Beni gnBreast Di sordersMichaela Onstad, MD, MPH*, Ashley Stuckey, MDINTRODUCTIONBenign lesions of the breast are much more common than malignant lesions, althoughtheactual incidenceisdifficult toestimate.1,2Theselesionsrepresent asignificantproportionofofficevisitstotheobstetrician-gynecologist,becauseofeitherbother-somebreast symptomsorabnormal imagingfoundonscreeningstudiesof breastcancer.Itisimportantfortheobstetrician-gynecologisttohaveanunderstandingofbenignbreastdiseasesoastoappropriatelyevaluateandaddresspatientssymp-toms, distinguish between benign and malignant processes, determine which benignbreast lesions require surgical management, and identify patients who are atincreased risk of developing breast cancer.Theauthorshavenothingtodisclose.Program in Womens Oncology, Department of Obstetrics and Gynecology, Women and InfantsHospital, Warren Alpert Medical School of Brown University, 222 Richmond Street, Providence,RI02903,USA*Correspondingauthor.E-mailaddress:maonstad@gmail.comKEYWORDS

Nippledischarge Mastalgia Palpablebreastmasses

Adolescentbreastdisorders InflammatorybreastconditionsKEYPOINTS Pathologicnippledischargeisassociatedwithmalignancyin5%to15%ofcasesandtherefore requires further evaluation. Breast pain is common, and in rare instances may be associated with infection or malig-nancy. Once these are ruled out, mastalgia is a benign condition that can be managed byavoidance of aggravating factors and use of alleviating factors. Palpable breast masses should be evaluated by obtaining a history, physical examination,appropriate imaging studies, and biopsy when indicated. Therearemanybenigncausesthatcanleadtoinflammatorybreastlesions; however,breast inflammation may also be a manifestation of malignancy. Screening mammograms may reveal benign breast abnormalitiesthat arenot otherwiseclinically evident or symptomatic. Some require further evaluation and referral to a breastsurgeon for surgical excision, whereas others may be associated with an increased risk ofdeveloping breast cancer in the future.Obstet Gynecol Clin N Am 40 (2013) 459473http://dx.doi.org/10.1016/j.ogc.2013.05.004 obgyn.theclinics.com0889-8545/13/$ see front matter 2013 Elsevier Inc. All rights reserved.The term benign breast disease encompasses a heterogeneous group of breast le-sions.Thisarticlereviewscommonbenignbreastproblemsinthemannerwherebythey are most likely to be presented to the clinician. A discussion of common breastsymptomsisfollowedbyareviewofbenignbreastprocessesfoundincidentallyonimaging and biopsies.NIPPLEDISCHARGEAsmuchas80%of womenwill experienceat least 1episodeof nippledischargeduringtheir reproductiveyears.35Thisdischargecanbebothersometopatients,especiallyifitiscopiousandpersistent,andcanalsoelicitfear,particularlywhenitisbloody. Most nippledischargeiscausedbybenignconditions, althoughupto15%may have an underlying malignancy3; therefore, appropriate evaluation and man-agement is important.Evaluationshouldstartwithobtainingathoroughclinicalhistory.Itisimportanttoclassify the discharge as unilateral or bilateral, bloody or nonbloody, and spontaneousor provoked. Spontaneous discharge is typically produced in large amounts. It can befoundonthepatientsclothingandisoftenreadilyapparent. Provokeddischargeoccurs with mechanical stimulation of the duct system, and can usually be reproducedduring the physical examination.6The history should also include the patients age, thetype and duration of nipple discharge, history of pregnancy and recent parturition, thepresenceof apalpablebreastmass, anyhistoryof breastcancerorbenignbreastconditions, and a thorough review of the patients current medications.5A family his-tory of malignancy, especially breast and ovary, should also be obtained.Physical examination should include a thorough breast examination to evaluate foranypalpablemasses.Anattempttoreproducethenippledischargeshouldalsobemade,withparticularattentionpaidto determiningwhetherthe dischargeoriginatesfrom 1 or multiple ducts of the nipple. Discharge originating from 1 duct is more con-cerning than flowfrommultiple ducts. The discharge should be tested for blood, whichcaneasilybedoneusingaHemoccultcard.Otherpertinentaspectsofthephysicalexamination include evaluation of the eyes for visual field deficits, palpation of the thy-roid to evaluate for enlargement or a palpable mass, and evaluation of other secondarysigns of pituitary tumor and thyroid abnormalities.5At one time it was recommendedthat nippledischarge be sampled during exami-nation and sent for cytologic evaluation. Recent studies have suggested that cytologyof