What are the main benign lesions of the breast? This concerns the classification of benign breast lesions. Except for malignant, all other benign breast lesions are benign, but nowadays there are more ways to classify benign breast lesions, and there are differences between domestic and foreign countries. In China, they are generally classified as congenital lesions, such as nipple invagination or parametrium (a breast growing out of the armpit); another category is proliferative lesions, that is, we often hear about mastopexy, these benign lesions account for a large part; then there are benign tumors and inflammatory diseases, and finally there are other rare diseases. The first category is congenital lesions, the second category is normal developmental reversion abnormalities, this category is what we often call hyperplastic lesions, and the third category is non-normal developmental reversion type of lesions. The most interesting one is the normal breast developmental rejuvenation abnormality, also known as mastopexy. The mammary gland develops throughout a person’s life, but the tissue degenerates with developmental rejuvenation, and if the developmental rejuvenation degenerates abnormally, it becomes abnormal, and in some cases, it becomes a disease. A typical example is that if you don’t have children, your mammary glands will not develop completely; if you have children and are breastfeeding well, your mammary glands will develop and regenerate very well. The most commonly heard term for abnormal breast development and rejuvenation is mastopexy, which is the pathological term. Mammary gland hyperplasia is not a real disease, but an abnormality resulting from inadequate development and rejuvenation. It is a cyclical change, mostly physiological, and only at a later stage can it turn into a pathology, such as fibroadenoma, or in severe cases, even atypical hyperplasia. Which of these benign lesions have the potential to become cancerous? What exactly is the relationship between benign lesions and breast cancer is a question that is being studied all over the world. Generally, if benign breast lesions are not life-threatening and do not affect the aesthetic appearance of the breast, they do not need to be treated. Why do people deal with it more now? Because we do not know very well which benign lesions are cancerous and which are not, and as a result, more interventions are carried out, and we can even say that there is a bit of over-treatment. Nowadays, many breast experts have basically come to the conclusion that no matter what kind of benign breast lesion is present, once atypical hyperplasia occurs, the risk of breast cancer is about five times higher than that of the general population (including ordinary hyperplasia or no hyperplasia). The so-called atypical hyperplasia is not seen by our general clinical manifestation, but needs to be examined by pathology. This kind of hyperplasia is manifested by thicker ductal or lobular proliferation layer and some abnormal cells, but it does not reach the standard of cancer. What is the concept that the chance of cancer is five times higher? If an average person without hyperplasia has a 1% chance of developing breast cancer within five years, then the chance of developing breast cancer for people with atypical hyperplasia is about 5%; that is, if you have atypical hyperplasia detected five years ago, your chance of developing cancer in the next five years is about 5%; if there is also a family history, the chance is ten times higher or even higher. Generally speaking, atypical hyperplasia is more likely to occur in sclerosing adenopathy or cystic hyperplasia, and in intraductal papilloma. Just because there is a higher chance of atypical hyperplasia does not mean that it will occur, and just because there is a low chance of atypical hyperplasia does not mean that it will not occur. Therefore, nowadays, we generally do not refer to which kind of lesion, nor do we care about which kind of lesion, but focus on the pathology. As long as there is atypical hyperplasia, then she belongs to the high-risk group of breast cancer; on the contrary, as long as there is no atypical hyperplasia, then she is the general population and there is no need to worry about it, as long as she is screened according to the general population in the future. It is said that the cancer rate of breast enlargement is 2% to 4%? This number is not correct, but the 5-year cancer rate of atypical hyperplasia is 5%, and if we count it as 10 years, it is about 10%. Therefore, we cannot say that the cancer rate of mammary gland hyperplasia is 2% to 4%. Generally speaking, the risk of cancer in common mammary gland hyperplasia is 0.5% to 1% after 5 years of follow-up, which is actually the chance of cancer in the general population, while the chance of cancer in people with atypical hyperplasia is about 5% after 5 years of follow-up, which is much higher than the general population. Is there any relationship between family history, age and atypical hyperplasia of the breast? Family history mainly refers to whether the female partner, such as your mother or sisters, has had breast or ovarian cancer. Generally speaking, if only one person in the family has the disease, it is a general family