Non-cancerous breast conditions are breast changes that are not cancer. They are very common and can be found in most women. In fact, most breast changes that are biopsied and looked at under the microscope turn out to be benign (bee-nine). Benign is another word for non-cancerous.

Unlike breast cancers, benign breast conditions are not life-threatening. But sometimes they can cause symptoms that bother you. And certain benign conditions are linked with an increased risk of developing breast cancer. We will cover this in more detail later.

Normal breast tissue and function

The main function of the breast is to make milk for breast-feeding. The breast has 2 main types of tissues: glandular tissues and supporting (stromal) tissues.

The glandular part of the breast includes the lobules and ducts. In women who are breast-feeding, the cells of the lobules make milk. The milk then moves through the ducts--tiny tubes that carry milk to the nipple. Each breast has many main ducts.

The support tissue of the breast includes fatty tissue and fibrous connective tissue that give the breast its size and shape.

Any of these parts of the breast can undergo changes that cause symptoms. The 2 main types of breast changes are benign (non-cancerous) breast conditions and breast cancers.

Here we will review some of the signs and symptoms of benign breast conditions and how they are found and diagnosed. We will also review the more common benign breast conditions, such as fibrocystic changes, benign breast tumors, and breast inflammation.

If you would like to know more about breast cancer, please call us or visit our Web site to get our document called Breast Cancer.

Finding benign breast conditions

Signs and symptoms of breast changes

Changes in the breasts may be caused either by benign conditions or cancer. The most common symptoms are likely to be caused by benign conditions. Still, it is important to let your doctor know about any changes you notice. Many symptoms of benign conditions are the same as those seen in breast cancer. It is hard to tell the difference between benign and cancerous conditions based on symptoms alone. Your doctor can do other tests to tell the difference between the two.

Some benign breast conditions may not cause any symptoms and may be found during a mammogram or a breast biopsy.

Lumps

A benign breast condition often causes a lump or thickened area. It may or may not feel tender. A woman often finds it while checking her breasts or under her arms, or her doctor or nurse finds it during a breast exam.

The most common causes of a single breast lump are:

• fibroadenoma -- a benign solid tumor
• fibrocystic changes -- benign breast changes
• atypical hyperplasia -- fast-growing abnormal cells
• cysts -- benign, fluid-filled sacs
• non-invasive cancers -- ductal carcinoma in situ or DCIS

All of these will be covered in more detail in the section "Types of non-cancerous breast conditions."

The younger a woman is, the more likely it is that a single breast lump will be benign. But certain changes are more common to women of certain ages, as shown here:

In any of these age groups, there is a chance that a single lump may be breast cancer although it is more likely in older women than in younger ones. No matter what age the woman is, lumps and other changes must be checked to be sure they are not breast cancer.

Having many lumps in both breasts is most often caused by fibrocystic changes.

Breast lumps, like other symptoms, have to be considered along with other symptoms a woman may be having. For example, a new, tender lump that comes up at the same time as skin redness and a fever may be a sign of a breast infection. Still, any new lump or other change should be checked by a doctor or nurse, because at least one type of breast cancer (inflammatory breast cancer) can look a lot like an infection.

Pain

Some women have breast pain or discomfort that is related to their menstrual cycle. This type of cyclic pain is most common in the week or so before a menstrual period. It often goes away once menstruation begins. Many women with fibrocystic changes have cyclic breast pain. This is thought to be caused by changes in hormone levels.

Some benign breast conditions, such as breast inflammation (mastitis) may cause a more sudden pain in one spot. In these cases the pain is not related to the menstrual cycle. Rarely, breast cancer lumps can be painful, too.

Nipple discharge

Although a discharge (other than milk) from the nipple may be alarming, in most cases it is caused by a benign condition. As with breast lumps, the younger a woman is, the more likely it is that the condition is benign. (See the section, "Nipple discharge exam".)

In benign conditions, a non-milky discharge is usually clear, yellow, green, or brown. If the discharge contains blood that you can see or that is found in lab tests, the cause is still not likely to be cancer. But it is cause for more concern and more testing.

If the discharge is coming from more than one breast duct or from both breasts it is usually because of a benign condition such as fibrocystic changes or duct ectasia (described later).

If the discharge (bloody or non-bloody) is from a single duct, it can be caused by a benign condition like intraductal papilloma or duct ectasia. But it can also be caused by a pre-cancerous condition (such as ductal carcinoma in situ) or by cancer, and should be looked at right away.

A milky discharge from both breasts (other than while pregnant or breast-feeding) sometimes can happen in response to the menstrual cycle. It can also be caused by an imbalance of hormones made by the pituitary or thyroid gland, or even caused by certain drugs.

Again, while benign conditions are much more common than breast cancer, it is important to let your health care team know about any changes in your breast so they can be checked out right away.

American Cancer Society recommendations for early breast cancer detection

Women age 40 and older should have a screening mammogram every year and should continue to do so for as long as they are in good health.

• Current evidence supporting mammograms is even stronger than in the past. Recent evidence has confirmed that mammograms offer great benefit for women in their 40s. Women can feel confident about the benefits associated with regular mammograms for finding cancer early. But mammograms also have limitations. A mammogram can miss some cancers, and it sometimes leads to follow up (such as biopsies) of findings that turn out not to be cancer.

• Women should be told about the benefits, limitations, and potential harms linked with regular screening. Mammograms can miss some cancers. But despite their limitations, they remain a very effective and valuable tool for decreasing suffering and death from breast cancer.

• Mammograms for older women should be based on the individual, her health, and other serious illnesses, such as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, and moderate-to-severe dementia. Age alone should not be the reason to stop having regular mammograms. As long as a woman is in good health and would be a candidate for treatment if breast cancer was found, she should continue to be screened with a mammogram.

Women in their 20s and 30s should have a clinical breast examination (CBE) as part of a periodic (regular) health exam by a health professional, preferably every 3 years. Starting at age 40, women should have a breast exam by a health professional every year.

• CBE is done along with mammograms, and offers a chance for women and their doctor or nurse to discuss changes in their breasts, early detection testing, and factors in the woman’s history that might make her more likely to have breast cancer.

