Fibrocystic breast changes

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Fibrocystic breast changes
Other namesFibrocystic change, fibrocystic breast disease, [1] fibrocystic breast condition
Fibrous breast changes.jpg
Benign fibrous breast growths (highlighted in yellow).
Specialty Gynaecology
Symptoms Breast pain, breast cysts, breast masses [2]
Usual onset30 to 50 years old [1]
Risk factors Early age at first menstrual period, having children late or not having children [2]
Diagnostic method Periodic examination, possibly medical imaging or breast biopsy [1]
Differential diagnosis Breast cancer [1]
TreatmentEducation about the condition, a well fitting bra, pain medication [1]
Prognosis Good [1]
FrequencyUp to 60% of women [3]

Fibrocystic breast changes is a condition of the breasts where there may be pain, breast cysts, and breast masses. [1] The breasts may be described as "lumpy" or "doughy". [3] Symptoms may worsen during certain parts of the menstrual cycle due to hormonal stimulation. [1] These are normal breast changes, not associated with cancer. [2]

Contents

Risk factors include an early age at first menstrual period and either having children at a late age or not at all. [2] It is not a disease but represents normal breast changes. [3] Diagnosis involves ruling out breast cancer. [1] Fibrocystic changes include fibroadenomas, fibrosis,papillomas of the breast, [1] and apocrine-type metaplasia. [4]

Management may involve education about the condition, using a well fitting bra, and pain medication, if needed. [1] Occasionally danazol or tamoxifen may be used for pain. [1] It is estimated that up to 60% of women are affected, [3] most commonly between the ages of 30 and 50 years. [1]

Signs and symptoms

The changes in fibrocystic breast disease are characterised by the appearance of fibrous tissue and a lumpy, cobblestone texture in the breasts. These lumps are smooth with well defined edges, and free-moving regarding adjacent structures. These lumps can sometimes be obscured by irregularities in the breast associated with the condition. They are often found in the upper, outer sections of the breast (nearest to the armpit), but can be found throughout the breast. Women with fibrocystic changes may experience a persistent or intermittent aching or breast tenderness related to periodic swelling. Breasts and nipples may also be tender or itchy.

Symptoms follow a periodic trend closely tied to the menstrual cycle. Symptoms tend to peak in the days to weeks before each period and decrease afterwards. At peak, breasts may feel full, heavy, swollen, and tender to the touch. No complications related to breastfeeding have been found.

Pathophysiology

Micrograph showing apocrine metaplasia associated with FCC. FNA specimen. Pap stain. Fibrocystic changes of breast - cytology 1.jpg
Micrograph showing apocrine metaplasia associated with FCC. FNA specimen. Pap stain.
Micrograph showing apocrine metaplasia of the breast with typical features H&E stain. Histopathology of apocrine metaplasia of breast, annotated.png
Micrograph showing apocrine metaplasia of the breast with typical features H&E stain.

The exact mechanism of the condition is not fully understood, though it is known to be tied to hormone level fluctuation; the condition usually subsides after menopause and is closely related to the menstrual cycle. Post-menopausal women under hormone replacement therapy have also reported symptoms of fibrocystic breast changes, indicating hormones may play a major role.[ citation needed ]

This condition is an accumulative process, partly caused by the normal hormonal variation during a woman's monthly cycle. The most important of these hormones include estrogen, progesterone and prolactin.

These hormones directly affect the breast tissue by causing cells to grow and multiply. [6] Other hormones such as TSH, insulin, growth hormone and growth factors such as TGF-beta exert both direct and indirect effects by amplifying or regulating cell growth. Chronic hormonal fluctuations eventually produce small cysts and/or areas of dense or fibrotic tissue over the years. By the age of 30, multiple small cysts and breast pain may arise. Larger cysts usually do not occur until after the age of 35. [7] Over time, presumably driven by aberrant growth signals, such lesions may accumulate epigenetic, genetic and karyotypic changes such as modified expression of hormone receptors and loss of heterozygosity.

Several variants of fibrocystic breast changes may be distinguished and may vary in cause and genetic predisposition. Adenosis involves an abnormal count and density of lobular units, while other lesions appear to mainly arise from ductal epithelial origins.

