breast, skin, and soft tissue
BENIGN BREAST DISEASE
Helen Cappuccino, MD, FACS, Ermelinda Bonaccio, MD, and Shicha Kumar, MD*
Clinicians should have an understanding of the evaluation
and management of breast disorders. One in two women
will consult a health care provider for a breast-related com-
plaint during her lifetime.1 The fundamental task facing a
physician who is evaluating a patient with a breast concern
is to determine whether the abnormality is benign or malig-
nant. Even though most breast complaints do not result in a
diagnosis of cancer, any woman presenting with a breast
complaint should receive a comprehensive evaluation. In
this chapter, we focus on the evaluation and management of
benign breast conditions.
Screening Recommendations
In the absence of a specific breast complaint, breast cancer
can be detected by screening. The three main methods of
breast cancer screening are breast self-examination (BSE),
clinical breast examination (CBE), and screening mammo-
graphy [see Table 1].2 American Cancer Society (ACS) screen-
ing guidelines for women age 40 years and older specify that
mammography and CBE should be included as part of an
annual health examination.3 Health care providers should
stress to patients the importance of promptly reporting any
new breast symptoms or findings. There is currently no role
for routine screening ultrasonography or screening mag-
netic resonance imaging (MRI) in the general population.
breast self-examination
In BSE, the patient inspects and palpates both breasts and
axillae. There is not yet conclusive evidence that BSE is of
significant value in improving breast cancer detection rates.
Many self-detected tumors are found incidentally, not
during BSE. Furthermore, the best technique for BSE and
optimal frequency has not been established. The ACS
recommends counseling patients on the benefits and limita-
tions of BSE as part of the breast cancer screening process
that also includes mammography and CBE.3
In BSE, the patient inspects and palpates both breasts and
axillae. Although strong evidence supporting the benefit of
BSE to reduce mortality from breast cancer is lacking, many
cancers are still self-detected. If women choose to do BSE,
their technique should be reviewed [see Figure 1].
clinical breast examination
In CBE, a qualified health care professional carries out a
complete examination of the breasts and axillae. As with
BSE, there is not yet conclusive evidence indicating that
annual or semiannual CBE increases breast cancer detection
rates.4 Nevertheless, it is prudent for the clinician to include
* The authors and editors gratefully acknowledge the contribu-
tions of the previous authors, Swati Kulkarni, MD, FACS,
Doreen M. Agnese, MD, FACS, Stephen P. Povoski, MD, FACS,
and Wiley W. Souba, MD, ScD, FACS, to the development
and writing of this chapter.
Red text is tied to a SCORE learning objective.
2014 Decker Intellectual Properties Inc
CBE as part of the physical examination performed on every
female patient [see Figure 2, Figure 3, and Figure 4].
screening mammography
Screening mammography refers to the imaging of asymp-
tomatic women to detect early, clinically occult breast
cancers. Mammography is the only breast imaging modality
proven to reduce mortality from breast cancer in multiple
randomized clinical trials.5 The Swedish Two-County Trial
updated its data in 2000 and demonstrated a 32% reduction
in breast cancer mortality in women invited to screening.6
Based on the findings from these trials, women should begin
annual screening mammography at age 40. There are sub-
groups of women at high risk for breast carcinoma who may
benefit from screening at a younger age or from the addition
of MRI to their screening, although no randomized con-
trolled trials support these recommendations.7 Currently,
there is no accepted upper age limit for mammographic
screening; however, the presence of significant comorbidi-
ties reducing life expectancy to less than 10 years should be
considered when ordering a screening mammogram in
women over the age of 70.
Most breast imaging centers in the United States use
digital mammography. The results from a large prospective
multicenter trial comparing digital to conventional film
mammography demonstrated no significant difference in
cancer detection rates.8 However, digital mammography
was found to be more sensitive than film in three subgroups:
women less than 50 years of age, women with radio-
graphically dense breasts, and women who were pre- or
perimenopausal.9
Evaluating Breast Complaints and Masses
history
Evaluation of a woman with a breast complaint should
include a thorough history, a physical examination, and
appropriate diagnostic studies. A complete history of the
current complaint should include onset, duration, and
progression of symptoms. Precipitating and ameliorating
factors should be noted, as should the relationship of pal-
pable abnormalities, pain, and tenderness to the menstrual
cycle. A recent history of trauma to the breast, previous
infections, fine-needle aspirations (FNAs), core biopsies, and
surgical biopsies should also be recorded. Medical records,
including operative reports and corresponding pathology
and radiographic reports, should be reviewed carefully. The
treating clinician should obtain and review previous breast
imaging as part of the patients history.
Symptoms or complaints involving the breast should be
evaluated in the context of historical breast cancer risk data
[see Table 2]. The remainder of the patients general history
should be evaluated with a focus on significant medical
problems that may impact surgical planning. Medications
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breast benign breast disease 2

Table 1 Three Main Methods of Breast Cancer Screening2,3

Method ACS Screening Guideline
Breast self-examination Counsel patients on the benefits and limitations of BSE as part of the breast cancer screening process
Clinical breast examination Should be included as part of an annual health examination
Screening mammography Should be included as part of an annual health examination
ACS = American Cancer Society; BSE = breast self-examination.

and supplements that may contain estrogen-like substances
and social history (especially tobacco, alcohol, work, exer-
cise, and even sexual history as it pertains to breast stimula-
tion) can be relevant. It is also important to note if a patient
is of Ashkenazi Jewish lineage.
physical examination
The breasts and axillae should be thoroughly examined in
the upright and supine positions. Breast asymmetry and
overall appearance of the skin, nipples, and areola should be
observed with the patient upright. Any erythema, indura-
tion, edema, peau dorange [see Figure 5], nipple retraction,
and ulceration should be noted. Occult skin retraction can be
demonstrated by having the woman raise her hands above
her head and then place them against her hips. Bimanual
examination of the breast tissue can facilitate identification
of masses in women with dense breast tissue. In the supine
position, turning the patient to either side to disperse breast
tissue facilitates a more thorough examination for women
with larger breasts. For the ptotic breast, palpation of the
breast tissue between the thumb and index finger of the
same hand may be useful. The location, mobility, and
characteristics of masses and thickening should be noted,
including size, firmness, presence of smooth or irregular
borders, overlying skin changes, consistency, and areas of
tenderness [see Table 3]. Drawings or digital images can be
made to document physical findings. All tissue between
the clavicle and costal margins should be palpated, from the
lateral sternal border to the posterior axillary line. Patients
should also be checked for nipple discharge with manual

a b c

Visual Inspection
Seated with Arms
Relaxed Asymmetry

Visual Inspection
Seated with Arms
Raised Above Head

Nipple
Retraction

e f g

Dimpling
Erythema
Edema of Skin

Figure 1 Visual inspection of the breasts. The breasts are inspected with the patient in a seated position with arms relaxed (a) and raised over
the head (b). Pertinent findings include asymmetry (c), nipple retraction (d), edema (e), erythema (f), and dimpling of the skin (g).

