What Are Breast Diseases?

Breast diseases refer to all conditions that occur in breast tissue and lead to structural or functional disorders. A lump felt in the breast, pain, discharge from the nipple, or differences in the appearance of the skin are common symptoms of these diseases. This term covers a very broad spectrum, ranging from simple and frequently seen benign changes to more complex and serious health problems that must be treated. Therefore, the meticulous evaluation of any unusual symptom in the breast by a general surgery specialist is the first and most important step in the correct diagnosis and effective treatment process.

What You Need to Know	Information
What are breast diseases?	Breast diseases are examined in three main groups: benign, inflammatory, and malignant (cancerous). Each requires different clinical signs and treatment approaches.
Benign breast diseases	These include lesions such as fibrocystic changes, fibroadenoma, breast cysts, intraductal papillomas, and fat necrosis. They are generally not cancerous and can be monitored through follow-up.
Fibrocystic breast changes	They develop due to hormonal changes. They are characterized by tenderness, pain, and irregular nodular structures in the breast. They may increase near the menstrual period.
Fibroadenoma	It is common in young women. These are mobile, well-circumscribed, round, and usually painless masses. They are generally benign and monitored. Large or suspicious ones may be surgically removed.
Breast cysts	These are round or oval structures containing fluid. They may be single or multiple. Large and painful cysts can be drained with a needle.
Diseases caused by infection	Mastitis (inflammation of the breast) and breast abscesses are seen especially in breastfeeding women. Pain, redness, swelling, and fever may accompany them. Antibiotics and drainage are applied when necessary.
Breast cancer	It is a malignant tumor that develops in breast tissue. It is one of the most common cancers in women. Early diagnosis increases treatment success.
Symptoms of breast cancer	Warning signs may include a hard, immobile lump, nipple retraction, dimpling of the skin, an orange peel appearance, and bloody nipple discharge.
Warning signs	A physician should be consulted when any breast lump, sudden-onset breast pain, nipple discharge, change in color or shape, redness of the skin, or retraction is noticed.
Evaluation methods	Methods such as physical examination, breast ultrasonography, mammography, magnetic resonance imaging (MRI), and biopsy are used for diagnosis.
Importance of regular follow-up	Although most breast diseases are benign, some may be confused with cancer. Therefore, regular check-ups and follow-up with imaging methods are important.

How Are Breast Diseases Fundamentally Classified?

To better understand the problems we see in breast tissue, we divide them into main groups. These diseases are fundamentally classified into four main groups.

• Developmental abnormalities (for example, an extra nipple or breast tissue)
• Inflammatory lesions (mastitis and abscesses)
• Benign masses and growths (fibroadenoma, cysts)
• Malignant neoplasms (breast cancer)

What Are Malignant Breast Diseases, Namely the Types of Cancer?

When we speak of breast cancer, we are not referring to a single disease. It has different types depending on the cell from which it originates and its behavior. The most common are:

• Invasive Ductal Carcinoma (IDC) – It begins in the milk ducts and is the most common type.
• Invasive Lobular Carcinoma (ILC) – It begins in the milk glands (lobules) and is the second most common type.
• Ductal Carcinoma In Situ (DCIS) – It is known as “cancer in place” and has not yet spread outside the duct.
• Lobular Carcinoma In Situ (LCIS) – It is considered more of a marker that increases future cancer risk than a cancer itself.

Why Is Inflammatory Breast Cancer (IBC) Different from Other Cancers?

This is one of the rare (1-5%) but most aggressive types of breast cancer. It is called inflammatory because it mimics an infection in the breast (mastitis). It usually does not form a distinct mass. Instead, cancer cells block the lymphatic channels in the breast skin.

This blockage causes the following symptoms to develop rapidly in the breast, within weeks or months:

• Redness
• Swelling and edema
• Increased warmth
• “Orange peel” (peau d’orange) appearance

Because these symptoms may be confused with an abscess or mastitis, diagnosis can be delayed. In such inflammatory conditions that do not respond to antibiotic treatment, inflammatory breast cancer must always be considered and a biopsy should be performed promptly.

