- Fibrocystic breast disease:
- Is the most common benign type of breast disease:
- Diagnosed in millions of women worldwide
- Certain hormonal factors underpin the function, evaluation, and treatment of this disease
- Is the most common benign type of breast disease:
- Benign breast disease:
- Is an umbrella term for various non-malignant lesions, such as:
- Tumors, trauma, mastalgia, and nipple discharge
- Is an umbrella term for various non-malignant lesions, such as:
- The above-mentioned benign lesions are not associated with an increased risk for malignancy:
- However, it associates with an up to 50% risk of developing breast cancer under certain histopathological and clinical circumstances
- A palpable mass upon clinical evaluation:
- Is evident in both benign and malignant breast conditions
- The clinical findings include symptoms such as dimpling of the skin (peau d’orange), thickening, pain, and nipple discharge
- The most common investigative tools to assess for these clinical findings are:
- Mammograms and ultrasound
- The main components of the breast are prone to fibrocystic changes during:
- Hormonal fluctuations
- These components include the:
- Stroma, ducts, and lobules of the breast
- During the reproductive age:
- Glandular breast tissue has a direct relation to cyclical surges of plasma levels of estradiol and progesterone
- Etiology:
- The etiology of benign breast disease has demonstrated a strong clinical association:
- With women receiving estrogen and anti-estrogen treatment
- The prevalence of benign breast lesions in postmenopausal women receiving estrogens and progestins for over eight years:
- Is increased by 1.7 fold
- During the Women’s Health Initiative study (WHI):
- The combined use of estrogen and progestin correlated with a:
- 74% risk of benign breast disease
- The combined use of estrogen and progestin correlated with a:
- The use of anti-estrogens:
- Led to a 28% reduction in the prevalence of benign proliferative breast disease
- The etiology of benign breast disease has demonstrated a strong clinical association:
- Epidemiology:
- Fibrocystic breast disease incidence is varies:
- Ranging from 30% to 60% of all women
- It is most common in women:
- Between the ages of 30 to 50 years
- One of the most common forms of benign breast disease is:
- Fibroadenomas:
- Characterized by localized proliferation of breast ducts and stroma
- This subtype accounts for 70% to 95% of all benign breast tumors
- The incidence is mostly seen in the 17 to 20 year age group:
- Extending to 2 years premenarche to 35
- Fibroadenomas:
- Fibrocystic breast disease incidence is varies:
- Pathophysiology:
- Mammary gland development, maturation, and differentiation:
- Act upon the hormonal and growth factor changes:
- Affecting the stromal and epithelial cells
- Act upon the hormonal and growth factor changes:
- During the late proliferative phase:
- Glandular breast tissue evolves to hyperplastic stages such as:
- Sclerosing adenosis or lobular hyperplasia:
- This state of hyperplasia, if associated with a 2% prevalence of Ki67 cell activity has a twofold increased incidence for the development of breast cancer
- Sclerosing adenosis or lobular hyperplasia:
- Glandular breast tissue evolves to hyperplastic stages such as:
- Various types of benign breast disease exist, such as:
- Hyperplasia, cysts, fibroadenomas, sclerosing adenosis, and mastitis
- Mammary gland development, maturation, and differentiation:
- Histopathology:
- There is a limited pathological consensus regarding the histopathological appearance of benign breast disease
- The main features are an extracellular matrix of collagen, peri canalicular patterns of stromal cells with the presence of florid epithelial hyperplasia
- During the menopausal phase:
- Fibroadenomas involute, which affects dense collagen stroma and atrophic glands
- Cystic changes derive from the terminal duct lobular unit (TDLU):
- Due to the expansion of the efferent ductules of the TDLU:
- Cysts form as a result of fluid accumulation in these structures
- The lining appears flat with a myoepithelial layer present
- Due to the expansion of the efferent ductules of the TDLU:
- History and Physical:
- Benign cysts are typically mobile within the glandular breast tissue, chest wall, and skin and are rubber-like in texture:
- Except for inflammatory type cysts, discomfort and tenderness experienced by a patient are either absent or mild
- Most patients present with multiple cysts upon further clinical and diagnostic evaluation
- Various subtypes of cysts are known, including hyperplastic fibrous cysts, adenosis, and papillomatosis
- These types of cysts are usually found in the:
- Upper outer quadrants of the breast, as well as in the central margins
- The texture upon evaluation ranges from a firm texture to multiple subcentimeter cysts
- Fibroadenomas present in varied sizes:
- With a common oval-shaped, well-defined margin
- As with cysts, fibroadenomas are mobile upon evaluation and are often multiple, occurring either simultaneously or over a specified period
- Nipple discharge is associated with:
- Ductal ectasia, intraductal papilloma, or in rare instances, carcinoma
- The finding of an intraductal papilloma:
- Is associated with a single duct presenting a bloody, sudden discharge with a small palpable nodule in the retro areolar region
- Multiple ducts presenting with nonspontaneous, green, yellow, clear discharges:
