrasounds). Some of the most important risk factors are outlined below.

Age

Age is the biggest risk factor for breast cancer. In other words, most cases of breast cancer occur due to the fact that the risk of breast cancer increases with age.

History

Most women with breast cancer do not have a history of breast cancer. A woman who has had prior breast cancer or who has a family history of breast cancer is certainly at risk herself, especially if multiple family members are involved, the cases occurred at a young age, or if cancer involved both breasts of a single family member.

Women who have received radiation therapy to the chest area as treatment for another cancer have a significantly increased risk for breast cancer.

Genetic factors

About 5% to 10% of breast cancer cases have been shown to be related to inherited gene changes (mutations). The most common mutations are those of the BRCA1 and BRCA2 genes, although other genetic mutations may also lead to breast cancers.

Abnormal findings on previous breast biopsies

The finding of certain conditions on previous breast biopsies can also increase the risk for developing breast cancer. Pre-cancerous growths and growths noted on a breast biopsy that represent an increased risk for the development of breast cancer include the following:

• Ductal carcinoma-in-situ (DCIS) is an uncontrolled growth of cells that has not spread beyond the milk duct where it is located. DCIS consists of cancer cells that have not invaded other tissues. Therefore, DCIS often is considered to be an early stage of breast cancer and is the most common type of noninvasive breast cancer. DCIS is not life threatening, but must be treated. Women with DCIS have an increased risk for developing a recurrence of the cancer or for development of a new cancer in either breast.
• Lobular carcinoma-in-situ (LCIS) is considered a condition in which abnormal cells are confined to the lobules in the breast (the glands that produce milk). Unlike DCIS, LCIS is not considered to have a high probability of becoming a cancer, but it is a sign of risk for that breast or the opposite breast for developing a cancer. Therefore, women with LCIS have a greater chance of developing breast cancer in either breast.
• Proliferative disease of the breast is a benign condition, but it can be a signal that breast cancer may develop in the future. Ductal hyperplasia (the overgrowth of normal cells within the breast ducts) and atypical hyperplasia (overgrowth of abnormal cells in the ducts or lobules that is not serious or extensive enough to qualify as DCIS or LCIS) are examples of conditions that increase the overall risk for developing breast cancer. Not surprisingly, women with atypical hyperplasia have a higher risk than do those with simple ductal hyperplasia (without atypia).

Women with DCIS, LCIS, atypical hyperplasia, or proliferative disease are at even higher risk of developing breast cancer if they have a history of breast cancer in the family.

The only way to be certain that a lump is not cancerous is to have a tissue sampling (biopsy). There are several ways to perform the biopsy.

Types of biopsy studies include:

• Fine needle aspiration: Fine needle aspiration (FNA) is similar to a blood test in that a needle is inserted into the mass and fluid is withdrawn. The fluid and cells are examined by a pathologist for signs suggesting malignancy.
• Core needle biopsy: For some women, may be indicated. In this procedure, a hollow needle is inserted into the suspicious area, and a core of tissue is removed through the needle.

To determine the correct location to sample by either method, the lump may be felt by hand (palpitated). The FNA or core biopsy may be done during an ultrasound examination or mammogram. FNA of a benign cyst may remove the fluid contents of the cyst and cause the mass to disappear or markedly decrease in size.

• Excisional biopsy: If no fluid can be aspirated, and the mass is solid, then a direct tissue sampling must be performed. Tissue sampling involves using either a core needle biopsy or an excisional biopsy (removal of all or a portion of the abnormal area in a surgical procedure). Excisional biopsy is the best method of making an accurate diagnosis. Typically it is done in the operating room using either local or general anesthesia.