• There may be some benefit in having the CBE shortly before the mammogram. The person who does your exam should talk with you about ways to get more familiar with your own breasts. Women should also be given information about the benefits and limitations of CBE and breast self-examination (BSE). Breast cancer risk is very low for women in their 20s and gradually increases with age. Women should be told to report any new breast symptoms to a health professional right away.

Breast self-examination or BSE is an option for women starting in their 20s. Women should be told about the benefits and limitations of BSE. Women should report any breast changes to their healthcare professional right away.

• Research has shown that BSE plays a small role in finding breast cancer compared with finding a breast lump by chance or simply being aware of what is normal for each woman. Some women feel very comfortable doing BSE regularly (usually monthly) which involves a careful step-by-step approach to looking at and feeling one’s breasts. Other women are more comfortable simply looking and feeling their breasts in a less systematic approach, such as while showering or getting dressed or doing an occasional thorough exam. Sometimes, women are so concerned about "doing it right" that they become stressed over the technique. Doing BSE regularly is one way for women to know how their breasts normally look and feel and to notice any changes. The main point, with or without BSE, is to report any breast changes to a doctor or nurse right away.

• Women who choose to do BSE should have their BSE technique reviewed during their physical exam by a health professional. It is okay for women to choose not to do BSE or not to do it on a regular schedule. But by doing the exam regularly, you get to know how your breasts normally look and feel and you can more readily find any changes. If something changes, such as a new lump or swelling, skin irritation or dimpling, nipple pain or retraction (turning inward), redness or scaliness of the nipple or breast skin, or a discharge other than breast milk that stains your sheets or bra, you should see your health care professional as soon as possible. But remember that most of the time these breast changes are not cancer.

Women at high risk (greater than 20% lifetime risk) for breast cancer should get an MRI and a mammogram every year. Women at moderately increased risk (15% to 20% lifetime risk) should talk with their doctors about the benefits and limitations of adding MRI screening to their yearly mammogram. Yearly MRI screening is not recommended for women whose lifetime risk of breast cancer is less than 15%.

• Women at high risk include those who:

• have a known BRCA1 or BRCA2 gene mutation
• have a first-degree relative (mother, father, brother, sister, or child) with a BRCA1 or BRCA2 gene mutation, and have not had genetic testing themselves
• have a lifetime risk of breast cancer of 20% to 25% or greater, according to risk assessment tools that are based mainly on family history
• had radiation therapy to the chest when they were between the ages of 10 and 30 years
• have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or have one of these syndromes in first-degree relatives

• Women at moderately increased risk include those who:

• have a lifetime risk of breast cancer of 15% to 20%, according to risk assessment tools that are based mainly on family history
• have a personal history of breast cancer, ductal carcinoma in situ (DCIS), lobular carcinoma in situ (LCIS), atypical ductal hyperplasia (ADH), or atypical lobular hyperplasia (ALH)
• have extremely dense breasts or unevenly dense breasts when viewed by mammograms

• If MRI is used, it should be in addition to, not instead of, a screening mammogram. This is because while an MRI is a more sensitive test (it's more likely to detect cancer than a mammogram), it may still miss some cancers that a mammogram would detect.

• For most women at high risk, screening with MRI and mammograms should begin at age 30 years and continue for as long as a woman is in good health. But because the evidence is limited regarding the best age at which to start screening, this decision should be based on shared decision making between patients and their health care providers, taking into account personal circumstances and preferences.

• Several risk assessment tools, with names such as BRCAPRO, the Claus model, and the Tyrer-Cuzick model, are available to help health professionals estimate a woman's breast cancer risk. These tools give approximate, rather than precise, estimates of breast cancer risk based on different combinations of risk factors and different data sets. As a result, they may give different risk estimates for the same woman. Their results should be discussed by a woman and her doctor when being used to decide on whether to start MRI screening.

• It is recommended that women who get screening MRI do so at a facility that can do an MRI-guided breast biopsy at the same time if needed. Otherwise, the woman will have to have a second MRI exam at another facility at the time of biopsy.

• There is no evidence at this time that MRI will be an effective screening tool for women at average risk. While MRI is more sensitive than mammograms, it also has a higher false-positive rate (where the test finds something that turns out not to be cancer), which would result in unneeded biopsies and other tests in a large portion of these women.

The American Cancer Society believes the use of mammograms, MRI in women at high risk, clinical breast exams, and finding and reporting breast changes early, according to the recommendations outlined above, offers women the best chance to reduce their risk of dying from breast cancer. This combined approach is clearly better than any one exam or test alone. Without question, a breast physical examination without a mammogram would miss many breast cancers that are too small for a woman or her doctor to feel, but can be seen on mammograms. While mammograms are a sensitive screening method, a small percentage of breast cancers do not show up on mammograms but can be felt by a woman or her doctors. For women at high risk of breast cancer as defined above, both MRI and mammograms of the breast are recommended.

Diagnosing benign breast changes

If your symptoms or mammogram results suggest that you may have breast cancer or benign breast disease, your doctor will take some more steps to diagnose the condition. It is important to find out exactly what the problem is so that the best treatment can be chosen.

Medical history and physical exam

The first step is a medical history and physical exam. Answering questions about your personal and family medical history will give your doctor information about symptoms and your risk factors for breast cancer and benign breast conditions. Next, the doctor will do a thorough breast exam to find any lumps and to feel their texture, size, and relationship to the skin and chest muscles. Any changes in the nipples or the skin of the breast will be noted. The lymph nodes under the armpit and above the collarbones may be felt because swelling or firmness of these lymph nodes might be a sign of spread of breast cancer. (Lymph nodes are small, bean-shaped collections of immune system cells that are important in fighting infections. They are connected by lymphatic vessels. Breast cancer cells can enter lymphatic vessels and begin to grow in lymph nodes.)

Along with taking your medical history and examining you, imaging tests and a biopsy may be done.

Imaging tests for breast disease (diagnostic tests)

Mammograms

A mammogram is an x-ray of the breast. Mammograms are mostly used for screening, but they can also be used to look at a woman's breast if she has a breast problem. When used in this way, they are called diagnostic mammograms. They can be used to find out more about a breast lump (mass), nipple discharge, or an area found on a screening mammogram that doesn't look normal. In some cases, special images known as cone views with magnification are used to "zoom in" on a small area of altered breast tissue to make it easier to evaluate.

