Pride Rock: let’s go on safari

Prof Carol-Ann Benn discusses the different types of non-predators, benign breast disease, that are not cancerous.


Do you remember the opening scene from The Lion King? Where all the animals were gathering? Diversity of creatures: mammals, birds, reptiles, big and small, predators and prey. All together as one. 

Benign breast disease (not cancer) can be viewed as non-predators and classified according to presentation. The most common symptoms are:

  • Mass or lump
  • Pain 
  • Nipple discharge 
  • Inflammation or infection 

Benign breast diseases are the most common reason for patients to present to a doctor. They’re often overlooked in the quest to exclude a cancer diagnosis.

When I teach about breast health, I often use analogies. One useful one is the concept of the African Bushveld. 

I am often told by patients, “I went for my ultrasound/mammogram and it was normal. But I now have a lump or pain. How is this possible?”

Think of a game drive

You drive past an area and see nothing and then at the same place you see a buck. All our breasts are different, like different areas in the bushveld. Some women have breasts like a wide-open savannah; and others dense scrub; and for some, it’s a jungle out there.

A triple-assessment is a three-way check: examination, radiology and core needle biopsy, and only then can the patient be reassured. 

Treatment is often necessary for benign conditions. Although, surgery should be discouraged in the presence of proven benign disease.

The density of the breast

There have been some studies that assess a woman’s cancer risk according to the density of their breasts. 

Wide-open savannah breast tissue

The concept is if your breast tissue is like a wide-open savannah, you’re at less risk of developing breast cancer. This would be due to the understanding that a desert gets less water (cancer fertilisers) and thus nothing grows. 

This doesn’t mean that the occasional predator can’t walk across the savannah. Just that they’re less likely to catch prey in the more arid environment. 

Scrubland breast tissue

A few acacia thorns; harder for the radiologist; and maybe a few giraffes and the occasional zebra. 

This would be the solid breast masses, like fibroadenomas. Where there is prey, there is also an occasional predator. Although, most places where there are zebras, there is not always a lion because predators aren’t always attacking and there is more prey to predators. Meaning, a zebra is not going to get eaten every single day from the same scrubland. 

To core biopsy or not

Breast masses are best assessed by ultrasound and can’t be accurately diagnosed by clinical examination alone. Not all require core needle biopsies. Remember, this is not a surgical biopsy. But, if in doubt, a core biopsy tells you what it is (not necessary to operate). 

If no core biopsy is done; this decision should only be made by a breast radiologist, and a minimum of a three-month ultrasound should be performed, to assess growth and stability. 

There is a type of breast cancer that mimics a fibroadenoma (an African version of a wolf in sheep’s clothing) and if a three-month ultrasound is done (the relook through binoculars), they can identify that this is in fact a predator. However, this isn’t a common occurrence. How often do sheep turn out to be wolves? 

The Big 3

The three of the Big 5 benign breast disease that need management are:

  • Elephant (fibroadenoma)
  • Buffalo (phyllodes tumour) 
  • Rhino (complex cyst)

The zebras, giraffes, and wildebeests, the ones we don’t often see, are the solid masses. 

Fibroadenomas

These are the most common lesion found in the breast and are present in 25% of all women. They are normally unilateral, but in 20% of women they may be multiple or bilateral (a herd). 

Fibroadenomas arise from a single lobule or group of lobules which become hyperplastic and enlarge in size. They are hormonally mediated and may grow in response to pregnancy, and will lactate like normal breast tissue. They also involute in response to menopausal changes (that savannah stage unless still being fertilised by HRT).

Fibroadenomas present as firm highly-mobile masses most commonly found in women aged between 15-35 years. The juvenile variety (the giraffe) can develop in younger girls as the breasts develop. 

Most will cease to grow at between 1-2cm in size. However, larger ‘giant’ fibroadenomas can enlarge to >10cms, particularly in young women. This elephant needs managing and can’t just roam free like smaller herbivores – excision. 

Fibroadenomas in older women 

can harden and calcify, requiring differentiation from malignancy. The calcifications are large and commonly known as popcorn calcification.

