Breast Cancer - Moose and Doc

A breast cancer explanations website

 

By Dr. Halls

Fibrocystic Breast Disease

 Fibrocystic  breast disease, also termed “Fibrocystic changes” (FCC) is the general, all-inclusive term, for a whole range of common and benign breast disorders.

The umbrella term, ‘fibrocystic breast disease’  includes all sort of benign conditions such as:-

Fibrocystic changes are extremely common and occur in 90% of women at some point in their lives.

However, most fibrocystic changes tend to occur in younger, premenopausal women. Specialists do not know exactly what genetic or biological factors predispose a woman to fibrocystic breast disease. 

However, medics generally accept that hormonal imbalances, particularly with regard to levels of progesterone and estrogen, are the most likely cause.

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fibrocystic breast disease

How are Breast Fibrocystic Changes (FCC) discovered?

  Most fibrocystic breast disorders are either discovered clinically, or brought to the attention of a family physician because of breast symptoms a women notices herself.

Symptoms of fibrocystic breast disease might include:-

  • Soreness or pain
  • Redness
  • Unusual discharges
  • A bulge or fibrocystic breast lump

For women who begin breast cancer screening at an earlier age (in the 40’s),  radiologists may incidentally discover some of these fibrocystic changes.

Usually there is enough information on the mammogram itself to rule out malignant breast cancer, but follow up procedures such as ultrasound and biopsy may be necessary as well.

Doctors may describe a fibrocystic disorder to a patient as a ‘lesion’.  Although this is a term that medics commonly use to describe early breast cancer developments,  this should not set off alarm bells.  A ‘lesion‘ simply means a “thing we are talking about.”

Is Fibrocystic Breast  Disease related to cancer?

Fibrocystic changes to the breast are not related to breast cancer. However, some of the disorders can occur simultaneously with breast cancer development.  This is why doctors will take fibrocystic breast disease seriously and fully investigate, just to be sure and rule out breast cancer.

The most important issue in fibrocystic diseases, particularly the solid lesions, is whether or not tests show the cellular changes that occur to be ‘typical’, or ‘atypical’. So, when there is ‘atypical’ cellular growth and change, then yes, the chances of breast cancer are higher.

Does Fibrocystic breast disease increase the risk for developing breast cancer?

 This has been a topic of interest in breast cancer research for many years. Generally speaking, the increase in the risk for breast cancer is the same ‘slightly higher’ risk for women with fibrocystic breast disease.

This same slightly higher risk is the same for all women who show a genetic predisposition towards fibrocystic breast changes. (Approximately the same risk as having a relative with breast cancer.)

Sometimes breast changes occur simultaneously to underlying breast cancer development

 However, it is possible that some fibrocystic breast disorders are secondary to changes in breast tissue resulting from a cancer occurring at the same time.

Bear in mind, however, that breast cancer tends to present in fairly predictable and distinguishable ways, and these factors would be apparent. Breast cancer also tends to occur with older, post-menopausal women.

Epithelial proliferations

 Of the most common breast fibrocystic disorders, the category that is perhaps the most allied to the biology at least, of breast cancer, is epithelial proliferation.

Proliferation means ‘cells are growing’, and this is also something that happens in breast cancer cells.  The question, again, is whether or not there is anything ‘atypical’ (random or grossly distorted) about the appearance or formation of the cells.

However, even with these ‘atypical’ fibrocystic proliferations the risk of subsequent breast cancer development is very low.

“Non-proliferative” versus “Proliferative” lesions

Medics often categorize the different types of breast fibrocystic changes as ‘proliferative’ or ‘non-proliferative’.

New or unexpected cell growth is not the cause of non-proliferative fibrocystic disorders.

These are the more ‘nuts and bolts’, or ‘bread and butter’ types of benign breast problems and can occur from:-

  • Imbalances in secretions
  • Blockages due to mineral deposits, infections or trauma

Common non-proliferative lesions would include:-

  • Periductal fibrosis
  • Nonsclerosing adenosis
  • Duct ectasia
  • Cysts
  • Epithelial-related calcifications
  • Mild epithelial hyperplasia
  • Papillary apocrine changes.

Non-proliferative lesions are the most common finding in breast cancer screening biopsies, accounting for about 70% of all cases.

Is there anything ‘atypical’ about a proliferative breast growth

Proliferative breast changes/lesions, on the other hand, do involve the growth of new cells.  So, that makes this category of fibrocystic breast disease a little more worrisome initially for underlying breast cancer.