A diagnostic mammogram may show that a lesion (an area of abnormal tissue, which may or may not feel like a lump) is most likely to be benign (not cancer). In these cases, it is common to ask the woman to come back sooner than usual for another look, usually in 4 to 6 months. On the other hand, a diagnostic mammogram may show that the abnormality is nothing to worry about at all, and the woman can then return to having routine yearly mammograms. But the results of a diagnostic work-up may suggest that a biopsy is needed to tell if the lesion is cancer. Even if the mammogram does not show a tumor, if you or your doctor can feel a lump, then usually a biopsy will be needed to make sure it isn't cancer. One exception would be if an ultrasound examination (see the section, "Breast ultrasound") shows that the lump is a cyst.

The mammogram is looked at by a radiologist (a doctor trained to interpret images from x-rays, ultrasound, MRI, and related tests). The radiologist reading the mammogram will look for several types of changes. The 2 main types of abnormalities doctors look for on mammograms are calcifications and masses.

Calcifications are tiny mineral deposits within the breast tissue. They look like small white spots on the films. They may or may not be caused by cancer. There are 2 types of calcifications:

• Macrocalcifications are coarse (larger) calcium deposits that are most likely changes in the breasts caused by aging of the breast arteries, old injuries, or inflammation. These deposits are related to non-cancerous conditions and do not require a biopsy. Macrocalcifications are found in about half of women over 50, and 1 in 10 women under 50.

• Microcalcifications are tiny specks of calcium in the breast. They may be alone or in clusters. They look like small white spots on the film. Microcalcifications seen on a mammogram are of more concern, but do not always mean that cancer is present. The shape and layout of microcalcifications help the doctor judge how likely it is that cancer is present. In most instances, the presence of microcalcifications does not mean you need a biopsy. Instead, a doctor may advise you to have a follow-up mammogram within 3 to 6 months. In other cases, if the microcalcifications look more suspicious, you will need a biopsy.

A mass, which may or may not have calcifications, is another important change seen on mammograms. Masses can be many things, including cysts (non-cancerous, fluid-filled sacs) and non-cancerous solid tumors (such as fibroadenomas). But they may be cancer and usually should be biopsied if they are not cysts.

• A cyst cannot be diagnosed by physical exam alone, nor can it be diagnosed by a mammogram alone. To confirm that a lump (mass) is really a cyst, either a breast ultrasound is needed or the fluid in the cyst must be removed with a thin, hollow needle.

• A cyst is filled with fluid. If a mass has any solid parts, it is no longer a simple cyst and more imaging tests may be needed. Some masses can be watched with mammograms, while others may need a biopsy. The size, shape, and margins (edges) of the mass help the radiologist figure out whether cancer may be present.

If your earlier mammograms are available, they may help show that a mass has not changed for many years. This would mean that it is likely a benign condition and a biopsy is not needed. Having your older mammograms available for the radiologist to review is very important.

Mammograms have limitations: Mammograms don't show breast changes as well in younger women, usually because their breasts are dense and this can hide a tumor. This is also true for pregnant women and women who are breast-feeding, though studies have shown that the breasts may or may not be any denser than before their pregnancy. Since most breast cancer occurs in older women, this is usually not a major problem. But it is a problem for young women who have a genetic risk factor for breast cancer because they often develop breast cancer at a younger age. For this reason, breast MRI is recommended along with mammograms to screen these high-risk women.

A mammogram may show something suspicious, but by itself it cannot prove that an abnormal area is cancer. Still, a diagnostic mammogram may show that an area of abnormal tissue is most likely benign. In these cases, the woman is asked to come back sooner than usual for a re-check, usually in 6 to 12 months.

If the diagnostic mammogram and breast exam results suggest cancer may be present, a biopsy is needed. A biopsy is a procedure in which the doctor removes a small amount of tissue. Then a pathologist looks at it to find out whether the abnormal tissue is a cancer. (A pathologist is a doctor who specializes in diagnosing disease by looking at tissue samples or cells under a microscope.)

You should also know that even diagnostic mammograms are not perfect at finding breast cancer. If you have a breast lump, you should have it checked by your doctor and consider having it biopsied even if your mammogram is normal. A biopsy is the only way to know for sure if a breast change is cancer.

Breast ultrasound

Ultrasound, also known as sonography, is an imaging method that uses high-frequency sound waves to look inside a part of the body. A handheld instrument placed on the skin transmits the sound waves through the breast. Echoes from the sound waves are picked up and translated by a computer into a picture that is displayed on a computer screen. This test is painless and you are not exposed to radiation.

Breast ultrasound is sometimes used to evaluate breast problems that are found during a screening or diagnostic mammogram or on physical exam. Ultrasound is not routinely used for breast cancer screening.

Ultrasound is useful for evaluating some breast masses and is the only way to tell if a suspicious area is a cyst without placing a needle into it to aspirate (pull out) fluid. A physical exam alone cannot accurately diagnose cysts. Breast ultrasound may also be used to help doctors guide a biopsy needle into some breast lesions.

Ultrasound has become a valuable tool to use along with mammograms because it is widely available, non-invasive, and less expensive than other options. But the effectiveness of an ultrasound test depends on the operator's level of skill and experience. Although ultrasound is less sensitive than MRI (that is, it detects fewer tumors), it has the advantage of being more available and less expensive.

Full-field digital mammograms

Full field digital mammography (FFDM) is much like standard mammography in that x-rays are used to produce an image of your breast. The differences are in the way the image is recorded, seen by the doctor, and stored. Standard mammograms are recorded on large sheets of photographic film. Digital mammograms are recorded and stored on a computer. After the exam, the doctor can look at the pictures on a computer screen and adjust the image size, brightness, or contrast to see certain areas more clearly. Digital images can also be sent electronically to another site for other breast specialists to look at. Although many centers do not offer the digital option at this time, it is expected to become more widely available in the future.

Because digital mammograms cost more than standard mammograms, studies are now underway to find out which form of mammogram will benefit more women in the long run. Some studies have found that women who have FFDM have to return less often for additional imaging tests because of inconclusive areas on the original mammogram. A recent large study from the National Cancer Institute found that FFDM was more accurate in finding cancers in women younger than 50 and in women with dense breast tissue, although the rates of inconclusive (uncertain) results were similar between FFDM and film mammograms. It is important to remember that standard film mammogram also is effective for these groups of women, and that they should not miss having their regular mammogram if digital mammogram is not available.