nippledischargehaspoorsensitivityandspecificity(16.7%and66.1%, respec-tively) anddoesnotaddmerittoclinical decisionmaking.7Itisthereforenolongerroutinely recommended.Based on the history and physical examination, an attempt should be made to clas-sify the nipple discharge as either physiologic discharge, nonpuerperal galactorrhea,or pathologic discharge (Box 1). Physiologic discharge is a benign process. Patientsshouldbereassuredthat approximatelytwo-thirdsof nonlactatingwomenhaveasmall amount of fluidsecretedfromthenipplewithmanual expression.8,9Thesewomen should be advised to avoid frequently checking for nipple discharge, becauserepeatedstimulationof thenipplewill promotetheproductionof moredischarge.Physiologicdischargeoftenresolveswhenthenippleisleft alone. Nonpuerperalgalactorrheaiscausedbyinappropriatelyelevatedprolactinlevelsthatcanbesec-ondarytomedications, diseasesof thepituitaryor thyroidglands, renal failure, orchronicbreast stimulation. Becausenonpuerperal galactorrheais not causedbybreast abnormality, it is not discussed further in this article. Instead the focus here ison the workupandetiology of pathologic discharge, which is a symptomof aOnstad & Stuckey 460pathologicprocesswithinthebreast.Malignancyisfoundin5%to15%ofpatientswith pathologic nipple discharge.8EvaluationofPathologicDischargeAllpathologicdischargeshouldundergofurtherevaluation,whichshouldbeginwithimagingstudiestodeterminewhether thereisanidentifiablemassor abnormalityassociatedwith the discharge. Amammogramand/or ultrasonogramshouldbeordered as initial steps, with biopsy performed when indicated.5,6,8,10The use of addi-tional imagingstudies, suchasdiagnosticductographyandmagneticresonanceimaging (MRI) of the breast, is controversial.8,10Diagnosticductographyinvolvestheinstallationofcontrastmaterial intotheductthat has been identified as producing the nipple discharge. This procedure reportedlyisatechnicallychallengingone,andrequiresthattheductisabletobecannulated.Morroghandcolleagues10describeaseriesof 178patientswithpathologicnippledischargewhounderwent ductography, 76%of whomhadanotherwisenegativeevaluationwithbreast examination, mammogram, andultrasonogram. Cannulationwassuccessful in84%of patients. Inthisseries, ductographyhadsensitivityof76%fordetectingmalignancy,specificityof11%,andapositivepredictivevalueof11%. A patient with a negative ductogram (and negative mammogram and ultrasono-gram),therefore,maystill harboramalignancy,andrequiressurgical management.Some breast surgeons are of the opinion that, despite this, ductography can be usefulinidentifyingthelocationof thelesiontoaidinminimizingtheamount of tissueremoved during surgery.8Theuseof breast MRI for evaluationof nippledischargeisalsocontroversial.Lorenzon and colleagues11retrospectively evaluated 38 women with pathologic nippleBox 1Classification of nipple dischargePhysiologic DischargeVarious colors (yellow, white, green, brown, blue-black)Does not occur spontaneouslyOriginates from multiple ductsNonpuerperal GalactorrheaMilk production unrelated to pregnancy or nursing, or occurring more than 1 year afternursingSpontaneous or provokedTypically persistentOccasionally voluminousAssociated with chronic breast stimulation and hyperprolactinemiaPathologic DischargeSpontaneousUnilateralTypically arises from a single duct openingBloody, serous, serosanguinous, or wateryPersistentBenign Breast Disorders 461dischargewhounderwentmammography, ultrasonography, andbreastMRI beforesurgery. Breast MRI had a sensitivity of 94.7%for detecting malignancy and specificityof78.9%.Threeof5cancersthatwerepresentinthisstudyweredetectedbyMRIalone. Theinvestigatorsconcludedthat MRI shouldbeorderedinall patientswithpathologicnippledischargewhohaveanegativemammogramandultrasonogram.Opponentsof thisstrategyarguethat MRI carriesasignificant false-positiverateandiscostly, andthat thereislimitedavailabilityof MR-guidedbiopsiesat manycenters in the United States.At present, ultimately all pathologic nipple discharge requires a tissue diagnosis toappropriately evaluate for malignancy. When an abnormality is detected by a mammo-gramor ultrasonogram, an image-guided biopsy should be performed. In the setting ofanormal mammogramandultrasonogram, surgical excisionshouldbeperformed,requiring referral to a breast surgeon. When a specific duct can be identified on exam-ination, a selective duct excision can be performed to obtain a tissue diagnosis. Other-wise, a central duct excision is recommended.12PapillaryLesionsPapillary lesions of the breast represent a spectrum of pathology that includes benign,atypical, andmalignantlesions. Papillarylesionsaremorecommonamongwomenbetweentheagesof30and50years.8Whenpapillarylesionsarelocatednearthenipple, they