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breast benign breast disease 3

a b

Axillae examined with

patient seated and
ipsilateral arm supported
to relax pectoral muscle

Up and
Clock
Down
Pattern
Pattern

Figure 2 Physical examination of the breasts. The breast tissue is examined in a systematic fashion to determine the presence of a dominant
mass (a). The axilla is examined with the patient in the seated position with the ipsilateral arm supported by the examiner (b).

Pads (not tips)

of first 3 fingers
used for palpation

Ipsilateral arm should be

placed behind head to spread
breast tissue across chest wall

Figure 3 Breast palpation technique. The breast is palpated in the supine position to spread the
breast tissue against the breast wall. The pads of the first three fingers are used to scan the texture of
the breast tissue.

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breast benign breast disease 4

Diagnostic Studies
Abnormal screening mammogram
with normal physical examination

Additional imaging including ultrasonography

Additional mammogram views

BI-RADS 1, 2 BI-RADS 3 (probably benign) BI-RADS 4, 5

Back to routine screening schedule Do 6-month mammogram Do image-guided biopsy
follow-ups for 1 year, up to 24 months

Skin and Nipple Changes

Skin and nipple changes

Blanching erythema
Fever, warmth, pain (elevated white blood cells) Nipple excoriation
Consistent with infection

Empiric antibiotics to cover gram- Topical steroids for 714 days

positive cocci

Resolution No improvement Improvement No improvement

Revert to normal screening Imaging and skin punch biopsy Short-term clinical follow-up Skin punch biopsy
Imaging per screening protocol Imaging

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 breast benign breast disease 5

Management of Specific Benign Breast Complaints

Abnormal physical examination

Breast pain Nipple discharge Palpable mass or thickening

No mass Mass
Physiologic Pathologic
Screening per standard recommendation See workup for mass Bilateral Bloody
Multiple ducts Single duct
Milky Single breast
Heme-negative Spontaneous
Normal Abnormal
Reassure; holistic measures Per abnormal mammogram
Mammography
Mass No mass
Ductography
See workup for mass Endocrine workup Excision (see text)

Cystic < 28 year old > 28 year old

Aspirate (discard fluid) if symptomatic Ultrasonography Mammography + ultrasonography

Normal Worrisome physical Nonsuspicious solid Suspicious solid Solid or complex Simple cyst Normal
examination (consistent with Bilateral mammography Core biopsy
Short-term Aspirate
fibroadenoma) + core-needle biopsy
clinic follow-up Mammography (discard fluid) if
Follow-up by physical symptomatic
examination and
ultrasonography in 6
months

High suspicion Low suspicion

Core biopsy 6-month follow-up

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breast benign breast disease 6

Lymph Vessel

Lymph Node

Fat

Lobules Areola

Lactiferous Duct Nipple

Suspensory
Ligament

Figure 4 Normal breast anatomy.

Table 2 Historical Breast Cancer Risk Data

History Factors to Consider
History of hormone use Duration
Estrogen vs estrogen + progesterone
Type, including oral contraceptives and hormone replacement therapy
Reproductive history Age at menarche
Age at menopause
Age at first live birth
Number of gestations and completed pregnancies
Lactation history
Family history Malignancies on maternal side, including age at diagnosis
Malignancies on paternal side, including age at diagnosis
History of predisposing genetic mutations in family members (i.e., BRCA)
Ashkenazi heritage
Medical history History of radiation to the chest
Personal history of genetic abnormalities
History of previous breast disease, surgeries, or abnormalities/symptoms/findings or trauma
Social history History of smoking
History related to alcohol intake
Dietary factors
Exercise and activity history
History of drug abuse (patients occasionally inject into breast veins, causing phlebitis)

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breast benign breast disease 7

imaging directed by a radiologist, who determines if the

Figure 5 Peau dorange.
compression of the nipple. Axillary, clavicular, and cervical
lymph node basins should also be palpated in the upright
and supine positions. The presence of adenopathy, includ-
ing the size, consistency (hard versus soft), number, lateral-
ity, location, and mobility of the lymph nodes, should be
documented.
diagnostic studies
Diagnostic
Mammography
and Targeted
Ultrasonography
As mentioned previ-
ously, screening mam-
mography refers to imaging of an asymptomatic woman.
Diagnostic mammography, on the other hand, refers to
imaging a woman with either a clinical complaint (a palpa-
ble lump, thickening, focal pain, discharge) or an abnormal
screening mammogram. The initial workup of an abnormal
screening mammogram involves additional mammographic
perceived abnormality is a real lesion. Spot and rolled views
(with or without magnification) can sometimes differentiate
between overlapping glandular tissue and an actual under-
lying lesion. The diagnostic mammogram report would then
be given a final Breast Imaging, Reporting and Data System
(BI-RADS) assessment.
When an abnormality is detected and the patient needs
additional mammographic and/or sonographic imaging [see
Figure 6], the initial screening mammogram in these patients
is given a final assessment 0 [see Table 4]. Once the diagnos-
tic workup is complete, the radiology report will have a final
assessment of 1 through 5. Women with a BI-RADS 1 or 2
should continue to undergo routine annual mammography.8
Women with a BI-RADS 3 should undergo short-term
followup, which typically involves an ipsilateral mammo-
gram in 6 months followed by a bilateral study at 12 and
24 months. A finding in this category should have a less than
2% risk of malignancy based on morphologic and distribu-
tion features.10,11 Any interval progression at follow-up
should prompt a biopsy. Patients with a BI-RADS category
4 or 5 lesion require a tissue diagnosis.
As an adjunct to diagnostic mammography, high-frequency
breast ultrasonography is often used in the diagnostic
workup of a mass and can distinguish between a solid and
a cystic lesion. If a solid mass is visualized sonographically,
ultrasound-guided core-needle biopsy (CNB) can be
performed for pathologic diagnosis.
FNA, Percutaneous Core/Needle, Excisional Biopsies
Breast biopsies should be performed percutaneously
whenever possible, using stereotactic, ultrasound, or MRI
guidance [see Table 5]. Such biopsies are preferable over
open surgical biopsies and allow for better surgical planning
for definitive management. CNB [see Figure 7] with a spring-
loaded or vacuum-assisted device has been confirmed in
multiple studies to be a reliable alternative to surgical exci-
sion.12,13 Stereotactic (mammographic) guidance is typically
used to biopsy indeterminate or suspicious calcifications as
well as masses or densities that are sonographically occult.
Ultrasound guidance is used to biopsy masses that can be
visualized sonographically and is the most cost-effective
type of image-guided core biopsy.14 MRI-guided CNB is
reserved for lesions that are occult to conventional imaging.
CNB is preferable over FNA [see Figure 8] because it
provides tissue for evaluation of histology, the presence of
invasion, and receptor status.

