What Is a Breast Lesion? Symptoms of a Breast Lesion

A breast lesion is the general term for any abnormal formation such as a cyst, solid mass, microcalcification, or structural distortion that differs from the natural structure of breast tissue. This expression, which is a medical umbrella term, is not a diagnosis of a disease on its own; it is the description of a tissue change detected during physical examination, mammography, or ultrasonography. The vast majority of detected lesions arise from benign processes such as fibroadenomas or simple cysts and do not directly indicate the presence of cancer. In general surgery practice, lesion management involves determining the nature of this structural change and distinguishing risky formations that may carry cancer potential.

What Is a Breast Lesion?

Due to its structure, the breast is one of the most dynamic organs in the body. From puberty to menopause and even after menopause, it is in a constant state of change. Monthly menstrual cycles, pregnancy processes, breastfeeding periods, and hormonal withdrawal that occurs with age cause continuous remodeling in breast tissue. During this intense cellular activity, things may sometimes deviate from the standard order and structural differences may develop in the tissue.

Medically, when we refer to a lesion, we mean any “unusual” condition that occurs in the milk-producing glands of the breast (lobules), the ducts that carry milk (ducts), or the fatty and connective tissues supporting these structures. Sometimes this condition feels like a marble under your hand. Sometimes it appears only as tiny white dots on a mammogram image (microcalcifications). Sometimes it is a fluid-filled bubble visible on an ultrasound screen.

A large proportion of these formations are harmless responses of the body to hormonal changes. However, some also have the potential to change shape or grow uncontrollably. Our entire effort is to distinguish clearly between these two. When making this distinction, the shape, borders, internal structure, and changes over time of the lesion guide us.

What Are the Symptoms of a Breast Lesion?

Most of the time, our patients consult us after feeling a difference during self-examination or completely by chance. Sometimes we detect a finding during routine screening even when there are no complaints. However, certain signals given by your body may indicate the presence of a lesion. Correctly interpreting these symptoms is vital for early diagnosis.

The most common symptoms we encounter in the presence of a breast lesion are:

• Palpable mass
• Retraction of the breast skin
• Inversion of the nipple
• Nipple discharge
• Skin discoloration
• Asymmetry in breast size
• Swelling in the armpit
• Edema of the breast skin

To explain these symptoms in more detail, not every palpable mass is the same. If you feel a structure under your hand that has very clear borders, a smooth surface, and moves from side to side when pushed with your finger, this usually indicates a benign process such as a fibroadenoma or cyst. However, masses that are firmly attached to the tissue, immobile, hard, and have indistinct borders put us more on alert.

Visual changes are just as important as a mass. When standing in front of a mirror, if you notice small dimples in the breast skin or a porous appearance resembling orange peel, this may indicate that an internal lesion has involved the skin. Likewise, inward pulling or a change in the direction of the nipple is a finding that should not be neglected. Regarding discharge, especially spontaneous discharge coming from one breast and appearing bloody or clear like water requires detailed evaluation.

Does Every Breast Lesion Carry a Cancer Risk?

This is the greatest fear of our patients. When a lesion is detected, cancer immediately comes to mind. However, I would like to reassure you that the vast majority of detected breast lesions are benign and do not carry a risk of becoming cancerous. We examine lesions in three main groups according to their risk and cellular characteristics. This classification is the most fundamental factor determining our treatment plan.

Non-Proliferative Lesions: This group is the one we encounter most frequently in outpatient clinics and find most reassuring. There is a change in the breast tissue, but there is no abnormal increase in cell number or deterioration in cellular structure.

The formations included in this group are:

• Simple cysts
• Ductal ectasia
• Simple fibroadenomas
• Mild epithelial hyperplasia
• Apocrine metaplasia

These lesions do not cause a significant increase in the risk of breast cancer. Cysts in particular are very common in women between the ages of 30 and 50. They are usually fluid-filled sacs and may grow or shrink with hormonal fluctuations. Most of the time, they do not even require treatment, and follow-up alone is sufficient.

Proliferative Lesions Without Atypia: In this group, there is an increase in the number of cells beyond normal levels (proliferation). In other words, the tissue is more active than it should be. However, there is no abnormality in the genetic structure or shape of the cells (atypia).

The lesions we evaluate in this category are:

• Radial scar
• Complex sclerosing lesions
• Intraductal papillomas
• Moderate hyperplasia
• Sclerosing adenosis

The presence of these lesions may slightly increase the risk of breast cancer by approximately 1.5 to 2 times. However, the main critical point here is that the radiological images of these lesions, especially structures such as radial scars, can closely resemble cancer. Therefore, these areas may often need to be removed to be certain.