typically present with pathologic bloody nipple discharge. However, theselesions may also be detected by abnormal imaging studies or may be found inciden-tally on biopsy performed for other indications.Intraductal papillomasarebenigntumorsof theepitheliumof mammaryducts.Approximately50%aresinglelesions.8Thesetumorscanrangeinsizefromlessthan 3 mm up to several centimeters. Grossly they are tan or pink, tend to be friable,and are typically associated with a dilated duct. Microscopically they consist of mul-tiple branching papillae with a fibrovascular core lined by epithelium. Surgical excisionof these lesions is recommended and is generally curative.Atypical papillomas are papillomas with atypical features found in the epithelial cells.Thesetumorscarryanincreasedriskof beingassociatedwithinsituandinvasivebreast cancers, and should be surgically excised when diagnosed by core biopsy.13Papillomatosisdescribespapillomascontainingductal hyperplasiawithoutatypia(proliferation of the ductal epithelial cells). Juvenile papillomatosis is a diseasedescribed in women younger than 30 years. It typically presents as a localized massand microscopically involves ductal hyperplasia without atypia, and may also be asso-ciatedwithotherbenignproliferativefindings.13Approximately10%ofpatientswithjuvenile papillomatosis have breast cancer.Papillarycarcinoma,mentionedforthesakeofcompleteness,ismorecommonlyfound among women older than 60 years.MammaryDuctEctasiaMammary duct ectasia is characterized by dilation of the mammary ducts. If symptom-atic it typically causes nipple discharge, which is frequently bilateral, present in multi-pleducts, andof variouscolors(nottypicallypathologicdischarge). Thedischargemay be described as cheesy or viscous.8It occurs most often in the perimenopausalperiod, but has also been described among younger women, children, and men.14Thecause is unknown, but an association with smoking has been described.15Mammaryductectasiagenerallydoesnotrequiresurgeryandshouldbemanagedconserva-tively. Whenasymptomatic, ductectasiadoesnotrequiretreatment. DuctexcisionOnstad & Stuckey 462is recommended if the clinical presentation and mammographic findings are otherwisesuggestive of malignancy.8BREASTPAINMany women will experience breast pain at some point in their lives. Most of the timethispainisself-limitedandresolvesonitsown;however,forsomewomenthepaincan be persistent. In a questionnaire sent to women in South Wales, 66% of respon-dents reported having some breast pain and 21% reported having severe breast pain.Less than half of the women with severe breast pain had discussed it with their physi-cian.16Nonetheless, breast pain is one of the most common breast symptomsencounteredbyprimarycarephysicians.17Inrareinstances, breast painmayberelated to infection, malignancy, or a condition not associated with the breast.Box2liststheextramammarycausesthatcanpresentasbreastpain.Oncethesepossibilities are ruled out, mastalgia is a benign entity.Evaluation of breast pain should begin with a detailed history and physical examina-tion. The history should help to classify the pain as cyclical or noncyclical, explore forpotential aggravating and alleviating factors, and evaluate for extramammary causes.Box 3 lists important aspects to include in the history.6,18Thephysical examinationshouldinvolvecareful observationandpalpationoftheaffectedarea, whichcanbereassuringtothepatient andindicatesthat her fearsandconcernsarebeingtakenseriously.6Inobservingthepatient,takenoteofskinmarksalongthebraline(indicatinganill-fittingbra) orshouldermarksfromheavyhandbag shoulder straps. Evaluate for any other skin lesions, including lesions char-acteristicofherpeszoster.Performathoroughbreastexaminationinthesittingandsupinepositions, evaluatingformassesorabnormalities. Toisolatepainrelatedtothe chest wall (chostochondritis) and differentiate it from true mastalgia, have the pa-tient lay on her side or in the sitting position, leaning forward, allowing the breast tissueto be displaced before palpating the underlying chest wall.Amammogramand/orbreastultrasonographyshouldbeorderedas indicatedforanyabnormalitiesdiscoveredonexamination. Whether adiagnosticmammogramshould be ordered to further evaluate mastalgia in a woman with a normal breast ex-amination is controversial. Astudy by Dujimand colleagues19concludes that in womenwith mastalgia alone, mammography provides reassurance. Others believe thatmammographyiswidelyoverusedinthissetting.17ItwouldcertainlybeappropriateBox 2Extramammary causes that may present as