Generality
Breast nodules are lesions of the breast tissue, the onset of which may depend on various causes. Their presence may be accidentally felt by the patient during the self-examination, or be detected by the clinician during routine examinations (breast examination, breast ultrasound and mammography).
The nodules of the breast are a signal not to be underestimated, but which must not cause too much concern: in 90% of cases it is, in fact, benign nodular formations, such as fibroadenomas and cysts.
To remove doubts and differentiate benign lesions from malignant ones, so to exclude the presence of a breast nodule of neoplastic origin, it is always advisable to consult a specialist, who will prescribe a series of investigations useful to identify their nature.
The management of breast lumps depends on the causes and their histological characteristics.
Possible causes
The presence of a breast nodule recognizes many causes: often, it is fibroadenomas, inflammations of various kinds or non-malignant fibrocystic alterations; although very feared, the possibility of a lump turning out to be a breast cancer is very low.
Some benign nodular lesions may slightly increase the risk of developing cancer.
- Fibrocystic mastopathy is the most common cause of breast lumps. It is a benign dysplasia (ie an abnormal development), quite common in women, especially between the ages of 30 and 50. On palpation, these nodules are rounded and often appear as agglomerates in both breasts or as well defined, mobile masses without signs of skin retraction. In fibrocystic mastopathy, the nodular lesions increase in volume and cause tenderness in the days preceding the arrival of the menstrual flow; the sense of swelling and tension in the breast tends to disappear, then, at the end of menstruation.
- Other fibrocystic changes that have no neoplastic significance include adenosis (nodules of hard consistency and variable size) and cysts (rounded, unique or multiple formations, with a liquid content). Other nodules may be due to ductal ectasia and mild hyperplasia .
- Fibroadenomas are benign solid nodules, typically painless and mobile (these lesions can be moved under the skin with the fingertips), similar to small balls with sharp, circumscribed and elusive contours. Usually, these lesions develop in young women (often in adolescents) and their characteristic mobility in the breast helps to distinguish them from other breast nodules. A simple fibroadenoma does not seem to increase the risk of breast cancer, while a lesion with a complex structure could slightly increase the risk.
- Breast infections ( mastitis ) cause intense pain, redness and swelling; an abscess resulting from this process can produce an appreciable mass to the touch. Mastitis is a rather rare disorder and is found mainly in the puerperium (ie in the post-partum period) or after a penetrating trauma. Furthermore, infections can appear following breast surgery. If an infection occurs in other circumstances, however, a tumor origin must be ruled out immediately.
- The breast abscess is characterized by a painful nodule which tends to gradually increase its size. The skin of the affected area is red, hot and with an "orange peel" appearance. Sometimes, fever is associated with chills and general malaise. The breast abscess is more frequent in the period of breastfeeding and represents a complication of mastitis.
- In the post-partum phase a galactocele can also appear, that is a roundish, mobile and milk-filled cyst. These cysts usually occur up to 6-10 months after stopping lactation and rarely become infected.
- In addition to these etiologies, a breast lump can manifest itself in the context of various types of tumors . The carcinoma of the breast manifests itself with a hard nodule, not well delimited, adherent to the skin or to the surrounding tissues. In this context, deviations, retraction or flattening of the breast or nipple profile, with or without blood or serous secretion, may also be evident. Other symptoms associated with breast cancer include redness and "orange peel" appearance of the overlying skin, breast tenderness and enlargement of axillary lymph nodes (lymphadenopathy).
Signs and Symptoms
Breast nodules can be distinguished in benign lesions and malignant tumors. These formations can be found on palpation or self-examination of the breast and, in some cases, are visible to the naked eye.
The breast nodules appear as a kind of circumscribed peanut, of a different consistency than the rest of the breast, fixed or mobile.
Their presence can cause pain and can be accompanied by other signs, such as:
- Leakage of fluid (serum or blood) from the nipple;
- Skin changes (such as erythema and lymphedema with an "orange peel" appearance);
- Sense of tension;
- Variations in the shape or size of the breast.
The presence of these manifestations could be the consequence of a scratch, an inflammation or other, to be investigated once again with the help of the doctor.
Benign breast lumps
Benign nodules have clear contours and are mobile, ovoid or roundish.
Depending on their nature, these lesions can tend to be solid (ie they have a hard consistency), adipose (soft) or liquid (cysts).
Malignant breast lumps
Malignant nodules have poorly defined contours (they tend to infiltrate the surrounding gland) and are not mobile.
The most advanced breast cancers almost always result in a retraction of the overlying skin, with changes in the shape of the breast and an accentuation of the cutaneous signs caused by the lymphedema. The presence of satellite nodules and lymphadenopathy is indicative of tumor spread.
Potential suspicious signals
Among the symptoms that must be suspicious, so that they should be referred to your doctor include:
- Perception of one or more hard nodules in the breast or armpit;
- Protuberances or thickening of the breast or axillary area;
- Changes in the mammary areola or alterations of the nipple (such as, for example, unusual light-lactating secretions or rashes in the surrounding area).
Some signs are of particular concern:
- Nodule fixed to the skin or to the chest wall;
- Presence of nodular masses of very hard consistency, of irregular shape;
- Axillary lymph nodes incorporated or fixed;
- Blood supply from the nipple;
- Appearance of skin dimples or retractions, swelling, redness, heat and cracking.