Computer-aided detection and diagnosis

Over the past 2 decades, computer-aided detection and diagnosis (CAD) has been developed to help radiologists find suspicious changes on mammograms. This is most often done with screen-film mammograms and less often with digital mammograms.

In most cases, the computer device will scan the mammogram first. It can find tumors that the radiologist can’t spot. The radiologist, knowing the results of the CAD, will then review the films to look for lesions (abnormal areas) the CAD missed. The radiologist will also decide the seriousness of the lesions the CAD found. Early research results suggest that CAD systems help radiologists diagnose more early stage cancers than mammograms alone.

Tomosynthesis

Tomosynthesis allows the breast to be viewed as many thin slices and may provide more accurate and earlier diagnosis of breast cancer. This technology is still considered experimental and is only available in clinical trials at this time.

MRI of the breast

Magnetic resonance imaging or MRI scans use radio waves and strong magnets instead of x-rays. The energy from the radio waves is absorbed and then released in a pattern formed by the type of tissue and by certain diseases. A computer translates the pattern of radio waves given off by the tissues into a very detailed image of parts of the body. A contrast material called gadolinium is often injected so the radiologist can see details better.

Patients have to lie inside a tube for this test. This is confining and can upset people with claustrophobia (a fear of enclosed spaces). The machine also makes a thumping noise that some people find disturbing. Some places provide headphones with music to block out the noise.

Although MRI machines are quite common, they need to be adapted to look at the breast. They can be used to better look at cancers found by mammogram or for screening women who have a high risk of developing breast cancer. MRI can also be used to guide biopsies so that the doctor can be sure to get tissue from the area of concern.

MRI is also used for women who have been diagnosed with breast cancer. It is used to better figure out the actual size of the cancer and to look for any other cancers in the breast.

MRIs are very expensive, although insurance plans generally pay for them once cancer is diagnosed. More insurance companies are paying for screening MRIs for high-risk women, and for MRI-guided biopsies. You may want to check with your insurance company to see if they will cover the procedure.

Ductogram

This test, also called a galactogram, is sometimes helpful in finding out the cause of bloody nipple discharge. In this test a very thin plastic tube is placed into the opening of the duct at the nipple. A small amount of contrast medium is injected, which outlines the shape of the duct on an x-ray image. The x-ray will show if there is a mass outlined inside the duct.

Nipple discharge exam (nipple smear)

If you are having a nipple discharge (fluid that comes from your nipple and stains sheets or underwear), some of the fluid may be collected and looked at under a microscope to see if any cancer cells are in it. Most nipple discharges or secretions are not cancer. In most cases, if the secretion looks clear, green, or milky, cancer is very unlikely. If the discharge is red or red-brown, suggesting that it contains blood, it might be caused by cancer. But an injury, infection, or benign tumor are more likely causes.

Even when no cancer cells are found in a nipple discharge, it is not possible to say for certain that a breast cancer is not there. If there is a suspicious mass, a biopsy is needed, even if the nipple discharge does not contain cancer cells.

Ductal lavage and nipple aspiration

Ductal lavage is an experimental test developed for women who have no symptoms of breast cancer but are at very high risk for it. It is not a test to screen for or diagnose breast cancer, but it may help give a better picture of a woman’s risk of developing it.

Ductal lavage can be done in a doctor’s office or an outpatient facility. An anesthetic cream is put on to numb the nipple area. Gentle suction is then used to help draw tiny amounts of fluid from the milk ducts up to the nipple surface. The fluid droplets help show the milk ducts’ natural openings on the surface of the nipple. A tiny tube (called a catheter) is then put into a milk duct opening on the nipple. A small amount of anesthetic is put into the duct to numb the inside. Saline (salt water) is slowly pushed through the catheter to gently rinse the duct and collect cells. The ductal fluid is withdrawn through the catheter and put in a collection vial. The vial is then sent to a lab, where the cells are looked at under a microscope.

Ductal lavage is not thought to be helpful for women who aren’t at high risk for breast cancer. It is not clear whether it will ever be a useful tool. The test has not been shown to detect cancer early. It is much more useful as a test of cancer risk rather than as a screening test for cancer. More studies are needed to better define the usefulness of this test.

Nipple aspiration also looks for abnormal cells that are in the ducts, but it is much simpler in that nothing is put into the breast. The device for nipple aspiration uses small cups that are placed on the woman's breasts. The device warms the breasts, gently squeezes them, and uses light suction to bring nipple fluid to the surface of the breast. The nipple fluid is then collected and sent to a lab for study. As with ductal lavage, the procedure may be useful as a test of cancer risk, but it is not a screening test for cancer. The test has not been shown to detect cancer early.

Biopsy

During a biopsy the doctor removes a tissue sample to be looked at under a microscope. A biopsy is done when mammograms, other imaging tests, or the physical exam finds a breast change (or abnormality) that may be cancer. A biopsy is the only way to tell if cancer is really present.

There are several types of biopsies, such as fine needle aspiration (FNA) biopsy, core (large) needle (CN) biopsy, and surgical biopsy. Each type of biopsy has its own pros and cons. The choice of which to use depends on your specific situation. Some of the factors your doctor will consider include how suspicious the lesion looks, how large it is, where it is in the breast, how many lesions there are, other medical problems you may have, and your personal preferences. If you need a biopsy, you might want to talk about the different biopsy types with your doctor.

Fine needle aspiration (FNA) biopsy

In FNA biopsy, the doctor uses a very thin, hollow needle attached to a syringe to withdraw (aspirate) a small amount of tissue from a suspicious area. The tissue is then looked at under a microscope. The needle used for FNA is thinner than the ones used for blood tests.

If the area to be biopsied can be felt, a lump for example, the needle can be guided into the area of the breast change as the doctor palpates (feels) it.

If the lump can't be felt easily, the doctor might use ultrasound to watch the needle on a screen as it moves toward and into the mass. Or the doctor may use a method called stereotactic needle biopsy to guide the needle. For stereotactic needle biopsy, computers map the exact location of the mass using mammograms taken from 2 angles. This helps the doctor guide the needle to the right spot.