The question again is whether or not the cell proliferation is ‘typical’ or ‘atypical’. Among the proliferative fibrocystic breast changes ‘without atypia’ are sclerosing adenosis, radial scar, intraductal papilloma, and moderate to florid hyperplasia (‘of the usual type’).

A finding of ‘hyperplasia’, which means extensive new cell growth, is really the only one which would conceivably be related to breast cancer. It would depend on the nature of this hyperplasia.  How much?  What do the cells look like?  What kinds of patterns and distributions do they exhibit?

The risk of breast cancer remains very low, even for atypical hyperplasia

 So, ‘atypical’ proliferative fibrocystic changes would include ‘atypical ductal hyperplasia‘ and lobular hyperplasia.  This is where atypical cell growth occurs in the breast ducts or less commonly in the breast lobules.

Atypical ductal hyperplasia (ADH) can be an early manifestation of breast cancer. However, it is important to remember that the absolute risk for developing breast cancer, even for atypical proliferative lesions, is still very low.

Over 80% of women who have a diagnosis of atypical hyperplasia, will never develop invasive breast cancer

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Cysts

The type of fluid within the cysts and the amount of solid elements can be variable. 

This fluid/solid element  leads to the sub-classifications of ‘simple cyst’, or ‘complicated cyst‘ and ‘complex cyst’.

Breast cysts are round or oval lesions full of fluid.  Indeed breast cysts are extremely common.  In fact breast cysts occur in up to a third of women between the mid-30’s to 50 year old range

Adenosis

Adenosis is a ‘proliferative’ breast disorder characterized by an increase in the number and size of glandular tissues, usually within the breast lobules.

Different types of adenosis worth noting include a sclerosing adenosis ( hardening ) and microglandular adenosis (MGA).

Other minor subtypes of breast adenosis include apocrine adenosis, adenomyoepithelial adenosis, and ‘blunt-duct’ adenosis.

Apocrine Metaplasia

Metaplasia is a particular kind of basically non-proliferative cell growth. The characteristics of metaplasia are a change or replacement of one type of cell with another.  This is in contrast to excessive growth of new cells.

Typically, these new cells develop as a result of an irritation of some kind. Apocrine metaplasia is a unique breast fibrocystic lesion characterized by ‘columnar’ cells and ‘apocrine’ protein patterns.

This condition is most common in young women and is a benign breast disease.  It is possible, however, for apocrine metaplasia to present in an ‘atypical’ pattern, which would be more cause for concern.

Metaplasia

 Another highly rare breast metaplasia is ‘clear cell metaplasia’. It is named because certain morphological characteristics bare a similarity to clear cell breast carcinoma, although they are not related. (Metaplasia does not suggest carcinoma unless there are significant atypical features)

Epithelial Hyperplasia

Epithelial hyperplasia refers to new cell growth occuring in lining tissues (epithelial cells) but in places other than the breast ducts or breast lobules.

In this sense it is kind of a nondescript proliferative breast lesion. As is the case with ductal and lobular hyperplasia, epithelial hyperplasia may have ‘usual’ characteristics ( benign ) or ‘atypical’ characteristics, that are somewhat more suspicious of malignancy.

Ductal Hyperplasia

Ductal Hyperplasia means that a lot of new cell growth is occuring within the breast duct elements. In the non-worrisome, benign form (typical), ductal hyperplasia has quite a uniform patterning of cells.

Atypical ductal hyperplasia (ADH), however, is not necessarily benign and may be a low grade presentation of ductal breast carcinoma in situ. ( DCIS )

Lobular Hyperplasia:

Lobular neoplasia, just like ductal and epithelial hyperplasia, implies new and rapid cell growth in the area of the breast lobules. ‘Atypical lobular hyperplasia‘ indicates unusual cell features and patterning.

If the cellular distortions are significant enough, the condition may be termed lobular carcinoma in situ (LCIS).  However, the only difference between atypical lobular hyperplasia (ALH) and LCIS is the degree and extent of epithelial proliferation.

The common standard now is to collectively place atypical lobular hyperplasia under the banner of ‘lobular neoplasia‘. This is a very rare breast lesion, and doctors will basically manage lobular neoplasia as a risk fact for breast cancer only.

There is no consistent, direct link between lobular neoplasia and invasive breast cancer.

