Are All Breast Lumps Malignant? Understanding When To Treat…
Breast lumps can be a cause of concern, often raising doubts and fear of cancer. It is true that some breast lumps are cancerous, but the majority are benign. To accurately diagnose a breast lump, a doctor needs to perform a clinical examination, use a imaging modality and needs tissue diagnosis if needed. This blog provides a comprehensive information of the types of breast lumps, risk of having a cancer and when to treat or follow up a breast lump.
Breast Lumps: Benign vs. Malignant
Breast lumps are sometimes scary, but majority of them are benign. Here are the common types:
- Benign Breast Lumps
- Fibroadenomas: Solid, round, non-cancerous tumors that move freely in the breast tissue on palpation between the ages of 15 to 35 years. They often go away on their own, but some require surgery.
- Breast Cysts: Upto 25% of breast lumps are fluid-filled cysts that can be tender and lumpy. They often get resolved without any treatment.
- Fibrocystic Breast Changes: Hormone level fluctuations can make breast lumpy, dense and tender, especially before menstruation. This is common between the ages of 30 to 50 years and go away without any treatment.
- Lipomas: Slow-growing, soft, painless and fatty tumors. They can be followed up or surgically removed after a tissue diagnosis if large.
- Intraductal Papilloma: A small, benign growth in a milk duct near the nipple that may cause nipple discharge. This may cause nipple discharge and is common in ages 30 to 50 years. Multiple papillomas (especially >5) can increase cancer risk and need to be surgically removed.
- Duct Ectasia: Also known as periductal mastitis, it is common in peri-menopausal period. It causes milk ducts to swell, thicken and blocked. It does not increase risk of cancer, and often respond to antibiotics treatment.
- Traumatic Fat Necrosis: These breast lumps are a scar tissue, resulting from a injury to breast, surgery or radiation therapy. They do not increase cancer risk.
- Galactocele: A galactocele is a milk filled retention cyst, occur almost exclusively in lactating women. It is a benign condition resulting from a mammary duct obstruction. Ultrasound-guided aspiration of galactocele is the preferred treatment, however complicated and recurrent ones might require simple excision.
- Mastitis or Abscess: It is infection or inflammation of the breast, caused by bacterial infection or a blocked milk duct, resulting in tender, red and swollen breasts and fever. It does not increase risk of cancer. Treatment involves antibiotics, ultrasound-guided aspiration of pus and surgical drainage if not responding.
- Malignant Breast Lumps: Malignant lumps are hard, irregular, and often fixed to surrounding tissues. It is important to know that clinical examination alone cannot diagnose a cancer. It needs further evaluation with imaging modalities like ultrasonography, mammogram or MRI and validation from a tissue diagnosis (FNAC or biopsy).
Role of Mammography in Evaluation of Breast Lumps
Mammography is one of the most important and convenient tool in breast imaging, which uses low-dose X-rays to produce high-resolution images of the breast. This modality is used in screening programs because of its low cost and convenience, and also in diagnostic settings as it is can characterise the breast lump or identify the cause of any symptom.
- Screening Mammograms: Used to identify and detect any changes in the breast in women who do not have any sign or symptom. The aim is to detect cancer early and treatment might be lesser invasive.
- Diagnostic Mammograms: Used to evaluate any specific breast changes, such as lump, pain, nipple retraction, ulceration, nipple discharge or any changes in size or shape of breast.
BIRADS: The Radiological Grading System
The Breast Imaging Reporting and Data System (BI-RADS), developed by the American College of Radiology (ACR), is a uniform way for the radiologists to characterise and describe the nature of breast lumps. BIRADS helps the radiologists to standardize their interpretations. Each BIRADS category, ranging from 0 to 6, has a follow-up plan and a course of action associated with it, to help the treating doctors appropriately manage a patient’s care.
Category | Assessment | Management | Likelihood of cancer |
BIRADS 0 | Incomplete | Need additional views/imaging to further evaluate | Not applicable |
BIRADS 1 | Negative | Continue routine annual screening | Essentially 0% |
BIRADS 2 | Benign | Continue routine annual screening | Essentially 0% |
BIRADS 3 | Probably Benign | Short-term interval follow up is suggested (6 months) | <2% probability of malignancy |
BIRADS 4 | Suspicious | Biopsy should be considered | ·       4A: low suspicion for malignancy (2-9%) ·       4B: moderate suspicion for malignancy (10-49%) ·       4C: high suspicion for malignancy (50-94%) |
BIRADS 5 | Highly Suggestive of Malignancy | Biopsy required | >95% probability of malignancy |
BIRADS 6 | Known Malignancy | Confirmed biopsy and treatment planning | Proven malignancy |
When to Follow Up on a Breast Lump and When to Treat?
When you should follow up on a breast lump? This is the question most frequently asked by the patients. As discussed in the previous section of the blog, the answer to this question depends on patient’s age, BIRADS category and other risk factors.
- Benign breast lumps (BIRADS 1 or 2) can be followed up with a routine annual screening and are usually harmless as the risk of developing a cancer is almost 0%
- Probably benign lumps (BIRADS 3) have a risk of <2% of cancer and thus can be followed up 6 monthly
- Other breast lumps with (BIRADS 4 or 5) need further evaluation with a FNA or biopsy (biopsy is preferred as it gives more information)
- Women who have a higher risk of breast cancer due to family history, genetic mutations like BRCA1/BRCA2 mutations, or any other genetic predispositions, need screenings with a MRI to detect any changes.
Final Thoughts
Noticing a breast lump can be unsettling, but it’s important to know that majority of the lumps are non-cancerous. BIRADS is helpful to characterise and differentiate benign and malignant breast lumps. It answers the important question- when a breast lump doesn’t require any treatment? Regular self-examination and noticing any new or unusual changes in the breast is the first step for maintaining breast health.
By keeping yourself aware about the breast self-examination and reaching out to your doctor, most breast lumps can be accurately diagnosed, treated or followed-up.