A local anesthetic (numbing medicine) may or may not be used. Once the needle is in place, fluid is drawn out. If the fluid is clear, the lump is most likely a benign cyst. Bloody or cloudy fluid can mean either a benign cyst or, very rarely, a cancer. If the lump is solid, small pieces of tissue are drawn out. A pathologist will look at the biopsy tissue or fluid under a microscope to find out if it contains cancer cells.

A fine needle aspiration biopsy can sometimes miss a cancer if the needle is not placed among the cancer cells. If it does not provide a clear diagnosis, or your doctor is still suspicious, a second biopsy or a different type of biopsy should be done.

Core needle (CN) biopsy

CN biopsy is much like FNA biopsy. A slightly larger, hollow core needle is used to withdraw small cylinders (or cores) of tissue from the abnormal area in the breast. The procedure is most often done with local anesthesia (you are awake but your breast is numbed) in the doctor's office. The needle is put in 3 to 5 times to get the samples, or cores. This is more invasive and takes longer than an FNA biopsy, but it is more likely to give a definite result because more tissue is taken to be studied. CN biopsy can cause some bruising, but usually does not leave scars.

The doctor doing the CN biopsy usually guides the needle into the abnormal area while palpating (feeling) the lump. If the abnormal area is too small to be felt, a radiologist or other doctor may use needle placement, a stereotactic instrument, or ultrasound to guide the needle to the target area.

Stereotactic core needle biopsy

Stereotactic core needle biopsy uses x-ray equipment and a computer to look at the pictures (x-ray views). The computer then shows the doctor exactly where the needle tip should be placed in the abnormal area. This procedure is often used to biopsy microcalcifications (tiny calcium deposits).

Larger core biopsies

Larger core biopsies use stereotactic methods to take out even more tissue than a core biopsy. The Mammotome^® and ATEC^® (Automated Tissue Excision and Collection) are 2 types of vacuum-assisted core biopsy. For these procedures the skin is numbed and a small cut (about ¼ inch) is made. A hollow probe is put into the cut and into the abnormal area of breast tissue. The probe can be guided into place using x-rays or ultrasound (or MRI in the case of the ATEC system). A cylinder of tissue is then suctioned in through a hole in the side of the probe, and a rotating knife within the probe cuts a tissue sample from the rest of the breast. Many samples can be taken from the same incision. Vacuum-assisted biopsies are done as an outpatient procedure. No stitches are needed, and there is little scarring. This method usually removes more tissue than core needle biopsies.

Surgical biopsy

Sometimes, surgery is needed to take out all or part of the lump to be looked at under a microscope. An excisional biopsy removes the entire breast abnormality (such as a mass or area containing calcifications), as well as a surrounding margin or edge of normal-looking tissue. In rare cases, this type of biopsy can be done in the doctor's office, but it is more often done in the hospital’s outpatient department under a local anesthesia (you are awake during the procedure, but your breast is numbed). Intravenous (IV) sedation is often given to make you drowsy and less aware of the procedure.

During an excisional breast biopsy the surgeon may use a procedure called stereotactic wire localization if there is a small lump that is hard to find by touch or if an area looks suspicious on the x-ray but cannot be felt. First the area is numbed with local anesthetic. Then a thin, hollow needle is put into the breast and x-ray views are used to guide the needle to the suspicious area. Once the needle tip is in the right spot, a thin wire is put through the center of the needle. A small hook at the end of the wire keeps it in place. The hollow needle is then removed, and the surgeon uses the wire as a guide to the abnormal tissue that is to be taken out.

If the tissue does not show cancer, no further treatment is needed.

Biopsy accuracy

The accuracy rates for fine needle aspiration (FNA), and core needle,(CN), and surgical biopsy are much the same. Much less data is available on the newer vacuum-assisted and larger core biopsy techniques. The accuracy of each method depends to a great degree on the doctor's experience with that method. This is especially true with methods that remove smaller amounts of tissue, like the FNA and core needle biopsy. A very precise needle placement is needed so that these methods can give accurate results.

Types of non-cancerous breast conditions

Fibrocystic changes

Fibrocystic changes include a range of changes within the breast in both the glandular (lobules and ducts) and stromal tissues. In the past, this was called "fibrocystic disease." Because this condition affects at least half of all women at some point, it is better defined as a change rather than a disease. You may hear fibrocystic changes called FCC for short.

Fibrocystic changes are most common in women of childbearing age, but can affect women of any age. FCCs are the most common benign condition of the breast. These changes most often affect women between the ages of 20 and 50 years of age, before they go through menopause. FCCs may be found in different parts of the breast and in both breasts at the same time.

Types of fibrocystic changes

Many different changes can be found when fibrocystic breast tissue is looked at under the microscope. Most of these changes reflect the way the woman’s breast tissue has responded to monthly hormone changes and have little other importance. But, some changes may mean a slightly increased risk of developing breast cancer later on. By understanding some of the words doctors use to describe these changes, you can better understand how serious they are and if you will need extra tests to check for cancer.

Fibrosis: As the term fibrocystic suggests, the 2 main features of this tissue are fibrosis and cysts. Fibrosis refers to the prominence of fibrous tissue, the same material that ligaments and scar tissues are made of. Areas of fibrosis feel rubbery, firm, or hard to the touch. Fibrosis does not increase your breast cancer risk and does not need any special treatment.

Cysts: Cysts are fluid-filled, round or oval shaped sacs within the breasts. They are found in about 1 in 3 women between 35 and 50 years old. A clinical exam often cannot tell the difference between a cyst and a mass, so an ultrasound or fine needle aspiration is needed for a diagnosis.

Cysts start out with a build-up of fluid inside breast glands. Microcysts (microscopic cysts) are too small to feel and are found only when tissue is looked at under the microscope. If fluid continues to build up, macrocysts (large cysts) are formed. These can be easily felt and may reach 1 or 2 inches across. As they grow, the breast tissue around the cyst may stretch and be painful.

A round, movable lump, especially one that is tender to the touch, suggests a cyst. Cysts often get bigger and become painful just before the menstrual period. This is due to the effect of monthly hormone changes. Cysts tend to be more noticeable just before the menstrual period starts.