Why Is the Center Where Breast Cancer Treatment Is Followed Important?

In breast cancer treatment, both the surgeon’s individual experience and the volume of cases treated at the center directly affect the patient’s long-term survival. Scientific studies clearly show that surgeons and centers performing more than a certain number of breast cancer operations per year achieve better outcomes.

Today, breast cancer treatment is a team effort. In this model called the “multidisciplinary approach,” many different specialists work together to achieve the best result. The specialists on this team are:

• General Surgeon (Performs diagnosis and surgery)
• Medical Oncologist (Plans medication and chemotherapy treatments)
• Radiation Oncologist (Administers radiation therapy)
• Radiologist (Interprets imaging and guides the biopsy)
• Pathologist (Examines the tissue sample and makes the definitive diagnosis of the disease)

The collaboration of these specialists creates synergy, ensures that the most accurate and up-to-date treatment plan is prepared for each patient, and increases treatment success.

How Is a Definitive Diagnosis Made for a Breast Lump?

Imaging methods such as mammography, ultrasound, or MRI may detect a suspicious area in the breast. However, these images cannot tell us exactly what that area is. The only and gold standard method for determining whether a lesion is benign or malignant (cancerous) is to perform a biopsy.

Today, “Core Needle Biopsy” is used most frequently for this procedure. Under local anesthesia and ultrasound guidance, several thin tissue samples are taken from the suspicious mass and sent to pathology for examination.

Why Is Vacuum-Assisted Breast Biopsy (VABB) Advantageous?

Vacuum-assisted breast biopsy (VABB) is a more advanced version of core needle biopsy. It has a vacuum system that allows more and higher-quality tissue samples to be obtained than with standard core needle biopsy. This greatly increases diagnostic accuracy, especially in uncertain lesions.

There are some special situations in which vacuum-assisted biopsy is preferred and several advantages:

• Microcalcifications (suspicious clusters of calcification seen on mammography)
• Very small, uncertain masses
• More reliable pathological diagnosis (because more tissue is obtained)
• Sometimes being able to remove small benign masses completely without surgery
• Leaving no scar or only a minimal scar compared with a surgical incision
• Very rapid recovery time (approximately 24 hours)

Especially when a high-risk lesion is suspected, obtaining more tissue with VABB reduces the risk of a “sampling error” and may save the patient from an unnecessary second operation.

What Happens If the Biopsy Report and Imaging Report Do Not Match?

This is a critical situation that requires great attention in breast surgery. Sometimes, based on imaging such as mammography or ultrasound, the radiologist may issue a report stating, “This lesion is highly suspicious and has a high probability of being cancer” (BI-RADS 4 or 5). However, the result of the needle biopsy taken from this suspicious lesion may be “benign.”

This situation is called “Pathology-Imaging Discordance,” and it is an alarm signal.

In such a case, there is a high probability that the needle biopsy has “missed” the actual cancerous area or has “sampled it inadequately.” Imaging findings are considered more important than the pathology result. Therefore, in every case of pathology-imaging discordance, it is mandatory to surgically remove the lesion completely and send the entire specimen for pathological examination.

How Is a Non-Palpable Breast Mass Found During Surgery?

Thanks to screening mammograms, we can now detect cancers when they are very small and not yet palpable. Although this is a wonderful development, it creates a new challenge for the surgeon: How do we find and remove this millimetric area during surgery when it cannot be felt?

Preoperative “marking” (localization) methods are used to find these lesions.

The traditional method was “Wire-Guided Localization” (WGL). On the day of surgery, the patient goes to the radiology department immediately before the operation. Under ultrasound or mammography guidance, the radiologist places a thin wire into the suspicious area. One end of the wire is inside the lesion, while the other end extends outside the skin. During the operation, the surgeon follows this wire to find and remove the lesion. However, this method has difficulties in terms of both patient comfort, because there is a wire outside the body, and hospital logistics, because of timing on the day of surgery.