- Are a common feature with duct ectasia
- Benign cysts are typically mobile within the glandular breast tissue, chest wall, and skin and are rubber-like in texture:
- Evaluation:
- Triple testing is a combination consisting of clinical examination, imaging, and excision biopsy
- This is essential for all women with a clinical finding, such as a discrete palpable mass
- Nodularity in young women less than 30 years of age:
- May have management with clinical surveillance and short-term follow-up examination in 2 to 3 months
- An investigation may be necessary if the lump has changed on review or if, at the initial presentation, there is a new change in her breasts
- Nodularity or thickening that is asymmetric in women over the age of 30 years;
- Further investigation utilizing mammography and ultrasound, is warranted
- Short-term follow-up is an important part of the management of nodularity so that the progression in size of a mass of nodularity or other associated findings (e.g., skin or nipple changes) is detected
- Mammography with ultrasound examination is required:
- For all discrete palpable lesions in women over 35 to distinguish cysts from solid lesions
- Complex cysts containing both fluid and solid matter require biopsy:
- Aspiration and the solid component persists core biopsy is performed
- For solid lesions, radiographically or ultrasonically directed core biopsy provides further information regarding the presence or absence of malignancy
- Core excision biopsy involves a cutting needle with a spring-loaded, automated biopsy instrument that allows sufficient specimen of tissue for histologic analysis
- FNA allows a cytopathologist to evaluate cellular material:
- However, the amount of material retrieved during FNA procedures being sufficient for diagnosis is non-successful in 35% to 47% of non-palpable lesions:
- A core biopsy is then the recommendation
- However, the amount of material retrieved during FNA procedures being sufficient for diagnosis is non-successful in 35% to 47% of non-palpable lesions:
- Cytology of nipple discharge has limited specificity and sensitivity to detect malignancy (35 to 47%)
- If the results of both clinical and diagnostic evaluations are benign:
- A 6 to 12-month clinical breast examination, ultrasound, and mammography are the suggested follow-up to confirm a stable appearance
- A study of 156 patients in Japan who had a benign breast biopsy showed that 13% required a subsequent biopsy within two years of having routine FNA procedures performed
- In a retrospective study, 150 patients with benign histology after ultrasound-guided vacuum-assisted biopsy for complex cystic breast lesions (BI-RADS 4) were assessed:
- This subset of patients underwent evaluation in 6 monthly intervals
- Of the 104 lesions, none led to the development of malignancy
- Routine ultrasound screening in Japan was used with 10,519 women to evaluate recall criteria:
- Researchers noted a cystic-type breast pattern in 6512 cases
- Only one of the patients reported malignancy the following year, related to a solid tumor with a cystic component, proven to be a micro-invasive cancer of less than 1 mm
- Treatment / Management:
- Due to the role of estrogen and progesterone treatments, promoting fibrocystic changes in the breast:
- Metformin has been suggested as a treatment method to reduce the excessive cell proliferation caused by associated hormones
- For patients presenting with mastalgia:
- The first-line options are lifestyle changes
- Other suggestions are the use of a supportive bra, as well as altering the dose of hormone replacement therapy regimen
- There is no evidence that reducing caffeine improves fibrocystic breast disease or mastalgia
- Analgesics such as aspirin and ibuprofen are options
- Researchers have proposed that a deficiency in prostaglandin E and its precursor gamma-linolenic acid (GLA) increase the sensitivity of breasts during the luteal phase of the menstrual cycle:
- GLA is subsequently also the active component of evening primrose oil
- Despite not having proven efficacy in previous studies, the use of evening primrose oil is warranted as supportive measures if pain persists despite treatment and advice
- A 3 to 6 month period is the suggested timeframe to observe the desired effect
- If breast pain is severe for more than six months and disrupts daily activities, other therapies such as tamoxifen, bromocriptine, or danazol can be options
- Due to the recurrent nature and long duration of these symptoms, several months of treatment is necessary
- Fluid from cysts aspirated for symptomatic relief does not require cytological assessment
- This evaluation is reserved for clinically evident lumps that resolve following the FNA procedure or where the cyst fluid appears macroscopically bloodstained
- Fluid from atypical cysts should have a cytological assessment
- Surgery is indicated for cysts that repetitively, despite frequent FNA, which have an intra-cystic solid appearance on ultrasound or have atypical cells present upon cytopathological evaluation
- Due to the role of estrogen and progesterone treatments, promoting fibrocystic changes in the breast:
- Differential Diagnosis:
- Breast lump
- Breast abscess
- Fibrocystic changes
- Fibroadenomas
- Infections
- Trauma
- Fat necrosis
- Papilloma
- Phyllodes tumor
- Breast ectasia
Rodrigo Arrangoiz MS, MD, FACS, FSSO 