Table 3 Physical Characteristics of Benign and Malignant Breast Masses81*

Characteristic Benign Malignant
Borders Well circumscribed Irregular
Texture Firm or rubbery, supple Hard
Mobility Mobile Fixed to surrounding tissue
Skin changes None Dimpling, retraction
Nipple changes None Retraction, bloody discharge, scaling
*Although the above characteristics may imply benign disease, their presence should not be used as justification for not thoroughly working up lesions that are
worrisome.

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breast benign breast disease 8

Cable to
Imaging Computer

Ultrasound Transducer

Growth/Tumor

Figure 6 Sonogram of the breast.

Table 4 American College of Radiology Breast Imaging Reporting and Data System (BI-RADS)
Category Assessment Description/Recommendation
0 Additional imaging evaluation required Additional imaging recommended
1 Negative finding Nothing to comment on; routine screening recommended
2 Benign finding Negative mammogram, but interpreter may wish to
describe a finding; routine screening recommended
3 Probably benign finding Very high probability of benignity; short-interval follow-up
suggested to establish stability
4 Suspicious abnormality Probability of malignancy; biopsy should be considered
5 Abnormality highly suggestive of malignancy High probability of cancer; appropriate action should be
taken
6 Known malignancy Known biopsy-proven malignancy
The report generated after the diagnostic workup is completed will have a final assessment of 1 to 5. The Breast Imaging Reporting and Data System (BI-RADS) lexicon was
developed to standardize mammographic reports.6 It defines the final assessment categories, which informs the referring physician about the likelihood of malignancy.

Percutaneous needle biopsies are not always feasible

Table 5 Guidance of Percutaneous Breast Biopsy
due to anatomic considerations such as the proximity of the
Guidance Target
lesion to skin, the nipple, or chest wall or if the patients
Stereotactic Indeterminate or suspicious calcifications as well breast tissue is not compressible. In such cases, open or
as masses or densities that are sonographically
occult surgical excisional biopsy [see Figure 9] is an alternative
and may require localization if the finding is not palpable.
Ultrasound Masses that can be visualized sonographically
Localization can be done with wires or newer appoaches,
MRI Lesions that are occult to conventional imaging such as radioactive seed localization [see Figure 10]. When

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breast benign breast disease 9

Growth/Tumor
Core Biopsy Needle

~ 2 cm

Core Samples of
Breast Tissue

Figure 7 Core-needle biopsy.

Growth/Tumor
Syringe with Fine Needle

Sample Cells on
Microscope Slide

Figure 8 Fine-needle aspiration.