breast painCostochondritisTietze syndromeCervical radiculopathyMyocardial ischemiaPneumoniaIrritation of the pleuraEsophageal spasmRib fractureShinglesBenign Breast Disorders 463to order a screening mammogramfor women older than 40 if not performed in the pastyear.CyclicalBreastPainApproximatelytwo-thirdsofwomenwithbreastpainhavecyclical pain.20Bydefini-tion, cyclical pain occurs in a predictable pattern with the menstrual cycle. It is typicallyworse in the luteal phase and is relieved by the onset of menses. It is frequently bilat-eral, andisoftenmost severeintheupper outer quadrants. Cyclical painismostcommon among women in the reproductive years, andtypically improves aftermenopause.The etiology of cyclical breast pain (mastalgia) is poorly understood. Many patientswith cyclical mastalgia also have breast nodularity and tenderness. However, there isno consistent association between symptoms and breast histology,17and fibrocysticchanges are now thought to be secondary to normal physiologic breast involution asBox 3Obtaining a clinical history of breast painLocationUnilateral versus bilateralLocalized within a specific area of the breastDeep or superficialInvolving chest wallTimingConstant versus variableVariations with menstrual cycleAssociated symptomsSymptoms of infection (fever, chills, erythema, swelling)Symptoms of malignancy (palpable mass, nipple retraction, skin changes)Previous surgeryRecent injuryAggravating and alleviating factorsCaffeine useTobacco useNonsteroidal anti-inflammatory useSeverityRecent weight changesLoss or gain of more than 10 lb (4.5 kg) in past yearMedicationsHormonal medicationsAntidepressantsSpironolactoneMethyldopaOnstad & Stuckey 464opposedtoa disease process.21Cyclical breast painis likely due tohormonalchanges, giventhatitoccursduringthereproductiveyearsandfluctuateswiththemenstrual cycle. However, studies have demonstrated that women with cyclical mas-talgia have hormone levels similar to those of women who do not have breast pain. Ithasbeensuggestedthat, rather thandifferencesinabsolutehormonelevels, anincreased sensitivity to hormones may explain cyclical mastalgia.17Management of cyclical mastalgia should start with reassurance. Women are oftenrelieved that breast pain is common and is rarely the sole manifestation of breast can-cer.6For some women, no further treatment is needed. In addition, there are lifestyleand dietaryinterventions that may alleviatecyclic mastalgia.The use of a well-fittingsupportbraandinitiationofregularexercisehavebeenprovedtoimprovemastal-gia.6,17,22Theeliminationofcaffeine(andothermethylxanthines)ismorecontrover-sial, asit hasbeenshowntoreducetheseverityof mastalgiainsomestudiesbuthas proved to be ineffective in other studies.17Avoiding caffeine is still commonly rec-ommended because it carries few risks and may have other health benefits. Vitamin Esupplementationalso may beeffectivein decreasingpain; however,thishas not yetbeen confirmed by a placebo-controlled trial. Evening primrose oil has been demon-strated to reduce mastalgia in placebo-controlled trials, although it often takes a longcourse of treatment (at least 4 months) to achieve this result.17Endocrinetherapies(suchasbromocriptine, danazol, andtamoxifen) havebeenshowntobeeffectiveintreatingcyclical mastalgia; however, suchtreatmentsareassociatedwithsideeffectsthatlimittheiruse.17Inameta-analysisevaluatingran-domized controlled trials for the treatment of cyclical mastalgia by Srivastava and col-leagues,23bromocriptine, danazol, andtamoxifenwereall foundtooffersignificantrelief frommastalgia. High-qualitydatacomparingeachof thesemedicationswithone another are not yet available.NoncyclicalBreastPainNoncyclical breast pain does not follow the typical menstrual pattern. It is more likelyto be unilateral and to vary in location. It is important to evaluate for specific pathologicprocessesthatcanbetreated,suchastraumaandpostoperativepainsyndromes,breast cysts, duct ectasia, and periductal mastitis.Traumatothebreast andbreast surgerycanobviouslycausepainintheacutesettingandistypicallyclinicallyobvious. Whatmaybelessobviousisthatapriorhistoryof traumatothebreast andprevioussurgerymayleadtofat necrosisorother remodelingprocesses, causingpainthat canpersist for many years afterthe initial event.6Imaging studies of fat necrosis are often concerning for malignancyandshouldbeevaluatedbytissuebiopsy, evenwhenapatient givesahistoryofpriortraumatotheregion.24Mondordiseaseisaformofsuperficial thrombophle-bitisoftheanteriorthoracoabdominalwall thatcanbecausedbytrauma(includingmuscular strain andelectrocution) or surgery. It presents with a