Today, “Wireless Localization” methods are increasingly being used. In these methods, such as Radioactive Seed, Magnetic Seed, or Radar Reflectors, a very small “marker” (seed or clip) is placed inside the lesion by the radiologist several days or even weeks before surgery. During the operation, the surgeon locates this marker using a special handheld detector, such as a gamma probe or magnetic sensor, and removes it together with the lesion. This greatly improves patient comfort and provides considerable flexibility in surgical planning.

What Does a “High-Risk” Breast Lesion Mean? Is It Cancer?

There are certain lesions described as “high-risk” based on the result of a needle biopsy. These are not yet cancer, but they have two important characteristics:

They increase the risk of developing breast cancer in the future.

More importantly, they may mask a cancer, usually DCIS, that has already begun immediately next to or within the lesion but was missed by the needle biopsy.

When a lesion reported as “high-risk” on needle biopsy is completely removed surgically, the rate at which the pathology result is “upgraded to cancer” ranges from 10% to 30%.

The most common high-risk lesions are:

• Atypical Ductal Hyperplasia (ADH)
• Lobular Carcinoma In Situ (LCIS) (especially pleomorphic or florid variants)
• Radial Scar (especially when accompanied by atypia)

Because of this “upgrade” risk, when a high-risk lesion such as ADH or an aggressive type of LCIS is diagnosed on needle biopsy, the standard approach is usually complete surgical removal of that area through excisional biopsy. This is done both to establish a definitive diagnosis and to avoid missing a possible cancer.

When Are Benign Breast Masses (Fibroadenomas) Operated On?

Most breast masses are benign. The most common of these is fibroadenoma, especially seen in women in their 20s and 30s. Fibroadenomas are not cancer and do not transform into cancer.

Most fibroadenomas are only monitored through physical examination and ultrasound. However, surgical removal (excision) may be recommended in the following situations:

• If it is growing very rapidly
• If its size is very large (usually over 3-4 cm)
• If it causes pain, tenderness, or cosmetic deformity
• If it causes distortion of the breast shape
• If there is any suspicion in the imaging or biopsy results

What Is Done in Cases of Breast Inflammation (Mastitis) and Abscess?

Especially during breastfeeding (lactational mastitis), infection may develop in the breast due to blockage of the milk ducts or bacteria entering through nipple cracks. If this condition is not treated or does not respond to treatment, inflammation may accumulate and form an abscess, meaning a collection of pus inside a capsule.

The treatment of a breast abscess has two components: antibiotics and drainage of the abscess. Giving antibiotics alone is not sufficient to eliminate the pus inside the capsule.

Today, the first-choice drainage method for breast abscesses is not surgical incision and drainage (I&D). The first choice is ultrasound-guided needle aspiration (NA). The location of the abscess is visualized with ultrasound, and all the pus inside the abscess is withdrawn with a needle under local anesthesia.

This method has many advantages: Recovery time is much faster, no scar remains because there is no surgical incision, there is no risk of damaging the milk ducts, and most importantly, it allows the breastfeeding mother to continue breastfeeding. Surgical incision and drainage (I&D) is used only if attempts at needle drainage fail or if the abscess is very large.

Is There a Permanent Solution for Recurrent Periareolar Breast Abscesses?

Yes, this is a very specific condition that requires a different management approach. These are chronic abscesses that recur immediately around the edge of the nipple (periareolar), usually outside the breastfeeding period and especially in women who smoke.

The underlying problem is blockage of one of the main milk ducts (lactiferous ducts) immediately beneath the nipple, causing chronic inflammation (Periductal Mastitis). Trying to treat this condition only with antibiotics and simple incision and drainage (I&D) does not work. The abscess recurs at the same site shortly afterward. With each recurrence, the breast tissue becomes more damaged and the nipple begins to retract inward.

The only permanent solution for recurrent periareolar abscesses is the operation known as Total Duct Excision (Hadfield procedure). In this operation, after the abscess period has passed, during a quiet phase, the chronically blocked and inflamed main milk ducts beneath the nipple are surgically removed as a core. Since this procedure eliminates the source of the problem, it provides a very high rate of permanent resolution and also produces a good cosmetic result.

What Options Are Available in Breast Cancer Surgery?