There is evidence that iodine deficiency contributes to fibrocystic breast changes by enhancing breast tissue sensitivity to estrogen. [8] [9] [10] [11]

Diagnosis

This is an exclusion diagnosis, mostly done based on the clinical presentation after ruling out breast cancer. Nipple fluid aspiration can be used as a classification cyst type method (and to some extent improve breast cancer risk prediction) but is rarely used in practice. Biopsy or fine needle aspiration are rarely warranted. [12]

Fibrocystic breast disease is primarily diagnosed based on the symptoms, clinical breast exam and physical exam. During this examination, the doctor looks for unusual breast areas, both visually and manually. Also, the lymph nodes located in the axilla and lower neck are examined. A complete and accurate medical history is also helpful in the diagnosing process. If the patient's medical history and physical exam findings are consistent with normal breast changes, no additional tests are needed; otherwise the patient will be asked to return a few weeks later for reassessment. [13] Women may detect lumps in their breasts during self-examination; if this happens it is strongly advised to visit a health professional immediately.

Imaging

In order to establish whether the lump is a cyst or not, several imaging tests may be performed, which may include mammography, X-rays, MRIs and ultrasound studies. Mammography is usually the first imaging test to be ordered when unusual breast changes are found during a clinical breast examination. A diagnostic mammography consists of a series of X-rays that provide clear and specific visualization of areas in the breast.

Ultrasounds and MRIs are commonly performed in conjunction with mammographies as they produce clear images of the breast that clearly distinguish between solid masses and fluid-filled breast cysts. These can better evaluate dense breast tissue, especially in young patients under 30.

Biopsy

Breast biopsy is a test used to confirm the suspected diagnosis only after imaging tests have already been performed and revealed unusual-looking areas. The procedure consists in removing a sample of breast tissue, which is then studied by a pathologist under a microscope. The specialist analyzing the tissue sample will be able to conclude if the breast changes are benign or malignant.

There are four main types of procedures for breast biopsy that may be performed, including fine-needle, core-needle, stereotactic biopsy and surgical approach. A fine-needle aspiration biopsy is usually ordered when the doctor is almost certain that the lump is a cyst. This test is generally performed in conjunction with an ultrasound which is helpful in guiding the needle into a small or hard-to-find lump. The procedure consists in inserting a thin needle into the breast tissue while the lump is palpated and seen live under sonographic ultrasound waves.

The core-needle biopsy is normally performed under local anesthesia and in a physician's office. The needle used in this procedure is slightly larger than the one used in a fine-needle biopsy because the procedure is intended to remove a small cylinder of tissue that will be sent to the laboratory for further examination.

A newer type of breast biopsy technique is the stereotactic biopsy which relies on a three-dimensional X-ray to guide the needle of non-palpable mass. The biopsy is performed in a similar manner, by using a needle to remove a tissue sample, but locating the specific area of the breast is done by X-raying the breast from two different angles. Surgical biopsy is performed to remove the entire lump or a part of it. It may be painful and is done under local anesthesia.

Treatment

Most women with fibrocystic changes who are asymptomatic do not need treatment; closer follow-up may be advised. [14] There is no widely accepted treatment or prevention strategy for this condition. When the patient is symptomatic, treatment may be necessary. The same guidelines are followed as for treatment for cyclical breast pain. There is still controversy whether benign breast conditions improve or worsen with the use of oral contraceptives or hormone replacement therapy. [15]

Small-scale studies have indicated that fibrocystic breast changes may improve by making dietary changes (especially by reducing caffeine intake and related methylxanthines found in chocolate or tea) and usage of vitamin supplements. [16] Tentative evidence has shown beneficial effects of iodine supplementation in women with fibrocystic breast changes. [8] [17] [18]

Prognosis

There are usually no adverse side effects associated with this condition. In almost all cases it subsides after menopause. A possible complication arises through the fact that cancerous tumors may be more difficult to detect in women with fibrocystic changes.