Fine needle aspiration can confirm the diagnosis of a cyst and, at the same time, drain the cyst fluid. Removing the fluid may reduce pressure and pain, but it is not necessary to remove the fluid unless it is causing discomfort. The fluid may come back and more aspirations may be needed. Having 1 or more cysts does not increase your risk of later developing breast cancer.

Diagnosing fibrocystic changes

In most cases, symptoms of fibrocystic changes include breast pain and tender lumps or thickened areas in the breasts. These symptoms may change as the woman moves through different stages of the menstrual cycle. Sometimes, one of the lumps may be more firm or have other features that lead to a concern about cancer. When this happens, a needle biopsy or a surgical biopsy may be needed to make sure that cancer is not present.

Treating symptoms of fibrocystic change

Most women with fibrocystic changes and no symptoms do not need treatment, but closer follow-up may be advised. Women with mild discomfort get relief from supportive bras or over-the-counter pain relievers.

For a very small number of women with painful cysts, draining the fluid by FNA can help relieve symptoms. Many women without any large cysts have breast pain and tenderness, too.

Some women report that their breast symptoms improve if they avoid caffeine and other stimulants (called methylxanthines) found in coffee, tea, chocolate, and many soft drinks. Studies have not found those stimulants to have a significant impact on symptoms, but many women and their doctors feel that avoiding these foods and drinks for a couple of months is worth trying.

Because breast swelling toward the end of the menstrual cycle is painful to some women, some doctors recommend that women reduce salt in their diets or take diuretics (drugs to remove salt and fluid from the body). But studies have not found diuretics to be better than pills that do not have any medicine in them (placebos).

Many vitamin supplements have been suggested, but so far none are proven to be of any use and some may have dangerous side effects if taken in large doses.

Some doctors recommend hormones, such as oral contraceptives (birth control pills), tamoxifen, or androgens. But these are usually used only in women with severe symptoms because of their potential for more serious side effects.

Hyperplasia

Hyperplasia (also known as epithelial hyperplasia or proliferative breast disease) is an overgrowth of the cells that line either the ducts or the lobules. When hyperplasia is in the duct, it is called ductal hyperplasia or duct epithelial hyperplasia. When it affects the lobule, it is referred to as lobular hyperplasia. Atypical hyperplasia (or hyperplasia with atypia) is a term used to describe cells that are slightly distorted in how they are arranged.

Based on how the cells look under the microscope, hyperplasia may be grouped as:

• mild hyperplasia
• hyperplasia of the usual type (without atypia) -- also known as usual hyperplasia
• atypical hyperplasia -- either atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH)

A woman with mild hyperplasia is not at increased risk for breast cancer. A woman with usual hyperplasia has a slightly higher chance of developing breast cancer. The risk is 1½ to 2 times that of a woman with no breast abnormalities. The risk for a woman with atypical hyperplasia is 4 to 5 times higher than that of a woman with no breast abnormalities. (See the section, “How benign breast conditions affect breast cancer risk” for more information.)

• About 7 in 10 biopsies done for benign breast conditions contain no hyperplasia.

• About 26% have mild or usual hyperplasia and only 4% (4 women in 100) have atypical hyperplasia.

• About 2 in 10 women with atypical hyperplasia will develop invasive cancer within 15 years of their biopsy.

Hyperplasia is usually diagnosed with a core needle biopsy or surgical biopsy. A diagnosis of hyperplasia, especially atypical hyperplasia, usually means you will need closer follow-up with your doctor. This may mean more frequent breast exams and a special effort to get yearly mammograms because having hyperplasia increases the chance of developing a breast cancer in the future. Ask your doctor whether your risk is high enough that you need breast MRI scans along with your screening mammograms.

Adenosis

In adenosis, the breast lobules are enlarged, and they contain more glands than usual. Adenosis is often found in biopsies of women with fibrocystic changes. If many enlarged lobules are close to one another, they may be large enough to be felt. There are many names for this condition, including aggregate adenosis, tumoral adenosis, or adenosis tumor. Even though some the word tumor is used, this condition is benign -- it is not a cancer. (A tumor is a lump or mass, but it is not always cancer.)

Sclerosing adenosis is a special type of adenosis in which the enlarged lobules are distorted by scar-like fibrous tissue.

When areas of adenosis and sclerosing adenosis are large enough to be felt, it may be hard for the doctor to tell these lumps from a breast cancer by doing only a breast exam. Calcifications (mineral deposits) may form in adenosis, in sclerosing adenosis, and in cancers. These can be confusing on mammograms. Fine needle aspiration biopsy of these lumps can usually show whether they are benign. A core needle biopsy can usually identify the mass as adenosis, but a surgical biopsy is needed in some cases to be sure it is not cancer.

Some studies have found that women with sclerosing adenosis have about the same risk of developing breast cancer as do women with usual hyperplasia (about 1½ to 2 times the risk of women with no breast changes).

Fibroadenomas

Fibroadenomas are benign tumors made up of both glandular breast tissue and stromal (connective) tissue. They are most common in young women in their 20s and 30s, but they may occur at any age. The use of birth control pills before age 20 is linked to the risk of fibroadenomas.

Some fibroadenomas are too small to feel and can be seen only under the microscope, but some are several inches across. They tend to be round and have borders that are distinct from the surrounding breast tissue. They often feel like a marble within the breast. You can move them under the skin and they are usually firm and not tender. Some women have only one fibroadenoma, but others may have many.

Fibroadenomas can be diagnosed by fine needle aspiration or core needle biopsy. Most fibroadenomas are simple fibroadenomas. These look fairly uniform (they look the same all over) when seen under a microscope. They do not increase breast cancer risk. But some fibroadenomas contain other components (macrocysts, sclerosing adenosis, calcifications, or apocrine changes). Women with these complex fibroadenomas have a slightly increased risk of breast cancer (about 1½ to 2 times the risk of women with no breast changes).

Many doctors recommend removing fibroadenomas, especially if they keep growing or if they change the shape of the breast. Sometimes (especially in middle aged or elderly women) these tumors stop growing or even shrink on their own, without any treatment. In this case, as long as the doctors are certain the masses are really fibroadenomas and not breast cancer, they may be left in place and watched to be sure they don't grow. This approach is useful for women with many fibroadenomas that are not growing. In such cases, removing them all might mean removing a lot of nearby normal breast tissue, causing scarring that would change the shape and texture of the breast. This could also make future physical exams and mammograms harder to interpret.