Simple fibroadenomas are non-proliferative and don’t increase the risk of cancer in the patient. Although, there is an association between previous excision of benign lesions (killing the one zebra attracts predators to the area; the promise of prey has grown with the smell of fresh meat) and increased breast cancer risk. (Let’s not cut just because we can).

Complex fibroadenomas

Fibroadenomas which contain proliferative elements are known as complex, and may have a slightly elevated risk of an associated breast cancer development. So, always get a copy of the core biopsy result and get an explanation within a specialist unit.

As with all breast masses, diagnosis is based on triple-assessment with clinical and radiological classical features confirmed on core biopsy. 

If the lesion is enlarging at a rapid rate, painful or greater than 3-5cm in size, surgical excision should be considered. This ensures a phyllodes tumour is not missed and no stretching deformity of the breast occurs. All excisions should be done through cosmetically placed incisions, either circumareola or base of breast.

Phyllodes tumour

Also known as cystosarcoma phyllodes, this is the buffalo who can be mean and mustn’t be underestimated.

These are fibroepithelial lesions of the breast that most often present mimicking a fibroadenoma (yup, you thought it was a wildebeest). 

Clinically, they can be difficult to differentiate from a fibroadenoma but classically rapidly enlarge precipitating surgery. The incidence is 0,5 – 1% of breast tumours, and although said to present at a later age than fibroadenomas, can be present at all ages.

Triple-assessment may aid in differentiating a phyllodes tumour from fibroadenoma, with phyllodes presenting as larger, and when ultrasounded (binoculars – you can see the differences) and core biopsy will show the branching leaf-like pattern on histology. 

Benign, borderline and malignant

Phyllodes tumour can be divided into benign, borderline and malignant, based on the microscopic and clinical pattern. Malignant lesions should be considered as sarcomas (soft tissue tumours), and both borderline and malignant tumours are capable of metastasising, primarily by haematogenous spread. 

Distant metastases occur in 20% of malignant phyllodes and have a universally poor prognosis. The tumours are poorly radiation- and chemo-sensitive.

All types of phyllodes tumours have a high-risk of local recurrence and success of surgical management is heavily dependent on margins. 

If a phyllodes tumour has been shelled out, as a presumed fibroadenoma, watch-and-wait policies result in an unacceptably high-rate of recurrence. The problem is, like a buffalo, these tumours are not predictable and one can’t guarantee that the benign ones won’t reoccur.

There is also a risk that recurrence will be of increased cellularity with more aggressive or malignant features. Benign tumours should be excised with at least a 1cm margin and malignant tumours taken with margins of at least 2cm.

Phyllodes tumours should be excised initially with a minimum margin, through carefully placed excisions. The pathologist should be allowed to assess the aggressive nature of the tumour fully. 

Discussion in the multi-disciplinary and onco-reconstructive meetings should then determine whether a second surgical procedure is necessary and what adequate clearance of margins is needed, followed by some form of reconstruction. 

In the presence of adequately excised margins, immediate reconstruction doesn’t increase the risk of recurrence and the need for a mastectomy is not necessary for malignant phyllodes as long as wide-margin clearance is achieved.

Other solid breast lesions

Other lesions, the warthogs and unusual buck, etc. that can develop within the breast are: 

Lipoma

Well-circumscribed lobulated mass of mature fat cells. These may be individual or associated with multiple lipomas and certain syndromes (Gardener’s syndrome). If reliably diagnosed, it doesn’t require removal unless it grows. Close follow-up is advised.

Hamartoma

Otherwise known as a fibroadenolipoma of the breast (often characterised as a breast within a breast). This lesion is made from breast and fat elements arranged in a nodular fashion. Because it has elements like normal breast tissue it can be difficult to visualise on ultrasound, but has a specific appearance on mammography. Recommended management is excision only if symptomatic.