Breast cancer risk

Breast cancer risk is elevated in a defined fraction of the lesions. Except for people with a strong family history of breast cancer, where the risk is two-fold, nonproliferative lesions have no increased risk. Proliferative lesions also have approximately a two-fold risk: in particular, atypical hyperplasia which is associated with an increased risk of developing breast cancer. [19] There are two types of atypical hyperplasia: lobular and ductal; the lobular type is associated a greater cancer risk of approximately five-fold and especially high relative risk in premenopausal women. Atypical ductal hyperplasia is associated with a 2.4-fold risk. [20] In contrast, a New England Journal of Medicine article [21] states that for women with a strong familial history of breast cancer, the risk of future breast cancer is roughly doubled, independent of histological status. The article further states "The relative risk of breast cancer for the cohort was 1.56 (95 percent confidence interval, 1.45 to 1.68), and this increased risk persisted for at least 25 years after biopsy. The relative risk associated with atypia was 4.24 (95 percent confidence interval, 3.26 to 5.41), as compared with a relative risk of 1.88 (95 percent confidence interval, 1.66 to 2.12) for proliferative changes without atypia and of 1.27 (95 percent confidence interval, 1.15 to 1.41) for nonproliferative lesions. The strength of the family history of breast cancer, available for 4808 women, was a risk factor that was independent of histologic findings. No increased risk was found among women with no family history and nonproliferative findings. In the first 10 years after the initial biopsy, an excess of cancers occurred in the same breast, especially in women with atypia."

It is not well understood whether the lesions are precursors of breast cancer or only an indication of increased risk; for most types of lesions the chance of developing breast cancer is nearly the same in the affected and unaffected breast (side), indicating only coincidence of risk factors. For atypical lobular hyperplasia there is high incidence of ipsilateral breast cancers, indicating a possible direct carcinogenetic link. [22]

Epidemiology

The estimated prevalence of fibrocystic breast changes in women over their lifetime varies widely in the literature, ranging from 30 to 60% [23] over about 50 to 60% [24] to about 60 to 75% of all women. [25]

The condition is most common among women between 30 and 50 years of age. [25]

Terminology

In ICD-10 the condition is called diffuse cystic mastopathy, or, if there is epithelial proliferation, fibrosclerosis of breast. [26] Other names for the condition include chronic cystic mastitis, fibrocystic mastopathy and mammary dysplasia. [27] The condition has also been named after several people (see eponyms below). Since it is a very common disorder, some authors have argued that it should not be termed a disease, [28] whereas others feel that it meets the criteria for a disease. It is not a classic form of mastitis (breast inflammation). [29]

Eponyms

This entity has historically also been termed Bloodgood’s disease, Cooper's disease (after Sir Astley Paston Cooper, 1st baronet), Phocas' disease, Reclus' disease and Reclus' syndrome (after Paul Reclus), Reclus-Schimmelbusch disease, Schimmelbusch disease and Tillaux-Phocas disease. [30]

Related Research Articles

<span class="mw-page-title-main">Biopsy</span> Medical test involving extraction of sample cells or tissues for examination

A biopsy is a medical test commonly performed by a surgeon, an interventional radiologist, or an interventional cardiologist. The process involves the extraction of sample cells or tissues for examination to determine the presence or extent of a disease. The tissue is then fixed, dehydrated, embedded, sectioned, stained and mounted before it is generally examined under a microscope by a pathologist; it may also be analyzed chemically. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. An incisional biopsy or core biopsy samples a portion of the abnormal tissue without attempting to remove the entire lesion or tumor. When a sample of tissue or fluid is removed with a needle in such a way that cells are removed without preserving the histological architecture of the tissue cells, the procedure is called a needle aspiration biopsy. Biopsies are most commonly performed for insight into possible cancerous or inflammatory conditions.

<span class="mw-page-title-main">Nipple discharge</span> Medical condition

Nipple discharge is fluid from the nipple, with or without squeezing the breast. The discharge can be milky, clear, green, purulent, bloody, or faintly yellow. The consistency can be thick, thin, sticky, or watery.

<span class="mw-page-title-main">Fibroadenoma</span> Medical condition

Fibroadenomas are benign breast tumours characterized by an admixture of stromal and epithelial tissue. Breasts are made of lobules and ducts. These are surrounded by glandular, fibrous and fatty tissues. Fibroadenomas develop from the lobules. The glandular tissue and ducts grow over the lobule to form a solid lump.