subcutaneous,tender, cord-likeindurationbetweentheepigastricandaxillaryregions. Thediag-nosisis confirmedbyultrasonography, andtreatment involvesanti-inflammatorymedications.25Large palpable breast cysts can be associated with breast pain. These cysts can beconfirmedbyultrasonographyandaretypicallyeffectivelytreatedbyneedleaspira-tion. Simple breast cysts are typically benign in nature. However, if a bloody aspirateisobtained,amasspersistsafteraspiration,orthecystrecurs,abiopsyshouldbeperformed.6Periductal mastitisisanotherimportantcauseofnoncyclical mastalgia.Examina-tion may demonstrate overlying skin erythema, a subareolar breast mass or abscess,Benign Breast Disorders 465or afistula. Diagnosiscanbeconfirmedbyultrasonography. Surgical treatment isusually indicated (see later discussion).PALPABLEBREASTMASSESA palpable breast mass may be described by the patient as a finding she noticed onherown, ormaybediscoveredonroutinephysical examination. Amedical historyshould be obtained, including the length of time the mass has been present, changesin size over time, fluctuations with the menstrual cycle, and any associated pain, skinchanges, or nippledischarge.26Prior historyof breast healthshouldbeobtained,includingpast breast biopsiesor surgeryandanyepisodesof abnormal imaging.Risk factors for breast cancer should be assessed, including a detailed family history.6A clinical breast examination should be performed with visual inspection, palpationof the axillae, supraclavicular, and cervical lymph node regions, and palpation of bilat-eral breasts.27Anypalpablefindingshouldbedescribedusingclear, descriptiveterminology, includingthesize, tissueconsistency, mobility, margincharacteristics,distancefromtheareolaredge,andtheclock-faceposition.Occasionallyapatientmay present for evaluation of a breast mass, but during the clinical examination neithershe nor the provider is unable to palpate it. In this instance it is recommended that shereturn for a repeat breast examination in 2 to 3 months, possibly in the follicular phaseof the menstrual cycle.27Whenadominantmassorconcerningareaisidentifiedonexamination, imagingstudies should be obtained. The ordering physician should describe the exact location(includingclock-facepositionanddistancefromthenippleor areolar margin) toensurethatthesestudiestargettheareaofinterest.Breastultrasonographyshouldbe performed to determine whether the lesion is solid or cystic and to further charac-terizeitassuspiciousorbenign-appearing.Forwomenolderthan30years,adiag-nosticmammogramshouldalsobeordered.27Mammographycanhelpdeterminewhetheralesionispotentiallymalignant,andalsoscreensforoccultdiseaseinsur-rounding tissue. The results of these imaging studies should be reported by the radi-ologist using the Breast Imaging Reporting and Data System(BI-RADS), whichclassifies studies according to the level of suspicion for malignancy (further discussedin the article by Garcia and colleagues elsewhere in this issue).In some instances, mammography and ultrasonographycannot identify any lesionthatcorrelateswiththepalpablefindings.Ifthepalpableareapersistsandremainsconcerning, a biopsy or referral to a breast surgeon should be obtained. A small per-centage of breast cancers are present only as a palpable mass but cannot be identi-fiedwithimagingstudies,soitisimportanttoconsiderthatnormal imagingstudiescannot completely exclude malignancy.18Imagingmaysuggestaspecificbenignlesionbasedonitscharacteristicappear-ance(BI-RADS2)ormaysuggestthatthelesionisprobablybenign(BI-RADS3).Ifthepatientshistoryand physicalexaminationare alsoconsistentwithbenigndis-ease, the lesion can be followed clinically or with short-interval follow-up. If the clinicalfindings remain worrisome despite reassuring imaging, a biopsy of the lesion is recom-mendedforfurtherevaluation.27ImagingstudiesthatresultasBI-RADS4or5aremore suspicious for malignancy, and a tissue biopsy is warranted.Percutaneouscore-needlebiopsyisnowthemost commonlyusedandfavoredmodality for obtaining a breast-tissue specimen for diagnosis.8It is a minimally inva-sive technique, has fewcomplications, and minimizes surgical changes to thebreast.27Fine-needle aspiration was used more commonly in the past, but has beencriticizedforhavingarelativelyhighrateof obtainingsamplesdeemedinadequateOnstad & Stuckey 466orsuboptimal.Onestudyfound28%ofsamplesinadequateandanadditional 22%lessthanoptimal.28Whenthepretest probabilityof malignancyislow, fine-needleaspiration can be used in combination with clinical examination and imaging studies,which is termed the triple test. When all 3 studies suggest a benign process, there is