Common benign breast concerns for the primary care physician
Release date: January 1, 2019
Expiration date: December 31, 2019
Estimated time of completion: 1 hour
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ABSTRACT
Women often visit their primary care physician because of breast concerns such as masses, pain, and nipple discharge. Most breast problems are benign, but it is important to know how to manage these and other breast problems and when to refer patients for further testing.
KEY POINTS
- The two most common breast symptoms are lumps and pain.
- Most breast problems are not caused by cancer.
- Evaluation of any breast problem begins with a focused history followed by a breast examination and, when necessary, imaging.
- If the results of the breast examination and imaging suggest a benign cause, no further follow-up is necessary.
- If there is discordance between imaging and breast examination results, or if there is a high clinical suspicion of cancer, then consider serial follow-up examinations at short intervals, referral to a breast surgeon for excision, or both.
IF THE PATIENT HAS AN ABNORMAL SCREENING MAMMOGRAM
Screening mammography can disclose abnormalities such as calcifications, masses, asymmetry, or architectural distortion.27 Abnormalities are reported using standardized BI-RADS categories designated with the numbers 0 through 6 (Table 3).23
A report of BI-RADS category 0 (incomplete), 4 (suspicious), or 5 (highly suspicious) requires additional workup.
,Category 1 (negative) requires no further follow-up, and the patient should resume age-appropriate screening.
For patients with category 2 (benign) findings, routine screening is recommended, whereas patients with category 3 (probably benign) are advised to come back in 6 months for follow-up imaging.
Diagnostic mammography includes additional assessments for focal symptoms or areas of abnormality noted on screening imaging or clinical examination. These may include spot magnification views of areas of asymmetry, mass, architectural distortion, or calcifications. Ultrasonography of focal breast abnormalities can help determine if there is an underlying cyst or solid mass.
MANAGEMENT OF BENIGN FINDINGS ON BREAST BIOPSY
Benign breast disease is diagnosed when a patient with a palpable or radiographic abnormality undergoes breast biopsy with benign findings.28,29 It can be largely grouped into 3 categories: nonproliferative, proliferative without atypia, and proliferative with atypia (Table 4).28,29
If core-needle biopsy study results are benign, the next step is to establish radiologic-pathologic and clinical-pathologic concordance. If the findings on clinical examination or imaging are not consistent with those on pathologic study, excisional biopsy should be performed, as imaging-directed biopsy may not have adequately sampled the lesion.30
Nonproliferative lesions account for about 65% of findings on core-needle biopsy and include simple cysts, fibroadenomas, columnar cell changes, apocrine metaplasia, and mild ductal hyperplasia of the usual type. These lesions do not significantly increase the risk of breast cancer; the relative risk is 1.2 to 1.4.28,29 Additionally, the risk of “upstaging” after excisional biopsy—ie, to a higher-risk lesion or to malignancy—is minimal. Therefore, no additional action is necessary when these findings alone are noted on core-needle biopsy.
Proliferative lesions without atypia account for about 30% of biopsy results and include usual ductal hyperplasia, sclerosing adenosis, columnar hyperplasia, papilloma, and radial scar. Generally, there is a slightly increased risk of subsequent breast cancer, with a relative risk of 1.7 to 2.1.28 Usual ductal hyperplasia and columnar hyperplasia have little risk of upstaging with excision, and therefore, surgical consultation is not recommended.
Previously, surgical excision was recommended for any intraductal papilloma due to risk of upgrade in pathologic diagnosis at the time of excision. However, more recent data suggest that the upgrade rate is about 2.2% for a solitary papilloma that is less than 1 cm in diameter and without associated mass lesion (either clinically or radiographically), is concordant with radiographic findings, and has no associated atypical cells on biopsy.31 In this case, observation and short-interval clinical follow-up are reasonable. If there are multiple papillomas, the patient has symptoms such as persistent bloody nipple discharge, or any of the above criteria are not met, surgical excision is recommended.28
Similarly, radial scars and complex sclerosing lesions are increasingly likely to be associated with malignancy based on size. Upstaging ranges from 0% to 12%. It is again important when evaluating radial scars that there is pathologic concordance and that there were no associated high-risk lesions on pathology. If this is the case, it is reasonable to clinically monitor patients with small radial scars, particularly in those who do not have an elevated risk of developing breast cancer.30
For all patients who have undergone biopsy and whose pathology study results are benign, a thorough risk evaluation should be performed, including calculation of their lifetime risk of breast cancer. This can be done with the National Cancer Institute Breast Cancer Risk Assessment Tool, the International Breast Cancer Intervention Study (IBIS) risk calculator, or other model using family history as a basis for calculations. Patients found to have a lifetime risk of breast cancer of greater than 20% to 25% should be offered annual screening with magnetic resonance imaging in addition to mammography.
ATYPICAL HYPERPLASIA: INCREASED RISK
When biopsy study shows atypical ductal hyperplasia or atypical lobular hyperplasia, there is an increased risk of breast cancer.28,32 The absolute overall risk of developing breast cancer in 25 years is 30%, and that risk is further stratified based on the number of foci of atypia noted in the specimen.29
When core-needle biopsy study reveals atypical ductal hyperplasia in the tissue, there is a 15% to 30% risk of finding breast cancer with surgical excision.28 Surgical excision is therefore recommended for atypical ductal hyperplasia noted on core-needle biopsy.28
In contrast, when atypical lobular hyperplasia alone is noted, the risk of upstagingto malignancy varies widely—from 0% to 67%—although recent studies have noted risks of 1% to 3%.33,34 Thus, the decision for surgical excision is more variable. Generally, if the atypical lobular hyperplasia is noted incidentally, is not associated with a higher grade lesion, and is concordant with imaging, it is reasonable to closely monitor with serial imaging and physical examination. Excision is unnecessary.35
Patients found to have atypical hyperplasia on breast biopsy should receive counseling about risk-reducing medications. Selective estrogen receptor modulators such as tamoxifen and raloxifene have been shown to reduce the risk of breast cancer by as much as 86% in patients with atypical hyperplasia.36 Similarly, aromatase inhibitors such as exemestane and anastrozole reduce breast cancer risk by approximately 65%.37