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breast
Growth/
Tumor
Figure 9 Excisional biopsy.
excisional biopsies are done, they should be done through
incisions along the lines of minimal skin tension [see Figure 11].
Incisional biopsies should be avoided [see Figure 12].
With any image-guided approach, it is important to
confirm that the pathologic results are concordant with the
imaging findings. Treatment decisions should be based
on both pathologic findings and the appearance of the
abnormality on diagnostic imaging. Discordant imaging and
pathologic findings should prompt a surgical biopsy.
Other Imaging Modalities
MRI is an imaging modality that uses strong magnetic
fields to create a cross-sectional image. Breast MRI requires
a specific coil and peripheral intravenous injection of a
gadolinium-based contrast medium. Contrast-enhanced
breast MRI has been shown to have a high sensitivity for
detection of invasive breast cancer and can find both inva-
sive and in situ carcinomas that are occult to conventional
imaging. In practice, the use of breast MRI is predominantly
limited to women diagnosed with breast carcinoma and
women at increased risk for developing breast cancer.
To date, there are no studies supporting the role for MRI
screening in the general population.
Tomosynthesis is a type of digital mammography that
uses low-dose images acquired in an arc [see Figure 13 and
Figure 14]. These images are then reconstructed into slices,
allowing for visualization in layers. This technology reduces
the issue of overlapping tissue, which can obscure a breast
cancer or mimic lesion. Recent studies suggest that the addi-
tion of tomosynthesis to standard digital mammography
can increase detection rates and decrease recall rates.
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benign breast disease 10
Excised Breast Lump
with Margin of Normal Tissue
Although a promising technology, the role of tomography in
clinical breast imaging is not yet determined.1517
At present, there is no indication for the use of positron
emission tomography in the diagnostic workup of breast
diseases outside a clinical trial. A number of new modalities
are being investigated, such as positron emission mammo-
graphy, breast-specific gamma imaging, and coned-beam
computed tomography. Although some of these modalities
are approved by the Food and Drug Administration (FDA),
they are not currently standard practice.
General Management of Clinical Findings in the Breast
palpable mass
Palpable masses can cause considerable anxiety in
patients and require appropriate evaluation with a thorough
history and physical examination [see Table 6]. A dominant
breast mass is defined as a discrete lump that is distinctly
different from the surrounding breast tissue. Overall,
approximately 10% of dominant breast masses are malig-
nant. The workup and management of a discrete breast mass
are governed by the age of the patient, the patients family
and medical history, the physical characteristics of the
palpable lesion, and findings on diagnostic imaging. These
factors should not be used to dismiss the findings of a
palpable mass, however.
solid masses
Evaluation of a palpable lump in a woman over 30 years
of age should include mammography and ultrasonography.
breast
Figure 10 Radioactive seed localization.
If she has a significant family history of breast cancer but
has not yet reached the age for routine bilateral screening,
contralateral mammography is indicated to rule our syn-
chronous lesions. Increased concern is appropriate in the
case where a solid mass is hard, fixed, and immobile and has
irregular borders clinically. For women less than 30 years
old, workup begins with ultrasonography, and mammogra-
phy is included depending on the sonographic and clinical
findings. If the mass is clinically suspicious, CNB (or surgi-
cal biopsy if CNB is not feasible or unsuccessful) should
be performed for tissue diagnosis even in the setting of
negative imaging.
cystic masses
Cysts are a common cause of dominant breast masses,
particularly in premenopausal women, and can present as a
mass or pain. They can be differentiated from solid lesions
by means of ultrasonography. Sonographically, simple cysts
are anechoic, well-circumscribed masses [see Figure 15].
Complex cysts with indistinct walls or solid components are
more likely to be associated with carcinoma [see Figure 16];
benign breast disease 11
therefore, imaging-guided aspiration, biopsy, or both should
be performed. For asymptomatic simple cysts, no further
intervention is required. For symptomatic cysts, FNA is
appropriate. If the mass does not disappear completely after
aspiration, then biopsy of any residual solid component
should be performed. Clear fluid should not be sent for
cytologic analysis because of the high likelihood of a false
positive result. Bloody fluid obtained from a cyst aspiration
should be sent for cytologic examination.
vague thickening or nodularity
Normal breast texture is often heterogeneous, particularly
in premenopausal women. Vague thickening or tender or
nontender areas of nodularity are frequently detected by the
patient or the clinician. It is important to distinguish this
vague breast thickening or nodularity from a discrete or
dominant breast mass. In clinical practice, the first step in
evaluating a nodular area is to compare it with the corre-
sponding area of the opposite breast. Symmetrical tender
nodularityfor example, in the upper outer quadrant of
both breastsis rarely pathologic. These areas often repre-
sent fibrocystic changes that may resolve with time and thus
should be followed clinically. Asymmetrical areas of vague
thickening in premenopausal women should be reexamined
after one or two menstrual cycles. If the asymmetry persists,
the patient should undergo mammography and ultrasonog-
raphy if she is 30 years of age or older and has not under-
gone a mammogram within the last 6 months. If the mass
is clinically suspicious, a surgical biopsy with specimen
orientation should be performed even in the setting of
negative imaging.
Management of
Specific Benign Breast
Complaints
mastalgia
One of the most
common complaints for
which a woman seeks a doctors opinion is mastalgia.
Mastalgia (breast pain) can be cyclical or noncyclical and
may be idiopathic. Often it is related to other common
processes that occur in the breast, such as fibrocystic change
or infection. Two thirds of women will complain about
mastalgia during the course of their lives.18 Its cause is poorly
understood. A history of the onset and course of the pain is
important, especially as it relates to a womans menstrual
cycle. Although rarely a presenting complaint of breast
cancer, mastalgia often causes considerable concern for
patients. Mastalgia resolves spontaneously in 20 to 30% of
cases but can recur in up to 60% of women. Some studies
suggest a relationship with caffeine intake, saturated fat
intake, premenstrual syndrome, and serum hormone
levels.19 Frequently, after a complete history and physical
examination to rule out a malignancy, the clinician is left
treating mastalgia of unknown etiology. Many women
respond well to reassurance18,20 and simple interventions,
such as wearing a properly fitted bra and reducing caffeine
and saturated fat intake. Commonly used remedies, includ-
ing evening primrose oil, vitamin E, and vitamin B6, have
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breast benign breast disease 12

Biopsy Incisions

Figure 11 Breast biopsy incision.

Growth/
Tumor

Excised Wedge of
Breast Lump

Figure 12 Incisional biopsy image.

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breast benign breast disease 13

Table 6 Breast Lesions that May Present as a

Palpable Abnormality81
Fibrocystic change
Simple and complex cysts
Pseudoangiomatous stromal hyperplasia
Fat necrosis
Lipomas
Abscesses
Adenopathy
Ductal ectasia
Fibroadenomas
Hamartomas
Ductal carcinoma in situ
Invasive carcinoma
Gynecomastia
Sarcomas
Phyllodes tumors
Sarcoidosis
Idiopathic granulomatous mastitis
Hematomas
Seromas
Mucoceles
Galactoceles
Amyloidosis
Focal fibrosis
Lactating adenomas
Epidermal inclusion cysts
Lymphadenopathy
Hemangiomas

Figure 14 Mediolateral oblique tomosynthesis.

Figure 15 Breast sonogram showing a well-circumscribed oval mass

with a thin wall and posterior acoustic enhancement consistent with
Figure 13 Craniocaudad tomosynthesis. a simple cyst.