history; if two people in the family have the disease, it is a clear family history and the risk of the disease is higher in this case. In other words, even if you do not have atypical hyperplasia, but you have a family history, the risk of cancer is higher than others; if you add atypical hyperplasia, the risk of cancer will be another layer higher. So, family history is an independent factor. Another factor is age. The risk of atypical hyperplasia increases with age. For example, there is a big difference between people before the age of 40 and those after 40. There will be less chance of atypical hyperplasia before the age of 40 and more after the age of 40. This is why breast cancer screening usually starts at the age of 40. I often see some ultrasound screening reports that say “lobular hyperplasia or cystic hyperplasia or ductal hyperplasia”, what is the difference between these? Mammography screening (mammography) is the main screening test in foreign countries. In China, mammography is not yet popular, and most breast cancer patients in our country are under 50 years old, when the gland is not completely degenerated and the sensitivity of mammography is low. Therefore, ultrasound is generally preferred in China. In the past, when there was no standard, ultrasound looked at the general condition of the breast and then made a diagnosis, such as lobular hyperplasia, breast cancer, cystic hyperplasia, and cysts; however, nowadays, according to international standards, ultrasound cannot directly make a diagnosis, but makes a graded assessment, and BI-RADS grading is the assessment mode of breast ultrasound. In fact, ultrasound does not under diagnose to avoid adding psychological burden to patients without pathology before and standardize the communication with clinicians. And what do we mean by grading? In fact, it is also to determine the risk of cancer and to determine whether the breast lesion should be biopsied or not. It is specifically divided into 0-6 grades. For example, what is the meaning of grade 0? The person himself has symptoms, such as lumps or nipple overflow, but the ultrasound examination cannot completely assess the lesion and needs to be further combined with other imaging examinations. When the doctor sees such an ultrasound report, he or she knows that there is no point in doing another ultrasound and should choose another method for further examination, such as a mammogram or MRI. If the report is grade 1, it means the result is negative and normal, follow up; while grade 2 means benign disease, regular follow up; grade 3 should be considered benign, but there is 2% chance of cancer, so a comprehensive judgment is needed, short term follow up or biopsy; if the report is grade 4, it means the chance of cancer is relatively high, in the range of 3% to 94%, breast biopsy is recommended; if it is grade 5, it means the risk of cancer reaches 95% and If it is grade 5, it means the risk of cancer is 95% and biopsy must be done; grade 6 means cancer is confirmed. In the past, patients were very nervous when they got the ultrasound report and saw that it said breast enlargement because the relationship between breast enlargement and breast cancer was overly promoted, causing psychological burden or anxiety to patients. Now after the adoption of imaging assessment grading, this misunderstanding has been reduced to some extent. This report can be read by doctors and later by patients, for example, if it says grade 3, they will understand that they only need to follow up regularly in the future, once every 3-6 months, not necessarily to do biopsy, but only when clinically necessary. Now all large hospitals in Guangdong Province should adopt this standard grading assessment method, which is more scientific and rigorous. Does it mean that the risk of cancer can be basically known by biopsy? Generally speaking, to determine the risk of cancer, the more accurate method is still to look at the pathological biopsy results. Of course, the hot topic some time ago about Jolie’s carrying BRCA1 mutation gene cut breast cancer prevention has a great impact1, which is one of the independent predictors of breast cancer. If there is a family history of people, such as a mother who has ovarian cancer or breast cancer, then the daughter can go for testing, because people with a family history of carrying a gene with a mutation have about 10-15% chance of having a mutation, and if the test finds a mutation, she belongs to a high-risk group, regardless of whether there is atypical hyperplasia on pathological examination. Julie took a more radical approach to the treatment: remove the whole breast and then do breast reconstruction. But this is only one of the treatment methods, in fact, there are two other treatment methods: one is to do MRI every two years, when cancer is found then do the next surgical treatment; the other method is to eat hormone antagonists, that is, endocrine prophylaxis. At present, there are no more ways to detect breast cancer early in our country. Usually, it is still a manual breast examination plus imaging (including ultrasound, X-ray, MRI) and biopsy, which we call the triple assessment method. In general, when is a breast biopsy necessary? If the imaging rating is 4 or 5, a