Atypical Ductal Hyperlasia (ADH)
Atypical ductal hyperplasia (ADH) is a term used to describe the cells lining the ducts of the breast. Normal cells can change in number, size, shape, appearance and growth pattern leading to ADH. ADH is not cancer but the abnormal cells can continue to change in appearance and multiply, evolving into a non invasive (insitu) cancer. For this reason, ADH is considered a risk factor for developing breast cancer in the future.
A diagnosis of ADH can be made on core biopsy or following complete excision of an abnormal area.
If the ADH diagnosis is made on core biopsy then this represents only a sample of the abnormal area so complete excision is then recommended. A patient may have an initial diagnosis of ADH on core biopsy but cancer on final excision of the abnormal area.
Patients with a final diagnosis of ADH only will have close surveillance under a breast specialist due to their increased risk of breast cancer. Follow up with a medical oncologist can be arranged to discuss medications to reduce the risk of developing breast cancer.
Atypical Lobular Hyperplasia
Atypical lobular hyperplasia (ALH) is a term used to describe the cells lining the lobules of the breast. Normal cells can change in number, size, shape, appearance and growth pattern leading to ALH. ALH is not cancer but the abnormal cells can continue to change in appearance and multiply, evolving into a cancer. For this reason, ALH is considered a risk factor for developing breast cancer in the future.
A diagnosis of ALH can be made on core biopsy or following complete excision of an abnormal area.
If the ALH diagnosis is made on core biopsy then this represents only a sample of the abnormal area so complete excision is then recommended. A patient may have an initial diagnosis of ALH on core biopsy but cancer on final excision of the abnormal area.
Patients with a final diagnosis of ALH only will have close surveillance under a breast specialist due to their increased risk of breast cancer. Follow up with a medical oncologist can be arranged to discuss medications to reduce the risk of developing breast cancer.
Calcifications are detected on mammography and may occur as a result of many breast processes. They can develop in response to harmless conditions such as inflammation as well as breast cancer. Calcifications can be large (macro) or very small (micro). The calcifications associated with breast cancer are usually microcalcifications.
Microcalcifications are not felt in the breast and can only be detected by mammography. The arrangement of microcalcifications can indicate whether they are related to a benign (harmless) or malignant (cancer) process. If microcalcifications are a certain shape and cluster together in a set pattern this is considered to be suspicious and a biopsy is recommended. Other microcalcifications may be present on mammography but not considered to be suspicious and close surveillance with a follow up mammogram in 6 months is usually recommended. Any change in number, clustering or shape of the microcalcifications on follow up mammography will result in a recommendation for a biopsy .
A biopsy of the microcalcifications can usually be performed using a mobile stereotactic mammography unit in the radiology suite. This is performed under local anesthesia with the patient awake. However there are limitations to the stereotactic procedure and sometimes a biopsy is not possible by this method. If the microcalcifications are too close to the chest wall, not easily visualized or too few are found in the biopsy specimen, a recommendation to perform surgery( excisional biopsy) under general anesthesia will be made.
If you do require surgery, the radiologist will perform a mammogram and insert a wire into the area of calcifications on the day of the procedure. Post wire placement films are performed so that the surgeon knows the correct area has been localized. Intraoperatively the breast specimen is checked for microcalcifications and a clip placed to mark the biopsy site. Most biopsies of microcalcifications do not reveal breast cancer but if cancer is detected at this very earlier stage the outcome for the patient is usually very favorable.
A cyst is a fluid-filled sac that develops in the breast tissue. Such cysts typically occur in women between the ages of 35 and 50 and are most common in those approaching menopause. They often enlarge and become tender and painful just before the menstrual period and may seem to appear overnight. Cysts are rarely malignant and may be caused by a blockage of breast glands.
Simple cysts are not cancer and do not change into cancer. However, in rare cases, cysts may have a cancer growing within them or close to them (complex cysts). Cysts can be asymptomatic or painful. A physician may drain a cyst to alleviate symptoms. Cysts can feel very different depending on their size and if they are near the surface or deep in the breast tissue. On clinical examination they usually feel very mobile with smooth edges. Cysts can be visualized on mammography and ultrasound. Ultrasound is used to determine whether a cyst is simple or complex. Cysts are usually drained (aspirated) and their contents sent for analysis. If a solid area persists after aspiration a core biopsy of the residual mass is performed. Lifestyle changes will help to reduce or eliminate symptoms of soreness or tenderness. Such changes include reducing the amount of fat in the diet, exercising regularly, and reducing stress.
Regular examinations by you and your physician are important, since cysts can happen anytime until menopause. All new lumps should be assessed to check whether they are fluid-filled cysts or solid lumps. Cysts sometimes refill and, if painful, can be drained.
Breast pain can be divided into 2 types:
Cyclical breast pain is the most common type of breast pain. It is likely caused by hormonal changes. The pain is usually in both breasts. The pain is often severe before a menstrual period and is relieved when the period ends. Cyclical breast pain occurs more often in younger women and disappears at the menopause.
Non-cyclical breast pain is most common in women 30 to 50 years of age. It often occurs in one breast. It is usually a sharp burning pain in one area of the breast. Occasionally, non cyclic pain may be caused by a fibroadenoma or a cyst. Other causes of breast pain include stress, thyroid problems and changes in medication.