<span class="mw-page-title-main">Fine-needle aspiration</span> Diagnostic medical procedure

Fine-needle aspiration (FNA) is a diagnostic procedure used to investigate lumps or masses. In this technique, a thin, hollow needle is inserted into the mass for sampling of cells that, after being stained, are examined under a microscope (biopsy). The sampling and biopsy considered together are called fine-needle aspiration biopsy (FNAB) or fine-needle aspiration cytology (FNAC). Fine-needle aspiration biopsies are very safe minor surgical procedures. Often, a major surgical biopsy can be avoided by performing a needle aspiration biopsy instead, eliminating the need for hospitalization. In 1981, the first fine-needle aspiration biopsy in the United States was done at Maimonides Medical Center. Today, this procedure is widely used in the diagnosis of cancer and inflammatory conditions. Fine needle aspiration is generally considered a safe procedure. Complications are infrequent.

Breast pain is the symptom of discomfort in either one or both breasts. Pain in both breasts is often described as breast tenderness, is usually associated with the menstrual period and is not serious. Pain that involves only one part of a breast is more concerning, particularly if a hard mass or nipple discharge is also present.

<span class="mw-page-title-main">Ductal carcinoma in situ</span> Pre-cancerous breast lesion

Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. DCIS is classified as Stage 0. It rarely produces symptoms or a breast lump one can feel, typically being detected through screening mammography. It has been diagnosed in a significant percentage of men.

Breast diseases make up a number of conditions. The most common symptoms are a breast mass, breast pain, and nipple discharge.

<span class="mw-page-title-main">Breast cyst</span> Medical condition

A breast cyst is a cyst, a fluid-filled sac, within the breast. One breast can have one or more cysts. They are often described as round or oval lumps with distinct edges. In texture, a breast cyst usually feels like a soft grape or a water-filled balloon, but sometimes a breast cyst feels firm.

<span class="mw-page-title-main">Thyroid nodule</span> Medical condition

Thyroid nodules are nodules which commonly arise within an otherwise normal thyroid gland. They may be hyperplastic or tumorous, but only a small percentage of thyroid tumors are malignant. Small, asymptomatic nodules are common, and often go unnoticed. Nodules that grow larger or produce symptoms may eventually need medical care. A goitre may have one nodule – uninodular, multiple nodules – multinodular, or be diffuse.

<span class="mw-page-title-main">Breast cancer screening</span> Medical screening of asymptomatic, healthy women for breast cancer

Breast cancer screening is the medical screening of asymptomatic, apparently healthy women for breast cancer in an attempt to achieve an earlier diagnosis. The assumption is that early detection will improve outcomes. A number of screening tests have been employed, including clinical and self breast exams, mammography, genetic screening, ultrasound, and magnetic resonance imaging.

Stereotactic biopsy, also known as stereotactic core biopsy, is a biopsy procedure that uses a computer and imaging performed in at least two planes to localize a target lesion in three-dimensional space and guide the removal of tissue for examination by a pathologist under a microscope. Stereotactic core biopsy makes use of the underlying principle of parallax to determine the depth or "Z-dimension" of the target lesion.

<span class="mw-page-title-main">Lobular carcinoma in situ</span> Medical condition

Lobular carcinoma in situ (LCIS) is an incidental microscopic finding with characteristic cellular morphology and multifocal tissue patterns. The condition is a laboratory diagnosis and refers to unusual cells in the lobules of the breast. The lobules and acini of the terminal duct-lobular unit (TDLU), the basic functional unit of the breast, may become distorted and undergo expansion due to the abnormal proliferation of cells comprising the structure. These changes represent a spectrum of atypical epithelial lesions that are broadly referred to as lobular neoplasia (LN).

<span class="mw-page-title-main">Duct ectasia of breast</span> Medical condition

Duct ectasia of the breast, mammary duct ectasia or plasma cell mastitis is a condition that occurs when a milk duct beneath the nipple widens, the duct walls thicken, and the duct fills with fluid. This is the most common cause of greenish discharge. Mammary duct ectasia can mimic breast cancer. It is a disorder of peri- or post-menopausal age.