It is important for women who have fibroadenomas that have not been removed to have breast exams regularly to make sure the mass is not growing.

Sometimes one or more new fibroadenomas grow after one is removed. This means that another fibroadenoma has formed -- it does not mean that the old one has come back.

Phyllodes tumors

Phyllodes (also spelled phylloides) tumors are rare breast tumors that, like fibroadenomas, contain 2 types of breast tissue -- stromal (connective) tissue and glandular (lobule and duct) tissue. The difference between phyllodes tumors and fibroadenomas is that phyllodes tumors have an overgrowth of connective tissue.

The cells that make up the connective tissue part can look abnormal under the microscope. Depending on how the cells look, phyllodes tumors may be classified as benign (non-cancerous), malignant (cancerous), or of uncertain malignant potential (the chance of the tumor becoming cancer is uncertain).

Phyllodes tumors are usually benign but in rare cases may be malignant (cancer). Less than 5% of these tumors spread to other areas, such as the lungs, or come back (recur) in distant areas after treatment. In the past, both benign and malignant phyllodes tumors were referred to as cystosarcoma phyllodes.

The tumors are usually felt as a painless lump, although some may be painful. They may grow quickly and stretch the skin. They are often hard to tell from fibroadenomas on imaging tests, or even with fine needle or core needle biopsies.

Benign phyllodes tumors can sometimes come back if they are removed without taking some of the tissue around them. For this reason, they are treated by removing the mass and a 1 to 2 cm (about 1/2 to 3/4 inch) area of normal breast tissue from around the tumor.

Malignant phyllodes tumors are treated by removing them along with a wider margin of normal tissue, or by mastectomy (removing the entire breast) if needed. Malignant phyllodes tumors do not respond to hormone therapy and are less likely than most breast cancers to respond to chemotherapy or radiation therapy. Phyllodes tumors that have spread to distant areas are often treated more like sarcomas (soft-tissue cancers) than breast cancers.

Close follow-up with frequent breast exams and imaging tests are usually recommended after treatment.

Intraductal papillomas

Intraductal papillomas are wart-like growths of gland tissue along with fibrous tissue and blood vessels (called fibrovascular tissue). These benign tumors grow within the breast ducts.

Solitary papillomas or solitary intraductal papillomas are single tumors that often grow in the large milk ducts near the nipple. They are a common cause of clear or bloody nipple discharge, especially when it comes from only one breast. They may be felt as a small lump behind or next to the nipple. They do not raise breast cancer risk, unless they contain other changes, such as atypical hyperplasia.

Papillomas may also be found in small ducts in areas of the breast further from the nipple. In this case there are often several growths (multiple papillomas). These tumors are less likely to cause nipple discharge. Unlike single papillomas, multiple papillomas are linked to an increased risk of breast cancer.

Papillomatosis is a type of hyperplasia in which there are very small areas of cell growth within the ducts, but they are not as focused as they are with papillomas. This condition is also linked to a slightly increased risk of breast cancer.

Ductograms are sometimes helpful in finding papillomas. If the papilloma is large enough to be felt, a needle biopsy can be done.

The usual treatment is to remove the papilloma and a part of the duct it is found in. This is usually done through an incision at the edge of the areola (the darker colored area around the nipple).

Granular cell tumors

Granular cell tumors are tumors that start in primitive (early) nerve cells. They are rarely found in the breast. Most are found in the skin or the mouth, but they are uncommon even in those places. They are almost always benign.

Most granular cell tumors of the breast can be felt as a movable, firm lump, although some may be attached to the skin or chest wall. They are usually about ½ to 1 inch across. Granular cell tumors are sometimes thought to be cancer when they are found on a physical exam because they are firm and fixed in place. They may also look like cancer on a mammogram. A fine needle or core needle biopsy can tell them apart from cancers.

This tumor is usually cured by removing it along with a small area of normal breast tissue around it. Granular cell tumors do not increase a woman’s risk of having breast cancer later in life.

Fat necrosis

Fat necrosis happens when an area of the fatty breast tissue is damaged, usually as a result of injury to the breast. It can also happen after surgery or radiation therapy. As the body repairs the damaged tissue, it is replaced by firm scar tissue.

Because most breast cancers are also firm, areas of fat necrosis with scarring can be hard to tell from cancers by a breast exam. It may also be hard to tell the difference on a mammogram. A needle biopsy, or sometimes a surgical excision, may be needed to know if cancer is present.

Some fat cells may respond differently to injury. Instead of forming scar tissue, the fat cells die and release their contents. This forms a sac-like collection of greasy fluid called an oil cyst. Oil cysts can be diagnosed by fine needle aspiration. This can also serve as treatment, although it is not usually needed unless the cyst is bothersome.

Fat necrosis is more common in women with very large breasts. It does not increase a woman’s risk of developing breast cancer.

Mastitis or other infection

Mastitis is a breast infection that most often affects women who are breast-feeding, but it can happen in any woman. A break in the skin or an opening in the nipple can allow bacteria to enter the breast duct, where they can grow. The body’s white blood cells release substances to fight the infection. This causes swelling and increased blood flow. The area may become painful, red, and warm to the touch. Other symptoms can include fever and a headache.

Mastitis is treated with antibiotics. Some cases may lead to a breast abscess (a collection of pus). Abscesses are treated by draining the pus by surgery or by using a needle (often guided by ultrasound), then giving antibiotics.

Having mastitis does not raise a woman’s risk of developing breast cancer. But an uncommon type of cancer known as inflammatory breast cancer has symptoms that are a lot like mastitis and can be mistaken for an infection. If antibiotic treatment does not help, a biopsy of the skin may be needed to be sure it is not cancer. Because inflammatory breast cancer can spread quickly, do not put off going back to the doctor if you still have symptoms after antibiotic treatment.

Duct ectasia

Duct ectasia is also known as mammary duct ectasia. It is a common condition that tends to affect women in their 40s and 50s. It occurs when a breast duct widens and its walls thicken, which can cause it to become blocked and lead to fluid buildup.

Duct ectasia may cause a green or black, often thick, sticky discharge. The nipple and nearby breast tissue may be tender and red. The nipple may be pulled inward. Sometimes scar tissue around the abnormal duct causes a hard lump that may be confused with cancer.