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breast
Figure 16 A mammary carcinoma that has irregular borders, is
hypoechoic, and shows irregular posterior shadowing.
limited evidence supporting their use to relieve symp-
toms.21,22 If simple interventions are not successful, consider-
ation can be given to pharmacologic agents including
nonsteroidal antiinflammatory drugs (NSAIDs), danazol,
bromocriptine, and tamoxifen.19,22,23 In very extreme and
otherwise completely nonresponsive cases, surgical excision
of the tender area can be considered, but such intervention
is rarely appropriate, especially since pain often persists
even after surgery.24
fibrocystic change
Fibrocystic change is often referred to by the misnomer
fibrocystic disease. It is a common finding in women who
are menstruating, occurring almost exclusively between the
ages of 30 and 50. Fibrocystic change is characterized by
lumpy or cobblestone breasts with ridges of tissue appre-
ciated on palpation. The change is considered a normal
variant. If a dominant mass is found in a woman with fibro-
cystic breasts, diagnostic imaging and biopsy should be
undertaken to rule out malignancy. Symptoms generally
improve with oral contraceptive use and abate with meno-
pause. Treatment is geared toward symptomatic relief using
the agents listed above for mastalgia and reassuring the
patient that there is no worrisome etiology or increased risk
of developing breast cancer.
nipple discharge: papillomas, ductal ectasia, and
galactorrhea
Nipple discharge is the third most common breast com-
plaint after mastalgia and breast mass.25 In the majority of
cases, the discharge is caused by noncancerous processes,
including (1) physiologic discharge, (2) ductal ectasia, and
(3) intraductal papilloma [see Table 7]. However, malignancy
should be ruled out as part of the workup for nonphysiologic
discharge.25 For women presenting with this concern, the
clinician should elicit a history that includes the characteris-
tics, frequency, and time frame of the discharge. The initial
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benign breast disease 14
Table 7 Noncancerous Processes that Cause
Nipple Discharge
Process Characteristics
Physiologic discharge Milky
Bilateral
Ductal ectasia Nonbloody but darker green or brown
Dilated ducts resulting from obstruction
with keratin plugs
Subsequent inflammation and secretions
Intraductal papilloma Bright red, rusty, brown, or green
Unilateral
Persistent
Eminates from a single duct
question to the patient should be whether the discharge is
spontaneous or self-induced. If self-induced, the patient
should be counseled to stop eliciting the discharge. If
spontaneous, the characteristics are important in determin-
ing the cause, including whether it is unilateral or bilateral,
in single or multiple ducts, milky, bloody, clear, posttrau-
matic, or cyclical. The history should also include questions
pertaining to symptoms associated with an endocrine
disorder (hypothyroidism) or to an intracranial etiology
such as a pituitary tumor (amenorrhea, visual disturbances,
and headache). A history of recent medication changes
should also be taken because numerous medications are
associated with galactorrhea [see Table 8].25
To understand physiologic nipple discharge, an under-
standing of breast physiology is critical. During pregnancy,
high circulating levels of estrogen result in development of
the breast into a predominantly glandular structure. With
parturition, estrogen production decreases, resulting in
prolactin secretion and increased secretory activity, whereas
oxytocin results in letting down or ejection of milk into the
ducts. A suckling infant or similar stimuli (i.e., sexual breast
stimulation, postthoracotomy syndrome)26 may result in
oxytocin release. Any of these conditions can result in
physiologic discharge, which is usually milky and bilateral.
Pregnancy can result in galactorrhea from the second
trimester to as late as 2 years postpartum. Elevated thyroid-
stimulating hormone (TSH) levels can also be associated
with elevated prolactin levels.
Nipple discharge characterized as nonbloody but darker
green or brown is associated with ductal ectasia, a benign
condition characterized by dilated ducts resulting from
obstruction with keratin plugs and subsequent inflamma-
tion and secretions. Ductal ectasia [see Figure 17] can arise in
one or multiple ducts. Dilated ducts are visualized on ultra-
sonography and on ductography. The characteristics of the
discharge from ductal ectasia can be similar to those seen
Table 8 Medications Associated with
Galactorrhea25
H2 receptor antagonists
Antihypertensives
Antidepressants
Antidopaminergic agents
breast
Normal Duct
Figure 17 Ductal ectasia.
with papillomas and ductal carcinoma in situ (DCIS) and are
therefore included in the differential diagnosis of pathologic
nipple discharge.
Bloody nipple discharge can appear as bright red, rusty,
brown, or green and is considered pathologic. It is charac-
teristically unilateral and persistent and emanates from a
single duct. Although the most common etiology of this
remains a solitary intraductal papilloma, DCIS and invasive
breast cancer can also present with pathologic discharge.
Of patients presenting with such a discharge, 17% have
malignancy, 65% have papillomas, and the remainder have
other benign lesions.27
A thorough physical examination that includes a search
for signs of an endocrine disturbance should be conducted
(e.g., thyromegaly, visual field defects). As part of the breast
evaluation, if nipple discharge is not apparent, the clinician
should gently squeeze the nipple to determine whether the
discharge is coming from a single duct or multiple ducts
and whether the discharge is bilateral. The breast should be
evaluated for the presence of a discrete mass that may be
associated with an underlying carcinoma.
Historical and physical findings suggestive of an endo-
crine disorder should prompt the clinician to order TSH and
prolactin levels. An MRI of the brain should be ordered
to rule out a prolactin-secreting tumor of the pituitary if
prolactin levels are elevated. In women of childbearing age,
a pregnancy test should also be ordered as part of the
workup of galactorrhea. Women with medication-induced
bilateral discharge should be counseled about the etiology
and reassured.
benign breast disease 15
Duct with Ectasia
For patients who are found to have pathologic discharge,
the diagnostic workup should begin with bilateral diagnos-
tic mammography. If imaging reveals a focal lesion or
microcalcifications, tissue diagnosis should be obtained.
Ductography may be able to identify an intraductal lesion
and guide surgical planning. Ductography involves cannu-
lating the discharging duct with a small catheter and then
injecting a small amount of radiographic contrast medium.
Magnified mammographic views are then obtained, and
lesions within the duct are identified as either a filling defect
or an abrupt cutoff. Ductoscopy, which uses a flexible or
rigid fibroscopic ductoscope to cannulate the nipple, can be
used to isolate areas of pathology for excision. In skilled
hands, it can be combined with ductal lavage or (brush)
cytology for improved accuracy.28,29 However, studies
supporting ductoscopy and ductal lavage remain limited,
and these techniques remain investigational.
Cytologic analysis of nipple fluid or discharge has little
clinical value. Heme testing nipple discharge for blood can
raise the suspicion of malignancy, but the absence of blood
does not rule out malignancy. FNA is also unreliable in
evaluating patients with drainage and/or papillomatous
disease30 (and many feel that even CNB of endoductal
lesions remains inadequate for definitive diagnosis of these
lesions).3134 Therefore, surgical excision is recommended
given the incidence of concomitant premalignant and malig-
nant disease in the setting of pathologic nipple discharge.31,35
When the location of the intraductal pathology is identified
prior to surgical resection, a more limited resection (i.e.,
single duct excision) of the disease is possible.36 If the duct
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breast
is peripheral in the breast, the duct can be localized via
needle localization. When possible, single duct excision is