Proliferative Lesions With Atypia: This is the group we focus on the most and can describe as a “red flag.” Here, both the number of cells has increased and the structure of the cells has begun to deteriorate and resemble cancer cells, but it is not yet a complete cancer.

The members of this high-risk group are:

• Atypical ductal hyperplasia
• Atypical lobular hyperplasia

These conditions are not cancer, but they are precancerous. In women with these lesions, the risk of developing breast cancer in the future may increase by 4 to 13 times. More importantly, when “atypical hyperplasia” is diagnosed with a needle biopsy, there is a possibility that an early-stage cancer focus may be found immediately nearby when the area is surgically removed. Therefore, we never leave these lesions in the body.

Which Imaging Tests Are Performed to Diagnose a Breast Lesion?

The physical examinations we perform in the clinic provide us with very valuable information, but we need technology to examine tissue depths that we cannot see with our eyes. During the diagnostic process, “Radiological Imaging” is our seeing eye. We decide which imaging test to perform according to the patient’s age and the structure of the breast tissue.

The main imaging methods we use in general surgery practice are:

• Digital mammography
• Breast ultrasonography
• Color Doppler ultrasonography
• Breast MRI (Magnetic Resonance Imaging)

For every woman over the age of 40, “Mammography” is the gold standard. The reason is that mammography is the best method for showing “microcalcifications,” which we refer to as calcifications and which may be the earliest sign of breast cancer. These calcifications are sometimes as small as a grain of salt and impossible to feel by hand.

However, in young women under the age of 40, breast tissue is very dense. Dense breast tissue appears white on mammography, and lesions also appear white. This is similar to “searching for a white rabbit in a snowstorm.” Therefore, in young patients or those with dense breast tissue, our first choice is “Ultrasonography.” Ultrasound works with sound waves and does not contain radiation. The clearest information it provides is this: Is the inside of this lesion filled with fluid (a cyst), or is it tissue (a solid mass)? If there is a solid mass, we evaluate whether it has blood flow using the Doppler feature because malignant formations generally show intense vascularity.

Breast MRI is a highly sensitive problem-solving method that we use in more specific situations, for example in patients with genetic risk or to check whether there are other foci in the breast before breast-conserving surgery.

What Does the BI-RADS Score in a Radiology Report Mean?

In the radiology reports you receive, you will always see the term “BI-RADS” in the conclusion section along with a number. Our patients usually have difficulty understanding these numbers. BI-RADS is a common language that we doctors, radiologists and surgeons, use to communicate with each other. This scoring system determines the likelihood of the lesion being cancerous and what we should do accordingly.

The BI-RADS categories and their meanings are:

• Category 0
• Category 1
• Category 2
• Category 3
• Category 4
• Category 5
• Category 6

Knowing what these categories mean will reassure you. Categories 1 and 2 indicate completely normal or definitely benign findings, such as a simple cyst. There is no cancer risk, and routine follow-up is sufficient.

Category 3 means “probably benign.” The risk of cancer is very low, less than 2%. In this case, we do not perform a biopsy immediately and instead apply a “wait and see” strategy. We usually recommend a follow-up after 6 months. If its shape does not change, we consider it benign.

Category 4 means “suspicious.” The range of risk here is broad. The moment we see this designation, we no longer have the option to wait. We must perform a biopsy to clarify the diagnosis. Category 5 refers to findings with a very high radiological suspicion of cancer, over 95%, and the diagnosis and treatment process should begin rapidly.

How Is a Breast Lesion Biopsy Performed?

Imaging methods show us the appearance and form of the lesion, but they cannot name it. For a definitive diagnosis, the cells must be examined under a microscope, which means a biopsy is essential. There is a very common but incorrect belief among the public: “If a knife touches it, it spreads” or “A biopsy aggravates cancer.” As a physician, I can clearly state that this is a myth with no medical basis. Biopsy is essential for planning the correct treatment and does not cause the disease to spread.

Today, biopsies are no longer performed through surgery but with much more comfortable needle-based methods.

The biopsy methods we frequently use are:

• Tru-Cut (Core needle) biopsy
• Fine needle aspiration biopsy
• Vacuum-assisted biopsy
• Surgical biopsy

The method we use most frequently is Tru-Cut Biopsy. The procedure is performed under outpatient clinic conditions. Since we numb the skin, you do not feel pain. Using needles equipped with a special gun mechanism, millimetric tissue samples are taken from within the lesion. The greatest advantage of this procedure is that it provides the pathologist not only with cells but also with the architecture of the tissue. In this way, we can understand whether the lesion behaves aggressively toward the surrounding tissue. We generally perform it under ultrasound guidance, meaning we aim to take an accurate sample by seeing where the needle is going on the screen.

