QuestionSBA
QuestionChoice
Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
32287
e
Follow up assessment in primary care in 12 months
QuestionChoice
The breast lump is likely to be a fibroadenoma based on its characteristics and the patient's age. This is a common, benign breast lump that is common in younger women due to increased sensitivity to oestrogen. However, all women over 30 with an unexplained breast lump should be urgently referred to the breast clinic for further assessment. This is likely to include further clinical assessment, imaging and biopsy or fine-needle aspiration (FNA)
32283
a
Urgent referral to secondary care
QuestionChoice
An urgent (two-week wait) referral is recommended for all women over 30 with an unexplained breast lump. For younger patients with no worrying features, a non-urgent referral is indicated
32285
c
Non-urgent referral to secondary care
QuestionChoice
Although this is likely a benign breast lump, guidelines recommended an urgent referral to secondary care
32286
d
Follow up assessment in primary care in 6 months
QuestionChoice
Although this is likely a fibroadenoma, the patient should be referred for further investigations
32284
b
Reassure the patient that this is a benign breast lump
Concept
Chapter
# Summary
 

Benign breast diseases are a variety of non-cancerous conditions that cause breast symptoms such as lumps, pain, and nipple discharge. They include fibroadenoma, breast cysts, mastitis, intraductal papilloma, radial scar, fat necrosis, fibrocystic breast disease, and mammary duct ectasia. Clinical examination, mammography, ultrasound, and biopsy are the key investigative tools, while management includes reassurance, medication, and sometimes surgical interventions.
 

# Definition
 

Benign breast diseases are a group of non-cancerous conditions affecting the breast, which often manifest as breast lumps, nipple discharge, or other abnormalities.
 

# Epidemiology
 

The majority of patients referred for breast symptoms are diagnosed with benign breast disease, making it a highly common condition. Women of various age groups can be affected, with some conditions like fibroadenoma being more common in younger women and others like breast cysts or fibrocystic breast disease being more prevalent from age 35 until menopause.
 

# Aetiology
 

 -  **Fibroadenomas** arise from the breast lobule stroma.
 -  **Breast cysts** occur due to the overgrowth of glandular and connective tissue, leading to blocked breast ducts and subsequent fluid accumulation.
 -  **Mastitis** is typically caused by bacterial infections, often related to breaks in the skin around the nipple.
 -  **Intraductal papilloma** is a benign tumour of the breast ducts.
 -  **Radial scar** is a benign sclerosing breast lesion.
 -  **Fat necrosis** is a response to adipose tissue damage.
 -  **Fibrocystic breast disease** is due to an exaggerated hormonal response causing inflammation, fibrosis, cyst formation, or adenosis.
 -  **Mammary duct ectasia** is due to inflammation and dilation of the large breast ducts.
 

# Signs and Symptoms
 
In general, features that suggest a breast mass is benign include being round, mobile, well-demarcated and smooth. This contrasts features that suggest a breast mass is malignant such as being hard or firm, having irregular borders and being fixed to the underlying structures (i.e. muscles or ribs). 

 -  **Fibroadenoma**: Highly mobile, encapsulated breast masses.
 -  **Breast cysts**: Presence of breast lumps, potentially with distension.
 -  **Mastitis**: Breast redness, mastalgia, malaise, and fever.
 -  **Intraductal papilloma**: Bloody discharge from the nipple which can present with/without a palpable mass. Breast tenderness may also be present.
 -  **Radial scar**: Presents on the mammogram as a stellate pattern of central scarring surrounded by proliferating glandular tissue.
 -  **Fat necrosis**: Painless breast mass, skin thickening, or radiographic changes on mammography.
 -  **Fibrocystic breast disease**: Breast lumps, pain, and tenderness.
 -  **Mammary duct ectasia**: Palpable peri-areolar breast mass, thick nipple discharge, and potential mammographic similarities to cancer.
 

# Differential Diagnosis
 

 -  **Breast cancer**: Characterised by hard, immobile lumps, nipple retraction, skin changes (like peau d'orange), or bloody nipple discharge.
 -  **Gynecomastia**: Enlargement of male breast tissue, which may be tender or painful.
 -  **Abscess**: A collection of pus in the breast tissue, often painful and associated with redness, warmth, and fever.
 -  **Lipoma**: Soft, mobile, non-tender fatty lumps beneath the skin.
 -  **Pregnancy**: During pregnancy and breastfeeding, women may experience an increase in the size of their breasts, darkening of the nipple and areola, and discharge of colostrum from the nipple. 
 

# Investigations
 
NICE Guidelines recommend referral under two-week wait protocols for:

- Women over 30 years with an unexplained breast lump
- Women over 50 with changes to the nipple (i.e. discharge, retraction, skin changes)
- A referral should also be considered in women with skin changes suggestive of breast cancer or for women aged over 30 years with an unexplained lump in the axilla.

Two-week wait clinic will consist of a triple assessment of: 

 -  Clinical breast examination: To identify any palpable abnormalities.
 -  Mammography and ultrasound: To visualise the internal structures and evaluate any identified lumps or abnormalities.
 -  Fine-needle aspiration or biopsy: To confirm the diagnosis of identified lumps or suspicious areas.


In cases of diagnostic uncertainty or when there is a more acute presentation, blood tests may be required to identify signs of infection or hormonal imbalances in certain cases.
 

# Management
 

 -  Reassurance: Often, benign breast diseases require only monitoring and reassurance, especially when symptoms are minimal and there is no sign of complications.
 -  Conservative measures such as ensuring a well-fitting bra and warm compresses may offer some symptomatic relief. 
 -  Antibiotics: Used in case of infections such as mastitis.
 -  Analgesics: To manage pain or discomfort associated with various conditions.
 -  Surgical intervention: In some cases, like large fibroadenomas, persistent cysts, or symptomatic intraductal papillomas.
 -  Hormonal therapy: May be considered in cases of fibrocystic breast disease.

 
#  Prognosis 
 
Benign breast disease can vary in prognosis from non-proliferative disorders with no associated increased breast cancer risk, to atypical hyperplasias with a significantly increased breast cancer risk. 

 
# NICE Guidelines 

[NICE Guidelines Breast Cancer Recognition and Referral](https://cks.nice.org.uk/topics/breast-cancer-recognition-referral/) 
 
 
# References

[Patient Info Benign Breast Disease](https://patient.info/doctor/benign-breast-disease#types-of-benign-breast-diseases) 

[BMJ Best Practice Assessment of Breast Mass](https://bestpractice.bmj.com/topics/en-gb/1179/differentials)
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Benign breast disease
Topic
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Breast Disease
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All women over 30 with an unexplained breast lump should be urgently referred for further assessment, regardless of lump characteristics.
A 32-year-old woman presents to her General Practitioner (GP) with a right-sided breast lump. She first noticed it one week ago and denies any other symptoms including breast pain, discharge, skin or nipple changes. She has no personal or family history of any cancers.

On examination, there is a smooth 1cm lump in the upper inner quadrant of the left breast. The borders are well defined, and the lump moves under the skin on palpation. There is no associated lymphadenopathy.

Which of the following is the best step in management?
a