Adenoma

These are derived from the epithelial elements of the breast and are most commonly seen in pregnant women as lactational adenomas. These mimic fibroadenomas with the same smooth firm surface and size. Growth in pregnancy can be rapid and alarming for a woman, but the vast majority will decrease in size after cessation of breast- feeding, and can be removed safely six months post-breastfeeding if needed. The mass-effect caused by an adenoma can necessitate its excision but otherwise they can be observed after biopsy-proven diagnosis.  

Fat necrosis

This is a non-suppurative inflammatory response to trauma that occurs within the fat cells of the breast tissue. It can be seen in patients’ post-surgery (therefore operating just for the sake of operating is not recommended) or following radiation for breast cancer, and following trauma to the breasts, such as a seatbelt injury; or even from a breast reduction surgery. 

Clinically, the mass feels hard and irregular, like a breast cancer, and it can cause an ill-defined or spiculate lesion on mammography which may be clinically and radiologically indistinct from breast cancer. 

A core biopsy enables clear diagnosis to be made, showing anuclear fat cells present with histiocytic giant cells and foaming histiocytes. Excision usually results in recurrence of the fat necrosis. So, don’t operate. Surprisingly a class of medicine (type of anti-inflammartory) works.

ANDI classification

Another classification of breast problems, which can aid understanding benign breast disease and risk lesions, is the Aberrations of Normal Development and Involution (ANDI) classification. 

It recognises the importance of distinguishing between problems (normally hormonally-mediated) that can occur in the breast and disorders where there is an abnormality requiring treatment. The groupings should be a tool for understanding breast disease rather than strict criteria of classification. This is genuinely the Pride Rock; or busy waterhole where many animals gather at different times. It’s not necessarily about the predator or prey but about the busy environment

Fibrocystic change

This is a term I dislike as I see so many women saying, “I have fibrocystic disease that is why I have breast pain.”

Fibrocystic change is the most frequently found aberration of the breast. The change in name from fibrocystic disease reflects the understanding that most of these symptoms are a natural part of the spectrum of breast conditions, particularly around the breast’s response to hormonal stimulus and breast involution. The watering hole of busy breast tissue; lots of activity (in other words this is the impala of the breast…at least one impala for each of us). 

It occurs in women between 20-50 years and affects up to 50% of women. On pathological examination of breast biopsies, evidence of this change is seen in 90% of women (that is most of us). 

Most commonly, the condition is multi-focal and bilateral and is characterised by pain and nodularity of breast tissue (we all get this). The cause of the condition is unclear but appears to be an imbalance between the oestrogen and progesterone stimulation of breast glandular tissue. 

The main elements of fibrocystic change is the presence of cysts, both macro and micro, and adenosis. (Adenosis of the breast is characterised by proliferation of the glandular components of the breast.)

Fibroadenosis is a purely benign condition not associated with an increased risk of cancer and doesn’t require surgery at all. So, imagine Simba playing with Timon and Pumbaa – it’s okay to have lumps, bumps and pains. Not all lions are predators. 

Proliferative breast disease 

These I like to call the baby lions. Areas of the breast involved in fibrocystic change may develop proliferative changes and become more hyperplastic. This is the jungle out there. Busy tissue; lots of fertiliser and higher risk of developing cancer. This is often seen as the start of the route that can precipitate breast cancer development, and proliferative breast lesions carrying a small increased risk of breast cancer. 

It’s important to understand that all risk lesions provide both the doctor and the patient with information about the increased potential for development of a breast cancer and how to manage such a risk without surgery. Like rain fertilisers; one can use anti-fertilisers in the breast: certain drugs, exercise and avoiding alcohol. 

Epithelial hyperplasia is one of the hardest lesions to diagnose and manage because treatment and risk is of often unclear. These lesions are most commonly impalpable but picked up by radiology-guided core biopsies, or rarely today on excision on a specimen for another cause, or guided by mammography in screening patients.

Hyperplasia can be present within the ductal epithelia or the lobules. All ductal hyperplasia is now characterised as ductal in-situ neoplasia (DIN 1-3). 

Usual ductal hyperplasia doesn’t infer an increased risk of breast cancer except when florid (red of blushed) where the risk becomes 1,3 – 1,9 times normal. 