Breast pain can be relieved by the following:
- Acetoaminophen , such as Tylenol
- NSAIDS such as ibubrofen (Advil or Motrin), naproxen (Aleve or Naprosyn) or aspirin (Anacin, Bayer)
- Wearing a sports bra during exercise
- Reducing caffeine intake
- Reducing dietary fat
- Evening primrose oil supplement
- Vitamin E supplement
What is an Intraductal Papilloma?
An intraductal papilloma is a tiny wart-like growth in breast tissue that sometimes punctures a duct. These benign tumors are composed of fibrous tissue and blood vessels. Intraductal papillomas grow inside your breast’s milk ducts, and can cause benign nipple discharge.
What do Intraductal Papillomas Feel Like?
If you have just one intraductal papilloma, and it is near or just beside a nipple, it may feel like a small lump. Solitary intraductal papillomas usually occur in the large milk ducts near your nipple. When one of these breaks a duct, it can cause a little clear or bloody nipple discharge, which is usually not worrisome. If you have multiple papillomas, they usually occur deeper inside your breast, and can’t easily be felt. A group of papillomas like this won’t cause nipple discharge.
What is a Ductogram (Galactogram)?
A ductogram, or galactogram, is an imaging study done specifically on the milk duct system. To begin this procedure, a patient must squeeze a small bit of discharge from the nipple, so that the radiologist can see exactly which duct is leaking. Once the duct is found, the radiologist gently inserts a very fine hollow needle into the duct, and injects some contrast fluid into the duct network. This contrast fluid will show up on a mammogram, and trace the related ducts. The resulting image may help to reveal the cause of your nipple discharge.
Types of Intraductal Papillomas: There are two types, and one related condition:
- Solitary intraductal papillomas – one lump, usually near a nipple, causes nipple discharge
- Multiple papillomas – groups of lumps, farther away from a nipple, usually doesn’t cause discharge, and can’t be felt
- Papillomatosis – very small groups of cells inside the ducts, a type of hyperplasia, more scattered than multiple papillomas
How are Intraductal Papillomas Treated?
Intraductal papillomas can be surgically removed if they prove bothersome. A small incision is made along the edge of your areola, then the papilloma and its duct are removed. The resulting scar can be nearly undetectable.
Do Intraductal Papillomas Increase Your Risk for Breast Cancer?
Having solitary intraductal papillomas does not increase your risk for breast cancer, unless they are composed of other conditions, such as atypical hyperplasia. If you have multiple papillomas or papillomatosis, your risk for developing breast cancer is slightly increased.
Fibroadenoma is the most common benign tumor of the breast and the most common breast tumor in women under age 30. Fibroadenomas are usually found as single lumps, but about 10 – 15% of women have several lumps that may affect both breasts. Black women tend to develop fibroadenomas more often and at an earlier age than white women. The cause of a fibroadenoma is not known.
Lumps may be:
They should have smooth, well-defined borders. They may grow in size, especially during pregnancy. Fibroadenomas often get smaller after menopause (if a woman is not taking hormone replacement therapy).
Exams and Tests
After a careful physical examination, a breast ultrasound and/ or mammogram may be performed. A biopsy is needed to get a definite diagnosis. Core needle biopsy is most often performed.
If a biopsy indicates that the lump is a fibroadenoma, the lump may be left in place or removed. The decision depends on the features of the lump and the patient’s preferences.
The outlook is excellent, although patients with fibroadenoma have a slightly higher risk of breast cancer later in life. Lumps that are not removed should be checked regularly by physical exams and imaging tests, following the doctor’s recommendations.
Most phylloides tumors are benign but 10% are malignant. The tumors grow in the supporting tissue of the breast and not in the ducts and lobules. Because they grow in the connective tissue of the breast, malignant phylloides are also referred to as breast sarcomas.
Phylloides tumors are very fast growing and can present as a large lump. Diagnosis is confirmed by a breast biopsy. Treatment of a phylloides tumor is wide excision. It is essential to remove the tumor and a wide margin of surrounding tissue. If adequate margins are not taken the tumor can easily grow back again. Once excision is complete the pathologist will be able to determine if this is a benign or malignant phylloides tumor. A malignant phylloides is also known as a cystosarcoma and is a form of breast cancer.
Treatment for a benign phylloides tumor is close surveillance to assess for recurrence. This is not cancer and so no radiation, chemotherapy or endocrine treatment is warranted.
Types of Breast Cancer
More than 95% of breast malignancies arise from the cells lining the breast ducts and lobules and are called breast carcinomas.
They can be divided into 2 major groups:
- Noninvasive (insitu) cancers in which the tumor cells remain confined to the ducts.
They are divided into whether they originate from the ducts or lobules of the breast.
— DCIS(ductal carcinoma in situ) originates from the ducts.
— LCIS(lobular carcinoma in situ) originates from the lobules.
- Invasive (infiltrating) cancers, in which the tumor cells have grown through the ducts.
They are largely divided into whether they originate from the ducts or lobules; Infiltrating ductal carcinoma originates from the ducts (most common type) Infiltrating lobular carcinoma originates from the lobules
There are other rare types of invasive carcinomas eg mucinous, tubular and papillary.
Many cancers have both DCIS and invasive components. If this is the case the cancer will be treated according to the protocol for invasive cancer.