Flat Epithelial Atypia, or Columnar cell breast lesions

 
Flat epithelial atypia, also called a breast ‘columnar cell lesion’, is not a term that specialists broadly accept or commonly use.

Essentially, these are new cells that mysteriously replace the ‘native’ cells in areas surrounding microcalcifications.  Breast cancer mammograms typically discover flat epithelial atypia.

The pattern of cell growth is visually ‘flat’, hence the name. This is an area of current research and not a lot is know about flat epithelial atypia. However, as certain patterns of microcalcifications have been associated with the development of ductal carcinoma in situ (DCIS), flat epithelial atypia cells may also be associated with early development of DCIS.

Radial Scar, Complex Sclerosing Lesion

A radial scar is so-named because of the radiating/star-like appearance on a breast X-ray.

Radial scar is a proliferative pseudo-lesion that causes cell hyperplasia in the breast ducts. The significance of a radial scar is uncertain, although  studies suggest there is an increase in the risk factor for breast cancer.

breast radial scar

Sometimes radial scars are accompanied by adenosis, epithelial hyperplasia, duct ectasia, and papillomatosis.

A ‘complex sclerosing lesion’ is essentially the same finding as a radial scar,  just larger in size.  Medics tend to use the term ‘radial scar’  for lesions that are less than 1 cm.

However, medics will use the term ‘complex sclerosing lesion’ when the area is larger than 1cm. Note, there is typically no ‘central mass’ to a radial scar and so ultrasound does not clearly detect these lesions. Usually a biopsy is necessary because the appearance of a radial scar can mimic that of tubular carcinoma.

Papilloma and Papillomatosis

A papilloma is a benign proliferative tumor that grows within the epithelial lining of breast ducts. This growth tends to form ‘fronds’ or ‘finger-like’ projections, and can block or partially block the normal flow of breast secretions.

The classic symptoms for papilloma include nipple discharge, but also breast swelling and pain, and possibly a lump. But no one knows exactly what causes the growth of papilloma.  However, a biopsy confirms that the cells do not contain malignant carcinoma.

Scientists generally consider an increase in the risk for breast cancer with a papilloma.  However, there is no direct, proven link between the appearance of papilloma and the development of invasive breast carcinoma.

Solitary or multiple papillomas

Normally solitary papillomas occur in isolation, but papillomas that develop towards the extreme ends of the ductal system can be multiple. The development of multiple breast papillomas is termed ‘papillomatosis’.

Breast Adenoma (Fibroadenoma)

An ‘Adenoma‘ is the name for a benign tumor ( ‘oma’ means tumor, or mass) that develops primarily from ‘glandular’ epithelial cells.

So an adenoma is a proliferative ‘neoplasm’ (an area of rapid new cell growth), and bears similarity to a malignant, cancerous tumor.

However, generally adenomas will generally not metastasize and will remain benign. The problem with adenomas is that they can cause blockages and impairments to normal breast function.  In addition, adenomas can also be a sign of hormonal imbalances.

Fibroadenoma

 The most common breast adenoma is a ‘fibroadenoma‘.  This means that the fibrous and glandular cells supporting milk production have ‘overgrown’.

A fibroadenoma will likely present clinically as a firm, painless, and mobile breast mass that is often palpable.

Fibroadenomas are the single most commonly occuring breast lesion and tend to occur in younger, premenopausal women. There is some speculation that the risk of developing fibroadenoma may be linked to the use of birth control medications.

Lactating Adenoma

 Other sub-types of breast adenoma include lactating adenoma,  this is associated with pregnancy and lactation. Also, there is tubular adenoma ( that may also be called ‘pure adenoma’).  Tubular adenoma has much less growth of stromal elements and large ducts, and is more confined to the smaller acinii of the milk producing glands.

Fibroadenomas with complexity

About half of all fibroadenomas will contain other proliferative changes of the breast, such as duct hyperplasia, adenosis, and sclerosing adenosis.

Where these mixed elements are present doctors sometimes call the lesion a ‘complex fibroadenoma’.   In terms of the possibility of breast cancer, adenomas are not associated with any immediate increase in risk. However, women with complex fibroadenomas may have a slight increase in the risk for breast cancer over the long term.

Nipple Adenoma

A nipple adenoma is a benign growth of ductal epithelial cells either on or underneath the nipple.

Often, a nipple adenoma appears as a small lump that a woman discovers herself.  Other times a nipple adenoma will present with symptoms of nipple erosion or nipple discharge.