a99%certainty that themass is benign.27Surgical excisional biopsy is generallyreservedforspecial circumstanceswhencore-needlebiopsycannotbeperformed,or when the results of the core-needle biopsy require that additional tissue be obtainedto confirm a benign diagnosis.27FibroadenomaFibroadenomasarecommon benignlesionsofthebreast thatarisefromtheepithe-liumandstromaoftheterminal ductlobularunit.8Theselesionsaremostcommoninyoungwomenbetweentheagesof20and40years,butcanbefoundinwomenof anyage. Fibroadenomastypicallypresent asadiscretepainlessbreast massdiscovered by the patient. On examination a fibroadenoma is smooth, mobile, well cir-cumscribed, and has a rubbery consistency. Approximately 10% to 20% are multipleandbilateral.8Onultrasonographytheyaretypicallyelliptical orlobulated, andarewiderthantall.Mostmeasurelessthan3cminsize.Afibroadenomalargerthan6 cm is referredto as a giantfibroadenoma,and must bedistinguishedfrom aphyl-lodes tumor (see later discussion). Unlike fibroadenoma, phyllodes tumors mayenlarge quickly and can visibly distort the breast.18Afibroadenomathathasbeenconfirmedbycore-needlebiopsydoesnotrequiresurgical excisionunlessit isbothersometothepatient or clinicallyenlargesovertime.18Newer technologies, suchasultrasound-guidedvacuum-assistedremovaland cryoablation, offer minimally invasive approaches to treating small fibroadenomassmaller than 2 cm.8PhyllodesTumorPhyllodes tumors are rare, accounting for less than 1% of all breast tumors.29Thesetumors are fibroepithelial, with the potential to become malignant, recur, and metas-tasize to other organs.8Most women present with a firm palpable mass with examina-tion findings similar to those of fibroadenoma. The average size is 4 to 5 cm, but theycan be small (1 cm) or extremely large (>30 cm). Unfortunately,there are no specificimagingfeaturesonmammography,ultrasonography,orMRI thatcandistinguishaphyllodes tumor from a fibroadenoma.29Histologically,phyllodestumorsareclassifiedasbenign,borderline,ormalignant.Of note, evenbenignphyllodestumorsrecur, andbothborderlineandmalignanttumors havetheability tometastasize. Management of nonmetastaticphyllodestumors requires wide local excisionwith margins 1 cm or greater. Totalmastectomyis recommended if negative margins cannot be obtained.29HamartomaHamartomas account for 4.8%of benign breast tumors,8and consist of ducts, lobules,fibrous stroma, and adipose tissue all arranged in a disorganized fashion. Hamartomaspresent as painless, well-circumscribed, mobilemasses, andaremost commonamongwomenaged30to50years. Onultrasonographytheyappear asasolidmass. Mammography demonstrates a sharply defined, homogeneously densemass.30Once confirmedby tissue biopsy, if no atypia is identified they can be managedwith observation alone.8Benign Breast Disorders 467FibromatosisAlso referred to as a desmoid tumor, fibromatosis of the breast is similar to fibroma-tosisat other sites. It isanuncommontumorcharacterizedasaninfiltrating, well-differentiatedproliferationof spindlecells.8Fibromatosismaybeseeninpatientswith a history of familial adenomatous polyposis (FAP). Women present with apalpablemassthatmayadheretothechestwall orcausedimplingorretractionoftheskin.Forthisreason,itcanbesuspiciousofmalignancy.31Onultrasonography,it canappear lobulatedor spiculated, withirregular margins.32It isfrequentlynotdetectable on mammography, but may appear spiculated and irregular whenseen.32MRI isthebestmethodfordeterminingthesizeandextentof thelesion.31The recommended treatment is wide localexcision. Positivemargins are associatedwith a high risk of recurrence, and should be re-excised.8LactatingAdenomaThe most common palpable breast mass among young pregnant women is alactating adenoma,33which only arise during pregnancy andin the postpartumperiod.Womenpresentwithwell-circumscribedmassesthattypicallymeasure2to4cm.8Ultrasonographydemonstratesanovoidmasswithwell-definedmargins. Acore-needlebiopsy shouldbeperformedtoobtainadiagnosis andevaluateformalignancy. Histologically a lactatingadenoma appears as a lobulatedmass ofenlargedacini surroundedby a basement membrane andedematous stroma.34Approximately5%of casesarecomplicatedbyhemorrhageandinfarctionof thebreasttissue.Itisthoughtthatinfarctionoccursbecauseofrelativevascularinsuffi-ciencyof thebreastduringthistime, owingtoahighrequirementforbloodsupplyduringpregnancyandlactation.34Followingcompletionofpregnancyandlactation,lactating adenomas typically involute. If the mass persists or enlarges, surgical exci-sionshouldbeconsidered.34ADOLESCENTBREASTDISORDERSBreast concernsamongadolescent womenarecommon. Concernsabout nippledischargeandbreastpainmay