This condition sometimes improves without treatment, or with warm compresses and antibiotics. If the symptoms do not go away, the abnormal duct can be removed through an incision at the edge of the areola (the darker colored area around the nipple).

Duct ectasia does not increase breast cancer risk.

Other benign breast conditions

Some other types of less common, benign tumors and conditions can also be found in the breast.

Radial scars

Radial scars, also called complex sclerosing lesions, are often found when a breast biopsy is done for some other purpose. They may distort the normal breast tissue. Radial scars are not really scars, but are called such because they look like scars when looked at under a microscope. Radial scars do not usually cause symptoms, but they are important for 2 reasons. First, if they are large enough, they may look like cancer on a mammogram, or even on a biopsy. Second, they also slightly increase the woman's risk of developing breast cancer, so women who have them may be advised to see the doctor more often than usual. Many doctors recommend removing radial scars.

Other benign lumps or tumors

Lipomas are benign fatty tumors that can appear almost anywhere in the body, including the breast. They are usually not tender.

Other benign lumps or tumors that are sometimes found in the breast include hamartomas, hemangiomas, hematomas, and neurofibromas.

None of these conditions raise breast cancer risk.

How benign breast conditions affect breast cancer risk

As noted above, some types of benign breast conditions are more closely linked to breast cancer risk than others. Doctors often divide benign breast conditions into 3 general groups, based on whether the cells are multiplying (proliferative) and whether there are atypical or unusual cells (atypia):

• non-proliferative lesions, which do not seem to affect cancer risk
• proliferative lesions without atypia, which may slightly increase cancer risk
• proliferative lesions with atypia, which raise the risk of cancer

Non-proliferative lesions

These conditions are not associated with overgrowth of breast tissue. They do not seem to affect breast cancer risk or if they do, the effect is very small. They include:

• fibrosis
• cysts
• mild hyperplasia
• adenosis (non-sclerosing)
• simple fibroadenoma
• phyllodes tumor (benign)
• a single papilloma
• fat necrosis
• mastitis
• duct ectasia
• benign lumps or tumors (lipoma, hamartoma, hemangioma, hematoma, neurofibroma)

Proliferative lesions without atypia

These conditions show excessive growth of cells in the ducts or lobules of the breast tissue. They seem to raise a woman’s risk of breast cancer slightly (1½ to 2 times the normal risk):

• usual ductal hyperplasia (without atypia)
• complex fibroadenoma
• sclerosing adenosis
• several papillomas or papillomatosis
• radial scar

Proliferative lesions with atypia

In these conditions, there is excessive growth of cells in the ducts or lobules of the breast tissue, and the cells no longer look normal. These conditions have a stronger effect on breast cancer risk, raising it 4 to 5 times higher than normal:

• atypical ductal hyperplasia
• atypical lobular hyperplasia

For women at increased breast cancer risk

Women with some of the breast conditions listed above may be at increased risk for breast cancer. But it is important to keep in mind what this increase in risk really means.

For example, a recent study looked at breast cancer risk among women with benign breast conditions. The study found that about 5 of 100 women without any benign breast conditions developed breast cancer within the next 15 years. Among women with a benign condition that increases risk 1½ to 2 times, this would mean that about 7 to 10 out of 100 might be expected to develop breast cancer in the next 15 years (and about 90 to 93 would not). Among women with atypical hyperplasia (ductal or lobular), whose risk is 4 to 5 times normal, about 20 to 25 women out of 100 would be expected to develop breast cancer within 15 years. The risk for cancer then declines after 15 years.

It’s also very important to keep in mind that there are many other factors that can affect a woman’s risk, including her family history of breast cancer and her personal menstrual and pregnancy history. These and other factors must be taken into account when trying to determine a woman’s actual risk of breast cancer. If you are at higher than average risk for breast cancer, talk with your doctor about whether you should have breast MRI along with your screening mammograms and whether you should start being screened at an earlier age.

Additional resources

More information from your American Cancer Society

We have selected some related information that may also be helpful to you. These materials may be ordered from our toll-free number, 1-800-ACS-2345 (1-800-227-2345).

• Breast Cancer (also available in Spanish)

• Breast Cancer Early Detection (also available in Spanish)

• Breast Cancer in Men

• Inflammatory Breast Cancer

• Mammograms and Other Breast Imaging Procedures

• Medicines to Reduce Breast Cancer Risk

• Talking with Your Doctor (also available in Spanish)

No matter who you are, we can help. Contact us anytime, day or night, for cancer-related information and support. Call us at 1-800-ACS-2345 (1-800-227-2345) or visit www.cancer.org.

References

Anderson BO, Lawton TJ, Lehman CD, Moe RE. Phyllodes tumors. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:991-1006.

Brennin DR. Management of the palpable breast mass. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast, 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:33-46.

Guray, M, Sahin. Benign Breast Diseases: Classification, Diagnosis, and Management. Oncologist. 2006; 11;435-449.

Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353:229-237.

Lewis JT, Hartmann LC, Vierkant RA, et al. An analysis of breast cancer risk in women with single, multiple, and atypical papilloma. Am J Surg Pathol. 2006 Jun;30(6):665-72.

Pisano ED, Gatsonis C, Hendrick E, et al. Diagnostic performance of digital versus film mammography for breast-cancer screening. N Eng J Med. 2005;353:1773-1783.

Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353:275-285.

Saslow D, Boetes C, Burke W, et al for the American Cancer Society Breast Cancer Advisory Group. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57:75-89. [Free full text article available at: http://caonline.amcancersoc.org/cgi/content/full/57/2/75]. Accessed July 29, 2008.

Schnitt SJ, Connolly JL. Pathology of benign breast disorders. In: Harris JR, Lippman ME, Morrow M, Osborne CK, eds. Diseases of the Breast. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 2004:77-99.

Scott BG, Silberfein EJ, Pham HQ, et al. Rate of malignancies in breast abscesses and argument for ultrasound drainage. Am J Surg. 2006 Dec;192(6):869-72.

Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines for breast cancer screening: Update 2003. CA Cancer J Clin. 2003;53:141-169.

Last Medical Review: 09/08/2008
Last Revised: 09/08/2008