Hamartoma

 A Hamartoma is an uncommon tumor-like mass that contains varying amounts of fibrous, glandular, and adipose (fat) tissue.

Unlike adenomas, a hamartoma is not a ‘neoplasm’.  The harmotoma cells are all ‘native’ to the area and are growing at the same rate as surrounding tissues.

Hamartoma is more a kind of ‘disorganization’ (dysgenesis) rather than a result of some kind of malignant cell process, and is completely benign. No one is sure what causes a hamartoma.

Unwanted cosmetic effects and duct blockages are potential problems of Hamartoma.   Doctors will typically treat hamartomas by surgical removal, but only after careful differential diagnosis for breast cancer.

Lipoma

 A lipoma is essentially a lump caused by an accumulation of mature fat cells.  Some cells growing and dividing more rapidly than others is the cause of lipoma.  However, the good news is that a lipoma is a ‘benign’ condition of the breast.

Specialists sometimes call a lipoma a ‘soft tissue’ tumor because it develops among the soft, fatty tissues of the breast. It is harmless, generally painless, soft to the touch, and moveable.  A lipoma tends to be a ‘common sense’ diagnosis based on clinical exam, mammogram, and ultrasound finding.

breast lipoma

Lipomas are generally just left alone with careful follow-up screening.

Lipomas do not transform into breast cancer. Note, lipomas can occur anywhere on the body where there is fat tissue, and really have nothing to do with the breast specifically.
 

 

Diabetic Fibrous Mastopathy

 Diabetic Fibrous Mastopathy is an uncommon breast lesion occuring mostly in premenopausal women.

However, diabetic fibrous mastopathy can also occur in men with long-standing type 1 diabetes, especiallly those who are insulin-dependent or who have had microvascular complications.

Sometimes diabetic fibrous mastopathy presents as a painless, immobile lump, or else is found on a breast cancer screening mammogram. It is characterized by overgrowth of connective tissues with vasculitis (inflammed or destroyed blood vessels) and some proliferation of ductal epithelium.

These lesions can occur singly or in multiples and tend to be ‘ill-defined’ in terms of shape, and this can raise suspicions for breast carincoma. However, it is entirely benign and unrelated to breast cancer.

Granular Cell Tumor

 Granular cell breast tumors are rare and usually benign neoplasms that develop from ‘Schwann Cells” of the peripheral nervous system.

It is more characteristic for these ‘soft tissue’ tumors to develop in the head and neck region, but about 5% to 6% of the time they develop within breast tissue.

Granular cell tumors are rock hard to the touch and appear to be fixed to the skin.  For this reason women or family physicians usually detect these tumors clinically prior to a screening mammogram.

These type of tumors can mimic breast cancers, especially apocrine carcinoma, for several reasons:-

  • The firmness of the lump
  • Ill-defined mammographic features,
  • The visual and textural aspects of biopsy samples

However, microscopic features of granular cell breast tumors are quite regular and usually benign. Granular cell breast tumors are not 100% benign, however. There are rare instances of malignant and metastasic granular cell tumors.

However, typically in these cases the cytological and microscopic features suggestive of malignancy are very obvious in the histological analysis. Glandular cell tumors tend to occur in women over 50, and it seems to be slightly more common in ethnic black individuals.

Pseudoangiomatous Stromal Hyperplasia of the Breast

 Pseudoangiomatous stromal hyperplasia (PASH, and sometimes called Pseudoangiomatous hyperplasia of mammary stroma) is a rare and benign proliferation of mesenchymal cells (stem cells that frequently form into connective tissues).

Sometimes PASH is just an incidental microscopic finding in biopsies that medics request for other reasons.   However, at other times it can develop into a large mass.

PASH occurs almost exclusively in younger, premenopausal women and features a large overgrowth (hyperplasia) of breast stromal cells and tissues. The cause of PASH is uncertain.

Studies originally suggest that PASH may be related to hormone levels, but this relationship has not been consistently demontrated. PASH is completely benign, and the only concern in the ‘investigative’ stages is that aspects of its presentation can mimic carcinoma, particularly angiosarcoma.

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About Steven Halls

Dr Halls has 25 years experience as a radiologist. He worked for 13 years at Cross Cancer Institute in Edmonton, a world-class cancer treatment facility. He has had high-volume experience with cancer, interventional procedures, clinical trials and his own phase 1 and 2 research in MRI and breast cancer staging.