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Etiology
Fibrocystic
changes (previously, fibrocystic disease) is a catchall term that refers to mastalgia, breast cysts, and nondescript lumpiness, which may occur in isolation or together; breasts have a nodular and dense texture and are frequently tender when palpated. Fibrocystic changes cause the most commonly reported breast symptoms and have many causes. Most causes are not associated with increased risk of cancer; they include adenosis, ductal ectasia, simple fibroadenoma, fibrosis, mastitis, mild hyperplasia, cysts, and apocrine or squamous metaplasia. Other causes, particularly if fibrocystic changes require biopsy, may slightly increase risk of breast cancer (see Breast Disorders: Breast Cancer). Fibrocystic changes are more common among women who had early menarche, who had their 1st live birth at age > 30, or who are nulliparous.
Fibroadenomas are typically painless lumps that feel like small, slippery marbles. They usually develop in young women, often in teenagers, and may be mistaken for cancer although they are benign and tend to be more circumscribed and mobile. Simple fibroadenoma does not appear to increase risk of breast cancer; complex fibroadenoma may increase risk slightly.
Trauma
to the chest wall or overuse of the pectoralis muscles (eg, due to exercise or weight lifting) may cause pain misperceived by patients as originating in the breast. Blunt trauma can cause localized fat necrosis, which can form a discrete tender lump deep within breast tissue or immediately under and fixed to the skin.
Hormonal
changes may cause premenstrual cyclic breast symptoms, such as enlargement, discomfort, and tenderness.
Breast
infections (mastitis—see Postpartum Care: Mastitis) cause pain, erythema, and swelling; an abscess can produce a discrete mass. Infections are extremely rare except during the puerperium (postpartum) or after penetrating trauma. They may occur after breast surgery. Puerperal mastitis, usually caused by Staphylococcus aureus, can cause massive inflammation and severe breast pain, sometimes with an abscess. If infection occurs under other circumstances, an underlying cancer should be sought promptly.
Galactocele is a round, easily movable milk-filled cyst that usually occurs up to 6 to 10 mo after lactation stops. Such cysts rarely become infected.
Cancers of various types can manifest as a lump or as pain (about 5%).
Evaluation
and Treatment
Painful, tender, rubbery lumps in a younger woman with previous history of similar findings suggest fibrocystic changes. A stony hard, irregular lump with skin dimpling suggests cancer. However, because manifestations of benign and malignant lesions overlap considerably and because failing to recognize cancer has serious consequences, tests are done to conclusively exclude breast cancer.
Initially, physicians try to differentiate solid from cystic lumps because cysts are rarely cancerous. Typically, ultrasonography is done. Lesions that appear cystic are sometimes aspirated, and solid lumps are evaluated with mammography followed by imaging-guided biopsy. Some physicians evaluate all lumps with needle aspiration; if no fluid is obtained or if aspiration does not eliminate the lump, mammography followed by imaging-guided biopsy is done.
Fluid aspirated from a cyst is sent for cytology only if it is bloody, if minimal fluid is obtained, or if a mass remains after aspiration. Patients are reexamined in 4 to 8 wk. If the cyst is no longer palpable, it is considered benign; if the cyst has recurred, it is reaspirated, and any fluid is sent for cytology regardless of appearance. A 3rd recurrence or persistence of the mass after initial aspiration (even if cytology was negative) requires biopsy.
Fibroadenomas can usually be excised using a local anesthetic, but they frequently recur. After patients have had several fibroadenomas established as benign, they may decide against having subsequent ones excised. Acetaminophen , NSAIDs, vitamin E, and athletic bras to reduce trauma can be used to relieve symptoms of fibrocystic changes.
Last full review/revision November 2005
Content last modified November 2005
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