Benign Breast Diseases: Epidemiology, Evaluation, and Management
BUNJA RUNGRUANG, MD, and JOSEPH L. KELLEY, III, MD Department of Gynecologic Oncology, Magee-Womens Hospital, Pittsburgh, Pennsylvania
Abstract: Benign breast diseases are common and encompass a spectrum of disorders. Themajority of diagnoses will stem from a patient presenting with symptoms such as a mass or discomfort, or as a result of breast imaging which shows abnormalities leading to percutaneous biopsy. When mammographic and pathologic findings are disconcordant or when a highrisk lesion that can be associated with a preinvasive or invasive malignancy is found, formal excisional biopsy is recommended. Key words:benign breast disease, palpable masses, radiographic abnormalities, fibrocystic change, benign neoplasms, mastalgia
Benign breast diseases are common and include presentations involving palpable masses, radiographic abnormalities, and mastalgia. The incidence of benign breast lesions begins to rise during the second decade and peaks in the fourth to fifth decades, as opposed to malignantdisCorrespondence: Joseph L. Kelley, III, MD, Division of Gynecologic Oncology, Magee-Womens Hospital, 300 Halket Street, Suite 2130 Pittsburgh, PA 15228. E-mail: firstname.lastname@example.org
CLINICAL OBSTETRICS AND GYNECOLOGY /
eases, where the incidence continues to increase after menopause with a peak incidence at the age of 70 years.1–12 The majority of patients presenting with breast complaints willbe found to have benign conditions.1–8 With the breast imaging and percutaneous needle biopsy, a diagnosis can be accomplished rapidly and without requiring additional surgical management in the majority of these lesions. After establishment of a nonmalignant diagnosis, treatment is generally aimed at symptomatic relief and patient education.
The most frequent benigndisorder of the breast is fibrocystic changes, affecting premenopausal women aged 20 to 50 years.1–8 Fibrocystic changes are generally multifocal and bilateral. Patients present with breast pain and tender nodules. Although the exact pathogenesis
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Benign Breast Diseases is unclear, a hormonal imbalance with estrogen predominance seemsto be a factor in its development.13 Fibrocystic changes are observed clinically in up to 50% and histologically in 90% of women.14,15 Pathologic correlates include the presence of cysts (macro and micro), adenosis (increased number or size of glandular components), ductal epithelial hyperplasia, apocrine metaplasia, radial scar, and papillomas. The indistinct clinical and pathologic findings callinto question the validity of referring to it as a disease. On account of the importance of determining whether these lesions are a risk factor for the subsequent development of breast cancer, they are evaluated under a classification system proposed by Dupont and Page,16 as nonproliferative lesions and proliferative lesions without and with atypia [atypical hyperplasia (AH)]. The majority ofbreast biopsies (up to 70%) show nonproliferative lesions. The subsequent risk for breast cancer for each of these lesions is classified based on the histologic appearance of the lesion.16,17 There is no elevated breast cancer risk in women with biopsy-proven nonproliferative lesions, whereas proliferative disease without atypia and with atypical ductal or lobular hyperplasia have an increased breastcancer risk, ranging from relative risks of 1.3 to 1.9 and 3.9 to 13.0, respectively, when compared with the general population.16,18,19 Absolute risk, however, for both proliferative diseases with and without atypia is quite low. More than 80% of patients with a diagnosis of AH do not develop invasive cancer during their lifetimes.
NONPROLIFERATIVE BREAST LESIONS
associated with an...