Fibrocystic Change

DEFINITION
A very common Refers to a spectrum of pain, tenderness and nodularity in the breast.
Terminology has been confusing and used to encompass physiological changes as well as pathological.
- this used to be called fibrocystic disease, but its not a disease really.
- "ANDI" assigned to it by the Cardiff Breast Clinic (stands for Aberrations of Normal Development and Involution).

D E A B M I M


EPIDEMIOLOGY

Incidence

Up to 90% of women in some form.

Age
Mostly in the last decade of reproductive life
33% of women 35-50 yrs old will have breast cysts
- uncommon in women >60 (~5%, half of whom are on HRT).

D E A B M I M
 

AETIOLOGY
 
Benign / degenerative.

Pathophysiology

The normal breast undergoes changes through a woman's reproductive life with superimposed cyclical changes.
Fibrocystic breast change may relate to:
- exaggerated breast changes to hormones and growth factors (Sabiston)
- cysts occur due to nonintegrated involution of stroma and epithelium (B&L)
D E A B M I M
 

BIOLOGICAL BEHAVIOUR

Pathology
Essentially a combination / spectrum of four features (B&L)
1. Cyst formation
- inevitable, variable in size; macro and micro.
2. Fibrosis
- fat and elastic tissue replaced by dense fibrous tissue.
- infiltrated with chronic inflammatory cells.
3. Hyperplasia
- in lining of ducts and acini, with or without atypia.
4. Papillomatosis
- hyperplasia may be so extensive it results in papillomatous overgrowth in ducts.

Natural history : Risk of Developing Invasive Carcinoma

*Carter et al; based on 16,692 women from Breast Cancer Detection Demonstration Project (Sabiston)
Different histological features found on biopsy have been ascribed the following RR of breast cancer.

1. No Increase

Adenosis
Apocrine metaplasia
Simple cysts that resolve with aspiration
Mild hyperplasia (>2 but <5 cells deep)
Duct ectasia
Simple Fibroadenoma
Fibrosis
Mastitis (inflammatory)
Periductal mastitis
Squamous metaplasia

2. Slight Increase (RR 1.5-2)
Moderate / florid hyperplasia, solid or papillary
Duct papilloma with fibrovascular core
Sclerosing adenosis, well-developed.

3. Moderately Increased (RR 4-5)
Atypical hyperplasia, ductal or lobular.

Insufficient evidence to assign risk
Radial scar lesion
Solitary papilloma of lactiferous sinus.

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MANIFESTATIONS

Symptoms

Constellation of breast pain, tenderness and nodularity.
Cyclical pre-menstrual mastalgia with pain and tenderness is common.
- non-cyclical commoner in perimenopausal women.

Signs
Spectrum:
- mild bilateral alterations in texture
- most notable in upper outer quadrants where most breast tissue is.
- to dense firm breast tissue with palpable lumps
- or gross cysts.
Lumpiness is seldom discrete.
- may be uni or bilateral
- commonly in upper outer quadrant
- less commonly confined to one quadrant of one breast

D E A B M I M


INVESTIGATIONS

Imaging
Mammogram
Usually bilateral, symmetrically diffuse or focally dense tissue.
Ultrasound
Cysts show clearly.

Cyst aspiration
Cyst fluid is turbid, green or amber.
If bloody - send for cytopathology, else discard.
- interpret results with caution
- much more importance is radiological appearance
- complexity or solid components must be biopsied, typically by radiologically-guided core biopsy.

Need surgical biopsy in addition if:
i) thick and blood tinged fluid
ii) no fluid, and a mass diagnosed.
iii) fluid, but residual lump.
iv) +/- rapid recurrence in <2 wks.

D E A B M I M


MANAGEMENT

Reassure


Medical
Patients with atypical ductal or lobular hyperplasia may consider Tamoxifen for risk reduction.
See mastalgia card for breast pain management.

D E A B M I M


REFERENCES
Sabiston 17th.
B&L 23rd.