preferred because it preserves nipple sensation and the abil-
ity to breast-feed. In cases where the focal pathology cannot
be isolated preoperatively, or in the case of multiduct
involvement, a major duct excision is more appropriate. This
involves removing all of the central lactiferous ducts and
sinuses, preventing further discharge. Both procedures can
be done on an outpatient basis and require only local anes-
thetic and monitered anesthesia care (MAC) with sedation.
fibroepithelial lesions: fibroadenoma and
phyllodes tumor
Fibroepithelial lesions encompass a spectrum of breast
abnormalities ranging from the fibroadenoma (FA) [see
Figure 18] to the phyllodes tumor (PT). FAs are the most
common benign breast lesions and occur most frequently in
the second and third decades of life. Their natural history is
one of stability or slow growth. Patients will often give a
history of a solitary nontender nodule. Physical examination
will usually demonstrate a well-defined solitary, rubbery,
and mobile nodule. Ultrasonography is particularly useful
in younger women and demonstrates a well-defined oval or
round hypoechoic mass with discrete margins. Mammogra-
phy should be obtained (in addition to ultrasonography) in
women over 35 years of age and typically demonstrates
a well-defined radiopaque mass with smooth borders [see
Figure 19]. If the history, physical examination, and imaging
are consistent with an FA, careful clinical follow-up is rea-
sonable with ultrasonography and CBE at 6-month intervals
to assess the stability of the lesion. When the diagnosis
is uncertain, CNB should be performed. For women who
request excision of a benign FA, enucleation of the lesion is
adequate. Conversely, if the lesion increases in size during
clinical follow-up, surgical excision is recommended to rule
out a PT.
PTs are uncommon, representing only 0.3 to 0.5% of breast
neoplasms.37 They have the same clinical appearance and
Scientific American Surgery
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benign breast disease 16
imaging characteristics as FAs but, unlike FAs, are charac-
terized by a clinical history of rapid growth and have larger
dimensions. With increased screening, more PTs are being
discovered mammographically. Given that these lesions do
not have any features on imaging that would be helpful
in differentiating them from FAs, CNB is recommended.
However, it can be difficult to differentiate between FA and
PT on CNB. A pathologic diagnosis of a fibroepithelial
lesion on CNB necessitates excision to rule out a PT. Tumors
are classified histologically as low, intermediate, or high
grade. Although most PTs have minimal metastatic poten-
tial, they have a proclivity for local recurrence and should
be excised with at least a 1 cm margin. Local recurrence has
been correlated with excision margins but not with tumor
grade or size.38 The most common site of metastasis from
malignant PT is the lung.
atypical hyperplasias, radial scar, lobular
neoplasia, and papillomas
During the course of a patients workup for a suspicious
physical finding or image-detected abnormality, CNB or
FNA may be performed. A pathologic diagnosis demon-
strating atypia, atypical ductal hyperplasia (ADH), atypical
lobular hyperplasia (ALH), lobular carcinoma in situ (LCIS),
papilloma [see Figure 20], or radial scar requires formal sur-
gical excision with preoperative localization to rule out the
presence of invasive carcinoma or DCIS. CNB of these
lesions understages findings related to these diagnoses in up
to 30% of cases.3943 These lesions may be an independent
risk factor for the development of carcinoma [see Evaluation
of Patients at High Risk for Breast Cancer, below] [see
Figure 21, Figure 22, and Figure 23].38
fat necrosis
Fat necrosis can masquerade as breast cancer. It often
presents as a firm, irregular mass within breast tissue, which
is occasionally tender. The patients history is helpful in
providing clues to this diagnosis and will often include a
Figure 18 Fibroadenoma.
breast
Figure 19 Mammogram depicting a smoothly marginated mass
with benign coarse calcifications consistent with a fibroadenoma.
history of trauma, reduction mammoplasty, or previous
breast surgery. Large cavity size, postoperative hematoma,
or infection, as well as adjuvant radiation, can increase the
likelihood of fat necrosis. A compromise to the surrounding
parenchymal blood supply is thought to be the underlying
factor in its development. Breast imaging can often be diag-
nostic of fat necrosis.44 Ultrasonography and/or stereotactic
CNB is appropriate if there is doubt about the diagnosis and
will reveal chronic inflammatory cells, lymphocytes, histio-
cytes, fat necrosis, and saponification. Should the physician
opt for short-term clinical follow-up (1 to 2 months) instead
of biopsy, it is important to have a patient who will be
compliant with keeping follow-up visits.45
Figure 20 Papilloma.
benign breast disease 17
galactocele
In the pregnant patient with complaints of a mass or ten-
derness, the clinician should bear in mind the hormonally
stimulated status of the breast, resulting in increased tender-
ness. However, any mass or thickening in the breast requires
prompt evaluation in the pregnant patient. Malignancy
should always be ruled out, particularly in older,
childbearing-age women. A galactocele, which is a collection
of milk within an obstructed, dilated duct, can form during
pregnancy, lactation, or recent postlactation. A patient may
complain of a tender nodule within the breast tissue.
A mammogram will demonstrate a well-circumscribed
mixed-density lesion, and ultrasonography will reveal a
corresponding partially cystic mass. Simple aspiration
can be both diagnostic and therapeutic, providing relief.
Malignancy should always be in the differential diagnosis,
particularly in older women of childbearing years.
mondor disease
Mondor disease is thrombophlebitis of the superficial
veins of the breast. It is characterized by the finding of a
tender and often inflamed cord palpated on the patients
breast. After a thorough history and physical examination of
the patients breasts, reassurance is appropriate because
most cases will resolve spontaneously. If particularly symp-
tomatic or unresolved over a period of time, treatment
should consist of NSAIDs, analgesics, and antibiotics. If
there is evidence of infection, or should the condition fail
to improve, surgical excision is appropriate for definitive
management and diagnosis.46
gynecomastia
Gynecomastia, or benign proliferation of male breast
tissue, is usually a benign condition in adolescent males and
presents as discoid, subareolar, rubbery thickening of the
breast tissue. Mammography can often be diagnostic of
gynecomastia, demonstrating a typical fan- or flame-shaped
density extending from the nipple toward the upper outer
quadrant. In the absence of any other findings, such as
testicular pathology, liver disease. or a history of ingestion
or use of substances associated with gynecomastia, these
patients should be reassured and reexamined. In the case of
especially prominent, large, long-standing, or symptomatic
gynecomastia, surgical excision is reasonable. It may even
require a subcutaneous mastectomy. In the mature male
population, a physical examination and history are vitally
important. Soft, diffuse enlargement is a result of medica-
tion in 20 to 25% of cases.47 Gynecomastia can also be due to
hormonal, physiologic, or idiopathic factors and can usually
be managed nonoperatively and with serial examinations.
Many medications resulting in gynecomastia are felt to
do so by elevating prolactin levels comparatively. If the
gynecomastia is attributable to medication, switching the
patient off the medication will often result in regression
over the course of a few months. For men who would like
to avoid surgery, some success has been noted in treating
gynecomastia with tamoxifen, raloxifene, and aromatase
inhibitors.48,49 However, a finding of a solitary hard mass,
especially with findings of adenopathy and skin changes,
requires aggressive workup to rule out cancer, including
mammography and tissue diagnosis, usually with percuta-
neous biopsy, especially if the finding is peripherally located.
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breast benign breast disease 18