When breast cancer is diagnosed, surgical treatment, together with regional lymph node evaluation, is the main treatment method. There are two basic surgical approaches:

• Breast-Conserving Surgery (BCS / Lumpectomy): Only the cancerous tumor is removed together with a certain amount of healthy surrounding tissue, creating a clear surgical margin. Most of the breast is preserved.
• Mastectomy: The entire breast tissue is removed.

What Are the Types of Modern Mastectomy?

Even when mastectomy is necessary, the goal is now to achieve the best aesthetic result and preserve the option of breast reconstruction.

• Total (Simple) Mastectomy (The nipple and part of the skin are removed together with all breast tissue)
• Skin-Sparing Mastectomy (The breast skin is preserved and used as an “envelope” for reconstruction)
• Nipple-Sparing Mastectomy (The skin, nipple, and areola are preserved and it provides the best aesthetic result)
• Contralateral Prophylactic Mastectomy (Removal of the healthy opposite breast because of high risk while the cancerous breast is removed)

Is Breast-Conserving Surgery as Safe as Complete Removal of the Breast?

Yes. This is one of the facts patients are most curious about and one of the cornerstones of modern breast surgery.

Very large and long-term scientific studies have clearly proven the following: In early-stage breast cancer, in patients who meet certain criteria, breast-conserving surgery (BCS) followed by radiotherapy (RT) to that breast has exactly the same long-term survival rates as mastectomy, meaning complete removal of the breast.

In other words, the ideas that “removing the entire breast is safer” or “let us remove all of it so the cancer does not return” are not supported by modern medical data for early-stage cancer. This is one of the most important pieces of information that gives these patients the opportunity to preserve their breasts and bodily integrity.

How Has “Oncoplastic Surgery” Changed Breast Cancer Treatment?

Oncoplastic surgery is an advanced form of breast-conserving surgery. It consists of two words: “Onco” (cancer) and “Plastic” (aesthetic/reconstructive).

The aim is not only to remove the cancerous tissue but also to reshape the remaining breast tissue using plastic surgery techniques. In this way, collapse, deformity, or asymmetry that may occur in the breast after removal of the tumor is prevented. Sometimes, an intervention such as reduction or lifting is also performed on the patient’s other breast to achieve symmetry. Oncoplastic surgery aims to preserve the patient’s aesthetic result, body image, and quality of life at the highest possible level without compromising the safety of cancer treatment, meaning oncological safety.

Why Is the Armpit (Axilla) Important in Breast Cancer Surgery?

When breast cancer first spreads (metastasizes), it usually reaches the lymph nodes located in the armpit. Therefore, checking the axillary lymph nodes during surgery is mandatory to determine the stage of the disease accurately (TNM staging) and to decide whether additional treatments such as chemotherapy or radiotherapy are required.

What Is Sentinel Lymph Node Biopsy (SLNB)?

In the past, all the lymph nodes in the armpit, usually 15-30 nodes, were removed from every woman undergoing breast cancer surgery. This procedure is called “Axillary Lymph Node Dissection (ALND).” However, this procedure had very serious side effects.

Sentinel Lymph Node Biopsy (SLNB) is a revolutionary technique that changed this approach. Its principle is as follows: Cancer cells coming from the tumor first reach one or several “sentinel” lymph nodes before spreading throughout the entire armpit.

During surgery, a special blue dye and/or a low-dose radioactive substance is injected into the breast tissue. These substances “color” or “mark” the first lymph node or nodes to which the tumor drains, namely the sentinel nodes. The surgeon finds and removes only these 1-3 sentinel lymph nodes. The pathologist examines these sentinel nodes immediately. If the sentinel nodes are clear, meaning cancer has not spread to them, this indicates that the other nodes are also clear, and no other lymph nodes in the armpit are touched.

Why Is Removal of All Axillary Lymph Nodes (ALND) Problematic?

The purpose of SLNB, meaning sentinel node biopsy, is to protect patients from the serious side effects of ALND, meaning removal of all axillary lymph nodes. Although ALND is a life-saving procedure when necessary, when performed unnecessarily it can permanently impair the patient’s quality of life.