Fine Needle Aspiration is used mainly to drain cysts or to obtain samples from lymph nodes in the armpit. It provides only fluid or cellular debris. It is not as reliable as Tru-Cut for diagnosing solid masses. Vacuum-Assisted Biopsy is an advanced method powered by vacuum that we use especially to sample the tiny calcifications, or microcalcifications, seen on mammography.

Does a Benign Breast Lesion Require Treatment?

Your biopsy result has arrived and says “benign.” You have taken a deep breath. So what happens now? Will that lesion remain there? The management of benign lesions varies according to the type of lesion and the patient’s complaints. We do not surgically remove every benign lesion.

The factors determining our treatment approach are:

• Size of the lesion
• Growth rate
• Whether it causes pain
• Presence of cosmetic deformity
• Patient’s age group
• Family history
• Patient psychology

For example, if you have simple cysts and they do not cause pain, we do not interfere with them. However, if there is a very tense and painful cyst, we drain the fluid inside it with a simple needle in the outpatient clinic, and the patient experiences immediate relief.

For fibroadenomas, which are common in young women, our rule is generally “follow-up.” If the mass is smaller than 2-3 cm, has a regular shape, and is not growing, surgery is not necessary. However, if the mass is growing rapidly, for example if it has doubled in size within 6 months, has become large enough to distort the shape of the breast, known as a giant fibroadenoma, or if the patient says, “I do not want to live with a mass inside me, it is affecting my psychology,” then surgical removal may be considered.

In addition, if the biopsy result shows the “high-risk” lesions with atypia mentioned above or suspicious papillomas, these must be surgically removed because of their potential to cause problems in the future, even if they are considered benign.

What Are the Surgical Options for a Breast Lesion?

If the lesion needs to be removed, whether it is a high-risk benign formation or a malignant condition, we plan the surgery very carefully. In the past, breast surgery brought to mind frightening major operations that disrupted bodily integrity. However, our surgical approach in modern medicine has completely changed. Our goal is no longer only to treat the disease but also to preserve aesthetic integrity.

Our current surgical approaches are:

• Breast-conserving surgery
• Oncoplastic surgery
• Skin-sparing mastectomy
• Nipple-sparing mastectomy
• Simple mastectomy
• Sentinel lymph node biopsy

Our priority is always Breast-Conserving Surgery. In this method, we do not remove the entire breast. We remove only the lesion together with a certain amount of healthy tissue around it, which we call a safe margin. In early-stage breast cancers, this method provides the same survival success as removing the entire breast.

However, when we remove the lesion, a space or depression may form in the breast. This is where Oncoplastic Surgery comes into play. It is the dance of general surgery and plastic surgery principles. We close the cavity created by removing the tumor by shifting your own breast tissue. Sometimes, since the patient is already undergoing surgery, we apply breast reduction techniques, both removing the lesion and giving the breast a more lifted and aesthetic shape.

If the lesion is very large or there are multiple foci in the breast and the entire breast must be removed, meaning a Mastectomy, we still do not abandon aesthetics. In suitable patients, we preserve the breast skin or nipple, remove the internal tissue, and reconstruct a new breast during the same operation using a silicone implant or the patient’s own tissue. In this way, the patient does not experience the trauma of organ loss when waking up and looking in the mirror.

Why Is the Pathology Report Important After a Breast Lesion?

After the operation is completed, a second process begins for us: pathological examination. Examining the removed tissue millimeter by millimeter in the laboratory is like creating an identity card for the disease. The pathology report is the most critical document determining the future roadmap of treatment.

The main information we look for in the pathology report is:

• Type of tumor
• Size of the tumor
• Surgical margins
• Tumor grade
• Lymphovascular invasion
• Hormone receptors
• HER2 status
• Ki-67 proliferation index

These parameters tell us how aggressive the disease is, the risk of recurrence, and which medications it will respond to. For example, the statement “Surgical margins are clear” indicates that the lesion has been completely removed and no tissue has been left behind. Positive hormone receptors, Estrogen and Progesterone, indicate that the disease will respond to hormone therapy, meaning oral medication.

After this report is issued, we surgeons come together with medical oncologists and radiation oncologists to evaluate our patient at the “Tumor Board.” Will chemotherapy be required, should targeted therapy be administered, and how should radiation therapy be planned? The answers to all these questions are hidden in the details of that pathology report.