ariseinthisagegroup.Theevaluationandmanage-ment of these problems in adolescents is similar to that conducted for adults. Adoles-cent womencanbegiven greaterreassurancethantheiroldercounterpartsthattheincidence of breast cancer among women of their age is very rare. Nonetheless, theirconcerns should be adequately evaluated and addressed.Themostcommonbreastmassesamongadolescentwomenarefibroadenomas.Giant fibroadenomas and phyllodes tumors can also occur, and should be consideredin the differential diagnosis. Palpable masses should be evaluated with ultrasonogra-phy. There is no role for mammography in the adolescent woman.A fewadditional concerns that may arise in adolescence are covered here, includingbreast asymmetry, tuberous breasts, and juvenile hypertrophy.BreastAsymmetryDuringpuberty,itisnotuncommonforonebreasttodevelopmorerapidlythantheother. Onphysical examination, asymmetryisnotedwithout anypalpablemasses.Ultrasonographymaybeorderedfor further evaluationof amasscontributingtoasymmetrywhenwarranted. Withanegativeevaluation, patientsandtheirparentscanbereassuredthat asymmetryoftenbecomeslessnoticeablewithage. Whenplastic-surgeryproceduresaredesired,theyshouldbedelayeduntilafterfullbreastdevelopment is complete.35Onstad & Stuckey 468TuberousBreastDeformityTuberousbreastsarebreastswithalimitedbreastbaseandoverdevelopednipple-areolar complex. This condition may be caused by the use of exogenous steroids orhormones. When extreme, they can be surgically managed.35JuvenileHypertrophyJuvenilehypertrophydescribesextrememacromastiawithpathologicovergrowthof bilateral breasts, withonsetatmenarche. Eachbreastmayweighasmuchas30to50lb(13.622.7kg),leadingtobackandneckstrain.Surgical managementwith reduction mammoplasty is often considered in the older teen or youngadult.35INFLAMMATORYLESIONSThere are many benign causes that can lead to inflammatory breast lesions; however,breast inflammationmayalsobeamanifestationof malignancy. It isimportant toappropriately evaluatetheselesions, prevent complications of infectious causes,and accurately and promptly diagnose inflammatory breast cancer. This section dis-cusses benign inflammatory lesions, ways to distinguish them from malignant lesions,and the management of such lesions. Inflammatory lesions may be classified as infec-tious, noninfectious, and malignant.The evaluation should begin with a thorough history. The patient should describe thetiming of the redness and whether the extent of redness has changed over time. Anyassociated masses should be noted as well as systemic symptoms including fevers,chills, and weight loss. Special attention should be paid to risk factors for breast infec-tionssuchaslactation,smoking,priorinfectionsorabscesses,nipplepiercing,andrecentsurgery.36Physical examinationshouldfocusonthebreastandaxilla,evalu-ating for erythema, masses, purulent drainage, and lymphadenopathy. Imagingstudies such as ultrasonography and/or mammography may be indicated to evaluatefor associated masses or evidence of malignancy.LactationalInfectionsLactationalmastitisis themost common formof mastitis.It occurs in approximately2%to10%ofbreastfeedingwomenandtypicallyoccursduringthefirst6weeksofbreastfeeding or weaning.8Lactational mastitis is associatedwith engorgement,poor milk drainage, and excoriated nipples. Women may present with fevers, malaise,and occasionally rigors. On examination there is typically erythema, localized engorge-ment,orswelling.Treatmentconsistsofantibioticsandencouragementofmilkflowfromtheengorgedsegment.37Asmallerproportionofbreastfeedingwomen(0.4%)develop a breast abscess, which in some cases may be due to suboptimal manage-ment of mastitis.37Asuspectedbreast abscessor anymastitisthat doesnot resolvedespitethecompletionof acourseof antibiotics shouldbeevaluatedwithultrasonography.Whenanabscessisidentified, managementshouldincludeeitheraspirationof thefluid or incision and drainage. When the tissue overlying the abscess is normal, aspi-ration may be the most suitable option. Aspiration should be done in combination withthe use of oral antibiotics, and reaspiration should be performed every 2 to 3 days untilno further purulent fluid can be drained.37If, however, the skin overlying the abscessappearsthinnedor necrotic, it maybemoreadvisabletoproceedtoincisionanddrainagerather thanattempt tomanagewithaspiration, giventhat thesepatientshave a higher likelihood of failing treatment with repeated aspiration.37Benign Breast Disorders 469NonlactationalInfectionsNonlactational infections include periductal mastitis, granulomatous lobularmastitis, and skin-associated infections (such