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Benign Breast Disorders

Cancer is twice as common as all gynecologic pelvic malignancies combined. When a persistent, palpable, dominant mass is identified, breast cancer should be excluded. All women should begin self-examination and have annual clinical examinations by age 20 years. Women age 40-49 years should have mammography every 1-2 years, and women age 50 and older should have mammography yearly.

The breasts are composed mostly of adipose tissue with interwoven fibrous bands (Cooper's ligaments). The glan dular tissue and ducts are organized into separate, anatomically distinct lobes, each with a single duct opening into the nipple. The physiologic function of the --lactation---occurs in the terminal duct lobular units. Specific intrinsic pathology originates at typical anatomic sites within an individual lobe.

MASSES

A persistent, palpable, dominant mass must be diagnosed definitively. This can be accomplished in the ambulatory environment by using the diagnostic triad of clinical examination, mammography, and fine-needle aspiration. A specific pathologic diagnosis can be obtained by fine-needle aspiration cytology (given an adequate cell sample) or by tissue histology with a sample obtained by core-needle or open surgical biopsy.

Fibrocystic disease is not a clinical or a histologic diagnosis. Historically, the term has been used to imply pre-malignant potential and an increased relative risk of cancer. Neither is true. The term is nonspecific, clinically confusing, and frightening to patients. More than 80% of women have histologic fibrocystic changes somewhere in their tissue. Of all the histologic manifestations of fibrocystic changes, only atypical epithelial hyperplasia correlates with an increased risk of cancer. Atypical hyperplasia (ductal or lobular) is a specific histologic diagnosis and is not associated with characteristic symptoms or physical or mammographic findings. Most women of reproductive age have some degree of palpable nodularity and lumpiness.

Microcystic (nonpalpable) changes within the are almost universal. Macrocysts (palpable) usually present asmultiple tender (cyclic) masses. Macrocysts can be readily diagnosed and treated by fine-needle aspiration. Cytology of clear cyst fluid is unrewarding and is indicated only for grossly bloody fluid. If there is a residual palpable mass after complete aspiration of a cyst, the mass should be diagnosed by open or core biopsy. Short-term (ie, 3 months) follow-up of an aspirated mastitis, change is essential to rule out a recurrent or the rare intracystic carcinoma. Since mammography is not reliable in differentiating between a and a solid mass, ultrasonography is an appropriate adjunctive technique for nonpalpable masses detected by mammography.

A fibroadenoma is the most common benign neoplasm and usually presents during the early repro ductive years. Fibroadenomas may be bilateral and multiple. Fibroadenomas are not premalignant and do not transform into cancer. As with ductal and lobular tissue anywhere in the, in situ and invasive malignancies can occur, but they are exceptionally rare. Fibroadenomas have a characteristic appearance on mammography, but imaging studies are not diagnostic. By palpation and serial mammography, have been noted to regress and calcify, particularly in postmenopausal women. If diagnosed by fine-needle aspiration, a may be either removed or followed as the patient chooses.

Lipomas have a characteristic mammographic appearance. The diagnosis can be confirmed by fine-needle aspi ration. Treatment is surgical excision or clinical follow-up as the patient desires.

Fat necrosis can mimic carcinoma by both palpation and mammography. Often there is a history of direct trauma to the area. The lesions tend to resolve spontaneously. Fine-needle aspiration diagnosis is not definitive. If the lesion is suspicious or persists for months, open surgical biopsy is required for a definite histologic diagnosis.

MASTALGIA

In obtaining a pertinent history for the assessment of pain,