Normal Duct Cells

Ductal Hyperplasia

Figure 21 Ductal hyperplasia.

Normal Duct Cells

Atypical Hyperplasia

Figure 22 Atypical hyperplasia.

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breast
Figure 23 Normal duct anatomy.
skin and nipple
changes
Common breast skin
and nipple changes
include bacterial infec-
tions (mastitis, cellulitis,
with or without under-
lying abscess), fungal
infections, and dermatitis. Women will often give a history
of an abrasion or crack in the nipple preceding an episode
of mastitis. Symptoms typically include erythema, tender-
ness, and swelling of the breast. Staphylococcus aureus is the
most common organism identified. Treatment involves
continued breast-feeding and antibiotics. The choice of
antibiotics should take into consideration the safety of the
breast-feeding infant.50 Nonresolution of the infection with a
course of appropriate antibiotics should prompt the surgeon
to consider the presence of an antiobiotic-resistant organism
or underlying abscess, which may require incision and
drainage. Fluid from an abscess should be sent for Gram
stain and culture to ensure the appropriate choice of antibi-
otic. If the symptoms persist in the absence of the above
causes, inflammatory breast cancer should be considered,
followed by appropriate imaging, punch biopsy of the skin,
and percutaneous biopsy of any underlying lesion.
In nonlactating women, cellulitis of the breast typically
occurs in the lower half of the breast and is more commonly
found in women who are overweight, smoke, and/or have
large, pendulous breasts. Breast abscesses are more fre-
benign breast disease 19
quently seen in women with a history of diabetes, rheuma-
toid arthritis, chronic steroid use, chronic granulomatous
lobular mastitis, and trauma.50 Treatment includes antibiot-
ics and identification of an underlying abscess followed by
aspiration or drainage. Aspiration should always precede
drainage. Intravenous antibiotics should be considered for
women with an elevated temperature and white blood cell
count or in immunosuppressed patients. Other skin condi-
tions in the breast include sebaceous cysts and hidradenitis
suppurativa. Appropriate antibiotics should be given, and
surgical excision is often required for resolution of the symp-
toms. Fungal (candidal) infections involving the breast are a
common complaint in women with large, pendulous breasts.
The lower breast and inframammary crease are common
locations for the characteristic erythematous moist patches.
Treatment includes keeping the area clean and dry and
topical antifungal powders or creams.
In nonlactating women, benign processes involving the
nipple are often the result of trauma or damage to the nipple
or subareolar ducts. Smoking is associated with periductal
mastitis, which can present with pain, inflammation, nipple
retraction, breast abscess, and discharge. Appropriate
antibiotics and abscess aspiration or drainage are the recom-
mended treatments. Trauma, dry skin, or dermatitis can
lead to excoriation of the nipple. Allergic or atopic dermati-
tis frequently occurs as a result of allergies to clothing, dyes,
perfumes, and detergents. Treatment is symptomatic, with
removal of the offending agent and a course of topical
steroids. Short-term clinical follow-up (1 to 2 weeks) is
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breast
essential to ensure resolution of the symptoms. Breast
cancer, including Paget disease of the nipple, can present
with these symptoms, and it is vital that the surgeon
conduct a thorough investigation including history, physical
examination, diagnostic imaging, and biopsy to make an
accurate diagnosis. If there is no improvement in the symp-
toms in 2 weeks, punch biopsy of the nipple should be done.
Evaluation of Patients at High Risk for Breast Cancer
Significant morbidity and cost are associated with breast
cancer treatment. Approximately one third of women diag-
nosed with breast cancer will succumb to the disease. This
has led to efforts to provide primary prevention to high-risk
women. A number of factors have been identified that
increase breast cancer risk [see Table 9].51 These risk factors
include (1) mutations in genes that confer a predisposition
to breast cancer52; (2) hormonal and reproductive factors51,5355;
(3) environmental factors, including diet and lifestyle
characteristics of developed Western nations56; (4) previous
radiation to the chest wall as a teenager or young adult57;
(5) a history of previous breast cancer, radial scar, or other
premalignant lesions41,58,59; and (6) increased mammographic
density.60 Recognition of factors that increase breast cancer
risk facilitates appropriate screening and clinical manage-
ment of individual patients. It must be recognized, however,
that most women have none of the known risk factors for
breast cancer, and the absence of these risk factors should
never prevent full evaluation or biopsy of a suspicious
breast lesion.
Approximately 10% of all breast cancers are hereditary.61
Hereditary breast cancer is characterized by early age at
onset, bilateral disease, and disease in other organ sites.
Therefore, an accurate and complete family history, includ-
ing all malignancies, is essential for quantifying a womans
genetic predisposition to breast cancer. Questions about
breast cancer in family members should go back several
generations, with age at diagnosis recorded if available.
Table 9 Magnitude of Known Breast Cancer
Risk Factors82
Relative risk < 2
Early menarche
Late menopause
Nulliparity
Age > 35 at first birth
Hormone replacement therapy
Obesity
Alcohol use
Proliferative breast disease
Previous breast biopsies
Relative risk 24
One first-degree relative with breast cancer
Radiation exposure
Previous breast cancer
Mammographic density
Relative risk > 4
Two first-degree relatives with breast cancer
Gene mutation
Lobular carcinoma in situ
Ductal carcinoma in situ
Atypical hyperplasia
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benign breast disease 20
Any personal history of cancer should be recorded, with
particular attention paid to breast, ovarian, and endometrial
cancers.
BRCA1 and BRCA2 account for the majority of hereditary
breast cancers. The lifetime risk of breast cancer in these
individuals can be as high as 85%. Mutations in these
genes are associated with other malignancies, most notably
ovarian, pancreatic, and prostate cancer. Specific founder
mutations in BRCA1 and BRCA2 occur within certain ethnic
groups (e.g., Ashkenazi Jews).61 Surgeons should also be
aware of mutations in other genes that are commonly associ-
ated with an increased risk of breast cancer, including muta-
tions in TP53 (Li-Fraumeni syndrome), mutations in the
PTEN gene (Cowden syndrome), and hereditary diffuse
gastric cancer syndrome (CHD1). Tests that detect mutations
in these genes are commercially available. Clinicians
should consult a licensed genetic counselor to determine
appropriate candidates for testing.
Genetic testing has significantly improved our ability to
define breast cancer risk for the subset of women who have
a mutation. For women without a known genetic predispo-
sition, the Gail,62 Claus,63 BRCAPRO, and Cuzick-Tyrer
models are tools that can screen women who may be at