Risk lesions 

Atypical ductal hyperplasia (ADH) is morphologically similar to low-grade ductal carcinoma in situ (DCIS) and carries a risk of breast cancer between 5 – 13 times normal. 

Patients with ADH (or DIN 3) and a family history of breast cancer or who are pre-menopausal are further at risk. ADH is most commonly picked up on screening mammography as areas of micro-calcifications, and these areas can be excised under guidance to allow for full diagnosis and investigation of intercurrent DCIS.

Other risk lesions of the breast include atypical lobular hyperplasia, lobular carcinoma in situ (LCIS) (often grouped together as lobular neoplasia), papillomatosis and sclerosing adenosis (the latter two being of lower risk than lobular neoplasia). These are the smaller predators, the jackals and hyenas, basically they are the scavengers of the bush. Not quite scary enough to be predators.

Lobular carcinoma in situ is not an obligate precursor to breast cancer as its name would suggest, but rather a risk marker for invasive disease. That means that a lobular carcinoma-in-situ will not necessary become a lobular cancer, but is a marker for the development of either a ductal or lobular cancer. 

The risk of development of breast cancer following LCIS appears to be bilateral and occur within 15-20 years following diagnosis. Not dissimilar from having a mole cut out that comes back dysplastic. You can’t have your skin removed but need to check more frequently as you’re at higher risk for developing skin cancer.

Careful risk assessment and breast evaluation should follow a finding of any of these with discussion around risk-reduction surgery or chemoprevention (medications to decrease risk) included. 

Cysts

These cystic (fluid-filled) masses are truly the bucks of the breast bushveld. They are round epithelial-lined fluid-filled lesions found in up to one third of women. 

Most women with cysts will have impalpable micro-cysts, however, in 20% of women a macro-cyst will be easily palpable giving the impression of a breast mass, but evident on ultrasound as a fluid-filled structure. 

There are essentially three types of cysts: simple cysts (a relaxed warthog like Pumbaa); complicated cysts (a high-strung meerkat like Timon) and complex cysts (a rhino – not to be mistaken for a rock).

Simple cysts are like the balloons that kids blow. These cysts don’t need to be drained or to undergo pneumocystograms (blowing air into the drained cyst). This is an old-fashioned approach that can introduce infection into the cyst. 

I often use the analogy that repeated aspiration of cysts is like a dog chewing a tennis ball; eventually you land up with a hard-rubbery shell that you can’t ever get rid of. 

Simple cysts can also be aspirated to provide symptomatic relief but this is usually not recommended. 

If, however, the cyst becomes acutely tender or red, aspiration maybe performed and antibiotics started. These are now complicated cysts; they have septae inside (seen on ultrasound) and look like blurry balloons. Most of these are merely associated with inflammation and duct ectasia; and patients often experience burning shooting breast pain.

The rare and elusive rhino

Complex cysts with any solid component should be treated as suspicious as a small number of these maybe malignant. Drainage of such a lesion under ultrasound-guidance, with a core biopsy of the wall of the lesion, will enable diagnosis. These can be papillary lesions and look like broccoli on a stalk and may require surgical excision of the cyst to determine diagnosis. 

Final thought

So, where as I write mainly about breast cancer (the predators), I think an understanding of the more common animals (not just the lions but the warthogs, bucks and the rest of the animals in the circle of life) (benign breast disease) are equally important. 

Understanding all that gather at Pride Rock will allow you to see Simba as a cute cub and manage and not wait for Scar to decimate the environment.

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established The Breast Health Foundation.

MEET OUR EXPERT – Prof Carol-Ann Benn

Prof Carol-Ann Benn heads up internationally accredited, multi-disciplinary breast cancer centres at Helen Joseph Hospital and Netcare Milpark Hospital. She lectures at Wits University and, in 2002, established the Breast Health Foundation.


One Reply to “Pride Rock: let’s go on safari”

  1. Prof Carol Ann Benn is an angel on earth. Thank you God for such an awesome, caring and humble person. God is good all the time.

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