as infected epidermal cysts andcellulitisofthebreast). Periductal mastitisdescribesaconditionofdamagedsub-areolarductsthatbecomeinfected.Smokingtobaccoisconsideredtobeamajorcausative factor, with 90%of patients who develop periductal mastitis beingsmokers.37Womenwithdiabetesaremorelikelytohaverecurrent infections.37Granulomatous lobular mastitis is less common, and typically presents as a periph-eral inflammatorymassof unknowncause. Nonlactatingabscessescanbeman-aged similarly to lactating abscesses, with aspiration or incision and drainagecombinedwithoral antibiotics. Recurrent infectionsaremorecommonthantheyareamonglactatingabscesses, typically becausetheunderlyingabnormalityinthecentral ductspersists.Womenwhohaverecurrentdiseasemayrequiredefini-tivesurgerywithtotal ductexcision,whichremovesthediseasedductstopreventinfectionfromrecurring.37MalignantInflammatoryLesionsInflammatorybreast cancer mimicsaninfectiousprocess. Most patientswhoarediagnosedwith inflammatory breast cancerwere initially misdiagnosedas having aninfectious process. When inflammation does not resolve with treatment, inflammatorybreast cancer should be considered. A mammogramand ultrasonogramshould be or-dered, and any suspicious findings should be biopsied. The skin can also be biopsiedto confirm the diagnosis.15BENIGNBREAST ABNORMALITYDETECTEDONIMAGINGANDBIOPSYRoutine screening mammograms may reveal benign breast abnormalities that are nototherwiseclinically evident or symptomatic. Onimaging, they may appear similar toma-lignancies: as calcifications, a mass or density, asymmetry, or an area of architecturaldistortion.18Of all screening mammograms performed, approximately 10%will requireadditional imaging. Of those, approximately 8%to 10%will require biopsy. Breast can-cer will be detected in 4 of every 1000 women undergoing screening mammography.The remaining women who undergo biopsy for abnormal imaging findings will be diag-nosed with benign breast disease.38,39It is important for the obstetrician-gynecologisttobefamiliarwiththesediseases.Somerequirefurtherevaluationandreferral toabreast surgeonfor surgical excision. Othersmaybeassociatedwithanincreasedrisk of developing breast cancer in the future. In general, these lesions can be classifiedas nonproliferative lesions, proliferative lesions without atypia, and proliferative lesionswith atypia.NonproliferativeLesionsBreast cysts are common nonproliferative lesions found incidentally on imaging, whichoriginate from the terminal ductal lobule unit and can vary in size from microscopic tolarge, clinicallypalpablemasses. Small simplebreast cystsfoundincidentallyonimaging are nearly always benign and do not require any further workup. Other nonpro-liferativelesionsincludemildhyperplasiaandpapillaryapocrinechange(commonlyfound in fibrocystic disease), which also do not require any further workup. In general,nonproliferative lesions are not considered to increase a womans risk of developingbreast cancer.27Onstad & Stuckey 470ProliferativeLesionsWithoutAtypiaProliferative lesions without atypia include fibroadenomas, intraductal papillomaswithoutatypia, sclerosingadenosisorradial scar,andpseudoangiomatousstromalhyperplasia(PASH).Fibroadenomasandpapillomasaredescribedinanearliersec-tionof thisarticle. Aradial scarisacomplexsclerosinglesionwitharadial center.When seen on a mammogram it appears spiculated, similar to a small invasive carci-noma. Histologically, it consistsof proliferativechangessurroundingafibroelasticcorethat canmimictheappearanceof amalignancy. Whendiagnosedonacorebiopsy, anexcisional biopsyisgenerallyrecommendedtoevaluatetheentiretyofthe lesion. Sclerosing adenosis can also present as a suspicious finding on imaging,but the risk of subsequent breast cancer is small, and no treatment is required.PASH is a myofibroblastic proliferation of the breast. On mammography it appearsasanoval masswithoutmicrocalcifications. WhenPASHisdiagnosedbypercuta-neouscorebiopsy,nofurthermanagementisnecessaryaslongastheabnormalityisconcordantwiththeimagingfindings.Ifimagingisotherwisesuspicious,surgicalexcisionisrecommended.40Thereisnoincreasedriskof developingsubsequentbreast cancer.40ProliferativeLesionswithAtypiaProliferativelesionswithatypiaincludevarioustypesof epithelial hyperplasiawithatypical cells. Women diagnosed with these lesions carry an increased risk of devel-oping breast cancer, with a relative risk of 3.9 to 13.0.15Depending on the type of cellsinvolved, they are classified as atypical ductal hyperplasia, atypical lobular hyperpla-sia, or flat epithelial hyperplasia. 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