<span class="mw-page-title-main">Fat necrosis</span> Medical condition

Fat necrosis is a form of necrosis that is caused by the action of lipases on adipocytes.

<span class="mw-page-title-main">Atypical ductal hyperplasia</span> Medical condition

Atypical ductal hyperplasia (ADH) is the term used for a benign lesion of the breast that indicates an increased risk of breast cancer.

<span class="mw-page-title-main">Breast mass</span> Localized swellings that feel different from the surrounding tissue

A breast mass, also known as a breast lump, is a localized swelling that feels different from the surrounding tissue. Breast pain, nipple discharge, or skin changes may be present. Concerning findings include masses that are hard, do not move easily, are of an irregular shape, or are firmly attached to surrounding tissue.

<span class="mw-page-title-main">Breast biopsy</span> Surgical diagnostic procedure for breast tumours

A breast biopsy is usually done after a suspicious lesion is discovered on either mammography or ultrasound to get tissue for pathological diagnosis. Several methods for a breast biopsy now exist. The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality. The different types of breast biopsies include fine-needle aspiration (FNA), vacuum-assisted biopsy, core needle biopsy, and surgical excision biopsy. Breast biopsies can be done utilizing ultrasound, MRI or a stereotactic biopsy imaging guidance. Vacuum assisted biopsies are typically done using stereotactic techniques when the suspicious lesion can only be seen on mammography. On average, 5–10 biopsies of a suspicious breast lesion will lead to the diagnosis of one case of breast cancer. Needle biopsies have largely replaced open surgical biopsies in the initial assessment of imaging as well as palpable abnormalities in the breast.

<span class="mw-page-title-main">Triple test score</span>

The triple test score is a diagnostic tool for examining potentially cancerous breasts. Diagnostic accuracy of the triple test score is nearly 100%. Scoring includes using the procedures of physical examination, mammography and needle biopsy. If the results of a triple test score are greater than five, an excisional biopsy is indicated.

Dynamic angiothermography (DATG) is a technique for the diagnosis of breast cancer. This technique, though springing from the previous conception of thermography, is based on a completely different principle. DATG records the temperature variations linked to the vascular changes in the breast due to angiogenesis. The presence, change, and growth of tumors and lesions in breast tissue change the vascular network in the breast. Consequently, through measuring the vascular structure over time, DATG effectively monitors the change in breast tissue due to tumors and lesions. It is currently used in combination with other techniques for diagnosis of breast cancer. This diagnostic method is a low-cost one compared with other techniques.

<span class="mw-page-title-main">Breast imaging</span>

In medicine, breast imaging is a sub-speciality of diagnostic radiology that involves imaging of the breasts for screening or diagnostic purposes. There are various methods of breast imaging using a variety of technologies as described in detail below. Traditional screening and diagnostic mammography uses x-ray technology and has been the mainstay of breast imaging for many decades. Breast tomosynthesis is a relatively new digital x-ray mammography technique that produces multiple image slices of the breast similar to, but distinct from, computed tomography (CT). Xeromammography and galactography are somewhat outdated technologies that also use x-ray technology and are now used infrequently in the detection of breast cancer. Breast ultrasound is another technology employed in diagnosis and screening that can help differentiate between fluid filled and solid lesions, an important factor to determine if a lesion may be cancerous. Breast MRI is a technology typically reserved for high-risk patients and patients recently diagnosed with breast cancer. Lastly, scintimammography is used in a subgroup of patients who have abnormal mammograms or whose screening is not reliable on the basis of using traditional mammography or ultrasound.

References

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  4. ↑ Carlos C. Diez Freire, M.D., Shahla Masood, M.D. "Apocrine metaplasia". Pathology Outlines.{{cite web}}: CS1 maint: multiple names: authors list (link) Last author update: 28 May 2020.
  5. ↑ Image by Mikael Häggström, MD. Reference for findings: Carlos C. Diez Freire, M.D., Shahla Masood, M.D. "Apocrine metaplasia". Pathology Outlines.{{cite web}}: CS1 maint: multiple names: authors list (link) Last author update: 28 May 2020.
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