biopsy should definitely be done. Some of the grade 3s are based on clinical needs, for example, if the patient is in her 40s or 50s and has a higher risk of cancer, we will advise her to have a biopsy; in addition, it will also be based on patient needs, for example, if the patient is anxious, even though the doctor has told her that the diagnosis is considered benign, but she is still worried about the atypical hyperplasia or that 2% cancer possibility, then a minimally invasive biopsy can be chosen at this time. However, in fact, after biopsy, about 99% of these patients are still benign and only 1% are malignant or atypical hyperplasia lesions. Therefore, for patients who are evaluated as grade 3, we still recommend close observation, usually three to six months to come back and review the ultrasound, and if a sudden increase in breast size or signs of grade 4 are found, it is not too late to biopsy at this time. As for many people’s concern about the delay of six months, in fact, there is no difference in the degree of tumor lesions within six months to one year. After atypical hyperplasia is found, what should be done next? There are three things to do. First, improve your eating habits. What kind of dietary habits? In the past, we liked to eat high-fat and high-protein food, and we were under great mental stress. We advocate three “less”, less angry, less late at night, less seafood. Among the seafood, shrimp is very risky, as well as farmed freshwater fish, because a lot of farmed feed now contains a variety of hormones, which we collectively call estrogen-like. It is not estrogen, but it has estrogen-like effects, and eating too much of it will produce stimulation. Why are now said to be more uterine fibroids, hyperplastic adenomas, in fact, is related to food, the environment. Plasticizers and heavy metals are also estrogen-like, and many of these things are inside the environment. Therefore, we must first improve our diet. The first thing you need to do is to improve your diet. You can eat vegetables, fruits, rice, steamed buns, soy products, etc. But shrimp, seafood, and freshwater fish, as little as possible; if you want to eat fish, it is best to eat deep-sea fish, and chicken is best to eat less of those feed chickens. In addition, we should be less angry, if we bury anything unhappy in our heart, we will easily get cancer. Second, regular checkups. In the past, you may only have a checkup once a year, but now you should have a checkup once every six months. X-rays are usually enough, and MRI once every two years to see if there is any development. Third, if you are at higher risk or have a family history, you have to take medication to prevent it. Triamcinolone and aromatase inhibitors are known to prevent breast cancer. Of course, if the atypical hyperplasia is too extensive and you are under great psychological pressure, you can have a total mastectomy and prosthesis reconstruction, which is more commonly used abroad. When should I have surgery if a breast nodule or lump is found? This is also based on the BI-RADS classification. For example, if you are only 20 years old and an ultrasound reveals a one-centimeter fibroadenoma and the report is grade 2, you can continue to observe without biopsy and without surgery. If a lump was felt or found to be a fibroadenoma according to the old criteria, surgery would be performed, but the modern view of diagnosis is still based on imaging evaluation before doing so, which is different from the old view. However, if a patient is 40 years old and a lump is felt, it is now advocated that after evaluation, if the risk is felt to be high, it can be done. Why is mammography not an option for patients with atypical hyperplasia for regular checkups? Dr. Chip Wang: If ultrasound can detect it, then ultrasound is the way to go. Of course, mammography is also an option during the follow-up because sometimes the lesion becomes calcified and it is difficult to determine with ultrasound. Also, why can’t we do too many mammograms? Because mammograms have X-rays, which have an impact on health, while MRIs do not have X-rays and do not have an irritating effect. We generally prefer MRI to examine atypical hyperplasia, but MRI is more expensive and can be chosen by patients who have the conditions. Just now I mentioned that I can take medicine for prevention, do I have to take it all the time? The standard course of treatment is to take five years, but Chinese patients have difficulty in adhering to it, and usually can’t persist after two or three years; foreign patients have better compliance, and more than 80% of them can persist in taking it, and those who persist can reduce the risk of cancer by 5%, which is still a significant figure. Now, we are studying which people take the medicine effectively and which people take it ineffectively, but there are no results yet. Many people are also worried about phytoestrogens and feel that they should not drink soy milk either. Phytoestrogens have very little effect on the human body and are beneficial. We advocate eating tofu and soy milk, and there are domestic epidemiological studies that have found that patients who like tofu and soy milk have a good prognosis, while those who eat freshwater fish have a poor prognosis.