Breast pain, on the other hand, is not a relevant symptom, as breast cancer remains sluggish in most cases; however, it is better to report it to the doctor for reassurance.
Diagnosis
Not infrequently, the clinical characteristics of benign and malignant pathologies overlap, so that, in general, it is necessary to undergo a series of clinical tests useful to identify their nature with greater certainty.
The discovery of a breast nodule requires a standardized diagnostic pathway, ranging from medical history to physical examination, from imaging studies to histological analyzes.
The indications for these specialized assessments depend on the age of the patient and, above all, on the data found during the breast examination. The diagnosis to be excluded is that of breast cancer.
history
The collection of anamnestic data concerning the disorder in progress must investigate how long the breast lump has been present or if it tends to recur and disappear periodically. During this phase, the patient will have to report to the doctor the possible finding of previous masses and the outcome of their evaluation.
The remote medical history must include risk factors for breast cancer, including diagnosis of prior breast cancer and radiation therapy in the thorax region before the age of 30 (eg treatment of a Hodgkin's lymphoma). The family history must instead ascertain the presence of cases of breast cancer in a 1st degree relative (mother, sister or daughter).
The evaluation must determine whether there is a breast secretion (clear, milky or blood) and the onset of symptoms that may suggest an advanced cancer (eg weight loss, malaise and bone pain).
Physical examination
Direct breast examination (breast examination) focuses on the observation and palpation of the breast and nearby tissues. The response to the touch of a nodule will reveal its size, tenderness, consistency (ie hard or soft, smooth or irregular) and mobility (if it can be moved with the fingertips or if it is welded to the skin or chest wall ).
During the evaluation, the mammary gland is inspected for alterations in the region where the nodule or mass is present, such as erythema, exaggeration of normal skin signs, lymphedema (orange peel skin) and nipple discharge. The axillary, supraclavicular and sub-clavicular regions are palpated in search of masses and adenopathy.
More in-depth checks
Depending on the doctor's judgment, the execution of:
- Breast ultrasound : ultrasound examination that is used to examine the structures of the breast and allows to differentiate nodules of solid consistency from liquid ones, such as cysts.
- Mammography : it is a radiograph of the breast useful for identifying even very small lesions, micro-calcifications or other indirect signs of a tumor. The breast is compressed with a special device and the X-rays, passing through the mammary tissues, imprint the radiographic image on a plate (or in the computer).
When the outcome of these tests is uncertain, the nodules on the breast that appear cystic are subjected to needle aspiration (or agocentesis ), which consists in taking a sample of cells from the affected area, followed by a cytological study to discover the presence of any neoplastic alterations. This procedure is performed under ultrasound guidance, inserting a thin needle into the suspicious nodule and aspirating the material contained therein, which will be subjected to histological examination. When the sample taken shows blood streaks, solid impurities and remains of unchanged size after the agocentesis, it can be indicated a sampling by needle-mammary biopsy followed by the cytological investigation, in order to further discriminate the nature of the lesion.
The solid nodules are examined by mammography followed by a radio-guided biopsy, in order to collect the tissue fragments to be analyzed under a microscope with local sampling and to allow a more detailed analysis of the lesion.
Another investigation that allows to obtain useful information to differentiate the characters of breast lumps is mammary magnetic resonance . This investigation is indicated when the mammary structure appears complex to the other visualization investigations (such as ultrasound and mammography) or it is necessary to visualize in detail some images deemed suspicious.
Self-examination to protect breast health
As doctors advise, breast self-control should be a regular appointment starting at 20 years of age, to be repeated at least once a month, a week after the end of menstruation (ie when hormonal activity is "at rest" and the breast is less swollen and painful). It only takes a few minutes to execute it.
This simple self-assessment test allows us to know the structure and general appearance of the breast, thus allowing the woman to catch any unusual change with respect to her basic physiognomy. If performed correctly and regularly, self-examination can limit the risk of diagnosing a tumor at an advanced stage, therefore it represents a valid instrument of "prevention".
If during the self-examination of the breast a nodule is found, there is no need to be too alarmed, as it is often a harmless response; it is however important to inform the doctor, who will be able to indicate the appropriate instrumental tests to ascertain the actual state of health.
For more information on how to perform breast self-examination, click here.
Treatment
The treatment of breast lumps depends on the specific cause and may involve various therapeutic interventions.
- Fibroadenomas can be excised with surgery under local anesthesia, but often recur.
- To alleviate the symptoms of fibrocystic alterations, on the other hand, the use of painkillers (such as paracetamol) and the use of sports bras can be useful to ensure adequate support and reduce transient painful sensations to the breast. In case of diagnostic doubt, surgical removal of the lesions may be indicated.
- Usually, breast cysts do not require treatment, except in cases where the symptoms and the size of these lesions are a cause of discomfort to the patient. In these cases, it is useful to drain the fluid contained within the saccular formations by means of needle aspiration; although rarely, surgical removal may be indicated. After this procedure, the mammary gland is less tense and painful, but the cysts in the breast can form again, as more liquid can be collected inside them.
In any case, breast lumps should not be neglected and their presence requires an attitude of periodic surveillance through self-examination and ultrasound / mammography monitoring.