The most important chronic side effects of ALND are:

• Lymphedema (permanent, progressive, and painful swelling in the arm on the operated side)
• Nerve damage (numbness, tingling, and chronic pain in the arm and chest wall)
• Restriction of shoulder movement
• Increased risk of infection in the arm

Is It Always Necessary to Remove All Lymph Nodes in the Armpit? (De-escalation)

No, it is no longer always necessary. This is one of the most important developments in modern breast surgery.

In the past, when even the smallest cancer cell, including micrometastasis, was found in a sentinel lymph node, the standard approach was to remove all lymph nodes in that armpit through ALND.

However, very large scientific studies conducted in recent years, especially the ACOSOG Z0011 trial, proved something remarkable:

• Rule 1 (For Breast-Conserving Surgery): If the patient has early-stage breast cancer, will undergo breast-conserving surgery (BCS), and will receive radiotherapy (RT) to the entire breast after surgery, then even if cancer is found in only 1 or 2 of the sentinel lymph nodes, removing the remaining lymph nodes through ALND provides no additional survival benefit.

Simply put, no difference in survival was found between removing all the lymph nodes in the armpit and not removing them in these patients. However, not clearing the armpit protects the patient completely from a heavy burden such as lymphedema. This is because the radiotherapy that will be administered already treats any microscopic disease that may remain in the armpit.

• Rule 2 (For Mastectomy): A similar approach also applies to patients undergoing mastectomy who will receive postoperative radiotherapy to the chest wall and regional lymph nodes (PMRT). Avoiding or omitting ALND is now also offered as an option in these patients with 1-2 positive nodes.

This “de-escalation” protocol is an evidence-based modern approach that allows surgeons to protect patients from a heavy burden such as lymphedema without compromising cancer treatment. Therefore, the surgeon’s command of these current guidelines is vital for the patient’s quality of life.

Frequently Asked Questions

How closely are breast diseases associated with genetic predisposition?

Genetic factors play an important role in some breast diseases, especially breast cancer. Gene mutations such as BRCA1 and BRCA2 may increase risk through familial inheritance and may require early screening.

What symptoms does fibrocystic breast disease cause?

Fibrocystic changes generally present with symptoms such as tenderness, a feeling of fullness, and lumps in the breast during the premenstrual period. This condition is benign but requires regular monitoring.

What is the role of ultrasound and mammography in breast diseases?

Ultrasound is generally used in young women, while mammography is used for screening in women over the age of 40. They are important for distinguishing the structure of masses and supporting diagnosis when cancer is suspected.

Why do breast cysts develop and when is treatment required?

Cysts develop as a result of fluid accumulation in the milk ducts. They are generally benign and do not require treatment; however, drainage or biopsy may be necessary if they are large, painful, or suspicious.

When is nipple discharge a sign of a serious disease?

Clear or bloody discharge should be carefully evaluated, especially if it is unilateral and comes from a single duct. This condition may sometimes be a sign of diseases such as breast cancer or intraductal papilloma.

How do mastitis and abscesses develop in breastfeeding mothers?

Mastitis, which develops due to blockage of the milk ducts or infection, presents with redness, pain, and fever. If it progresses, an abscess may form and surgical intervention may be required.

What role does hormonal imbalance play in breast diseases?

Imbalances in estrogen and progesterone may cause tenderness, cyst formation, and fibrocystic changes in breast tissue. Hormonal irregularities may also affect the risk of certain cancers.

How are benign tumors in breast tissue most commonly described?

Fibroadenoma is the most common benign tumor. It is generally seen in young women and is mobile, well-circumscribed, and painless. The diagnosis is confirmed with ultrasound and, if necessary, biopsy.

How do breast diseases progress after menopause?

Hormonal changes during menopause lead to changes in breast tissue. Newly developing masses are evaluated more carefully during this period because the risk of cancer increases.

Which lifestyle changes are recommended to prevent breast diseases?

Regular exercise, maintaining a healthy weight, balanced nutrition, avoiding smoking, and limiting alcohol consumption may reduce the risk of breast diseases. Regular check-ups are also critical for early diagnosis.