increased risk and would therefore benefit from enhanced
surveillance and chemoprevention. It should be noted that
these mathematical models define population-based risk,
not individual risk.
Histologic markers of risk include both ductal and lobular
atypia, radial scar, and LCIS. Atypia and radial scar confer
a fourfold increased risk of developing breast cancer.64,65
LCIS is associated with an increased lifetime risk of subse-
quent carcinoma between 20 and 25%. Pleomorphic LCIS, a
pathologically distinct entity of LCIS, appears to be associ-
ated more frequently with invasive cancer.66,67 At present,
women with these high-risk lesions should be offered
screening and chemoprevention.
Currently, there are three options for women to manage
their risk: (1) enhanced surveillance, (2) chemoprevention, and
(3) risk-reducing surgery (i.e., prophylactic mastectomy).
For women with LCIS or a family history of breast carcinoma,
surveillance should include twice-yearly CBE. Mammogra-
phy should be performed annually after the diagnosis of
LCIS or atypical hyperplasia. Women with a family history
of breast cancer should have screening mammography per-
formed annually, beginning 10 years before the earliest age
at which cancer was diagnosed in a first-degree relative.68
For women with known genetic mutations and other
women from families with an autosomal dominant pattern
of breast cancer transmission, annual mammographic screen-
ing should begin at age 25.68 There are several prospective
nonrandomized trials that were designed to assess the
benefit for adding yearly screening breast MRI for women at
high risk for breast cancer.6973 These studies demonstrated
that breast MRI is more sensitive than mammography. In
2007, the ACS published recommendations for the use
of screening breast MRI as an adjunct to mammography.
Annual screening with breast MRI is recommended for the
candidates listed in Table 10 [see Table 10].
It is important to remember that although the sensitivity
of breast MRI for cancer is high, the specificity is relatively
low and can result in high recall and biopsy rates.74 Breast
breast
Table 10 Candidates Who Should Be
Considered for Annual Screening with
Breast MRI74
BRCA mutation carriers
First-degree relatives of a BRCA mutation carrier who have
never been tested
Women with a lifetime risk of 20 to 25% based on risk models
that are predominantly dependent on family history
Women with a history of radiation to the chest between the ages
of 10 and 20 years
Women with Li-Fraumeni syndrome (mutations in the TP53
gene)
First-degree relatives of women with Li-Fraumeni syndrome
Women with Cowden and Bannayan-Riley-Ruvalcaba
syndromes (mutations in the PTEN gene)
First-degree relatives of women with Cowden and Bannayan-
Riley-Ruvalcaba syndromes
MRI = magnetic resonance imaging.
MRI should be used as an adjunct to mammography and
not a replacement. Mammography and MRI can be done
simultaneously or alternating with each other at 6-month
intervals to coincide with the CBE. Given the specificity of
breast MRI and the fact that many enhancing lesions seen on
breast MRI are occult to conventional imaging modalities, it
is essential that any facility performing screening breast MRI
should have the capability for MRI-guided breast biopsy.
Chemopreventive strategies are designed either to block
the initiation of the carcinogenic process or to prevent
(or reverse) the progression of the premalignant cells to an
invasive cancer.75 Selective estrogen receptor modulators
(SERMs), tamoxifen, and raloxifene are currently FDA
approved for chemoprevention in breast cancer. Large
multicenter randomized trials demonstrated the efficacy of
these agents in the primary prevention setting for women at
increased risk for breast cancer based on a Gail score of 1.67
or a personal history of ADH or LCIS. The overall risk of
invasive breast cancer was reduced by 50% after treatment
for 5 years and limited to estrogen receptor (ER)-positive
breast cancers in these high-risk women. Raloxifene is
currently approved only for postmenopausal women and
has the added benefit of treating postmenopausal osteopo-
rosis. It is noteworthy, however, that raloxifene was not
found to prevent noninvasive breast cancers in this trial.76
The aromatase inhibitor exemestane has been shown to be
effective in the chemoprevention of breast cancer in high-
risk women and is increasingly used for this indication;
however, it is not yet FDA approved in this setting.77
The hot flashes, deep vein thrombosis, and endometrial
cancer associated with tamoxifen have made it an unattrac-
tive option for many women. This has generated interest
in identifying other chemopreventive agents. Aromatase
inhibitors, which are used to treat ER-positive breast cancers
in postmenopausal women, reduce the risk of contralateral
cancers and may have a role to play in chemoprevention as
noted above. In addition, gonadotropin-releasing hormone
agonists, monoterpenes, lignans, retinoids, rexinoids, vita-
min D derivatives, and inhibitors of tyrosine kinase are all
undergoing evaluation in clinical or preclinical studies with
a view to assessing their potential chemopreventive activity.
benign breast disease 21
Whether any of these compounds will play a clinically
useful role in preventing breast cancer remains to be seen.
Additional consideration needs to be given to lifestyle
factors (avoiding excess alcohol, consuming a balanced diet,
exercising, maintaining an ideal body mass index [BMI]),
which may play a role in risk management as well.
For those women at significant risk for breast cancer
attributable to genetic predisposition, bilateral prophylactic
mastectomy can be considered. High-risk women who
underwent this procedure, compared with those who did
not, had their breast cancer risk reduced by at least 90%.78
Oopherectomy also confers up to a 50% breast cancer risk
reduction in premenopausal women.79 The benefits of pro-
phylactic mastectomy must be weighed against the irrevers-
ibility and the psychosocial consequences of the procedure.
Research involving high-risk women is challenging
because of the large numbers of women who must be
recruited and followed for many years and because of the
cost associated with such an undertaking. Improved risk
assessment tools that can aid in improved risk stratification
are under active investigation.80 Current trials are focused
on identifying and using intermediate biomarkers of breast
cancer risk to test potential chemopreventive agents.
Financial Disclosures: Helen Cappuccino, MD, FACS, Ermelinda Bonaccio, MD,
and Shicha Kumar, MD, have no relevant financial relationships to disclose. This
chapter was previously authored by Swati Kulkarni, MD, FACS, Doreen M. Agnese,
MD, FACS, Stephen P. Povoski, MD, FACS, and Wiley W. Souba, MD, ScD,
FACS, with disclosure made at the time of initial publication. This chapter has been
reviewed, updated, and rereleased by the authors listed.
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Acknowledgments
Figures 1 through 9, 11, 12, 17, 21, 22, and 23 Christine Kenney
Figures 15 and 19 Courtesy of George Plitas, MD, and Monica
Morrow, MD, FACS.
Figure 16 Courtesy of Angela Gucwa, MD, J. Garrett Harper,
MD, and D. Scott Lind, MD.
Scientific American Surgery
04/14