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Fibrocystic Changes of the Breast
Alain Michael P. Abellada, MD
image BASICS
DESCRIPTION
  • Fibrocystic changes (FCC) is not a disease but refers to a constellation of benign histologic findings. It is the most frequent female benign clinical breast finding.
  • The most common symptoms are cyclic pain and tenderness, swelling, and fullness.
  • The breast tissue may feel dense with areas of thicker tissue having an irregular, nodular, or ridge-like surface.
  • Women may experience sensitivity to touch with a burning sensation. For some women, the pain is so severe that it limits exercise or the ability to lie prone.
  • Usually affects both breasts, most often in the upper outer quadrant where most of the milk-producing glands are located.
  • Histologically, in addition to macrocysts and microcysts, FCC may contain solid elements including adenosis, sclerosis, apocrine metaplasia, stromal fibrosis, and epithelial metaplasia and hyperplasia.
    • Depending on the presence of epithelial hyperplasia, fibrocystic change is classified as nonproliferative, proliferative without atypia, or proliferative with atypia.
  • System(s) affected: endocrine/metabolic, reproductive
  • Synonym(s): diffuse cystic mastopathy; fibrocystic disease; chronic cystic mastitis; or mammary dysplasia
EPIDEMIOLOGY
FCC occurs with great frequency in the general population. It affects women between the ages of 25 and 50 years and it is rare below the age of 20.
Incidence
Unknown but very frequent
Prevalence
Up to 1/3 of women aged 30 to 50 years have cysts in their breasts. It most commonly presents in the 3rd decade, peaks in the 4th decade when hormonal function is at its peak, and sharply diminishes after menopause.
  • With hormone replacement therapy, FCC may extend into menopause
  • Less common in East Asian races
ETIOLOGY AND PATHOPHYSIOLOGY
  • FCC originates from an exaggerated response of breast stroma and epithelium to a variety of circulating and locally produced hormones (mainly estrogen and progesterone) and growth factors.
  • Cysts may form due to dilatation of the lobular acini possibly due to imbalance of fluid secretion and resorption, or due to obstruction of the duct leading to the lobule.
RISK FACTORS
  • In many women, methylxanthine-containing substances (e.g., coffee, tea, cola, and chocolate) can potentiate symptoms of FCC, though a direct causality has not been established.
  • Diet high in saturated fats may increase risk of FCC.
COMMONLY ASSOCIATED CONDITIONS
FCC categorized as proliferative with atypia confers a higher risk of breast cancer.
image DIAGNOSIS
PHYSICAL EXAM
  • The patient should be examined in the following positions while disrobed down to the waist (1):
    • With the patient standing with arms at sides, observe for elevation of the level of a nipple, dimpling, bulging, and peau d'orange.
    • With the patient's arms raised above her head, observe for dimpling and elevation of the nipple (may accentuate a mass fixed to the pectoral fascia). If so, have the patient push her hands down against her hips to flex and tense the pectoralis major muscles, move the mass to determine fixation to the underlying fascia.
    • If the patient has large and pendulous breasts, ask her to lean forward, so that her breasts hang free from the chest wall (retraction and masses may become more evident).
    • With the patient lying supine, palpate with the pads of the three middle fingers (with varying pressures from light, to medium, to deep), rotating the fingers in small circular motions and moving in vertical overlapping passes from rostral to caudal and then back caudal to rostral in the next pass. The lateral half of the breast is best palpated with the patient rolled onto the contralateral hip and the medial half with the patient supine, both with the ipsilateral hand behind the head. The entire breast from the second to sixth rib and from the left sternal border to the midaxillary line must be palpated against the chest wall.
  • Be certain to examine the creases under and between the breasts. If the patient has noted a lump, ask her to point it out; always palpate the opposite breast first.
  • Patients with fibrocystic changes have clinical breast findings that range from mild alterations in texture to dense, firm breast tissue with palpable masses.
DIFFERENTIAL DIAGNOSIS
  • Pain
    • Mastitis
    • Costochondritis
    • Pectoralis muscle strain
    • Neuralgia
    • Breast cancer
    • Angina pectoris
    • Gastroesophageal reflux (GERD)
    • Superficial phlebitis of the thoracoepigastric vein (Mondor disease)
  • Masses
    • Breast cancer
    • Sebaceous cyst
    • Fibroadenoma
    • Lipoma
    • Fat necrosis
  • Skin changes
    • Breast cancer (peau d'orange: thickened skin similar to peel of an orange)
    • Eczema
DIAGNOSTIC TESTS & INTERPRETATION
  • Evaluation should focus on excluding breast cancer.
  • Testing may be conducted based on a level of clinical suspicion.
  • FCC can be evaluated with mammogram, though dense breast tissue may appear normal in women <35 years of age.
  • Ultrasound is the most important method in assessing a cyst.
Initial Tests (lab, imaging)
  • On mammogram, FCC appears as nodular densities of breast tissue; solitary cysts can appear as round or ovoid or well-circumscribed masses, usually with low to intermediate density. FCC may also contain calcifications.
  • On ultrasound, if a simple cyst is demonstrated as an anechoic structure with imperceptible wall and posterior acoustic enhancement, benign diagnosis is confirmed and no further imaging or intervention is indicated. However, if the cyst appears to be thickwalled and/or contains internal echoes, differential diagnosis should include a complicated cyst, an abscess, a galactocele, or a focal duct ectasia in the appropriate clinical contexts.
  • MRI is indicated in patients with BRCA1 or BRCA2 mutation or in any woman with ≥25% lifetime risk for breast cancer.
  • On MRI, cystic changes are well-circumscribed lesions of high-signal intensity on T2-weighted sequences and of low-signal intensity on T1-weighted images.
Diagnostic Procedures/Other
  • Fine-needle aspiration (FNA) and biopsy:
    • Allows differentiation of cystic and solid lesions
    • Aspirate may be straw-colored, dark brown, or green.
    • Cells sent for cytology can reveal cancer with high accuracy.
    • Low morbidity
  • If mass disappears, no further evaluation is necessary (including cytologic evaluation of aspirated fluid).
  • P.379

  • On the basis of the presence and degree of epithelial hyperplasia, FCC is comprised of nonproliferative, (approximately 65% of the total), proliferative without, (approximately 30% of the total), and proliferative with atypia, (approximately 5% to 8% of the total) (2).
Test Interpretation
Certain histologic changes in the setting of fibrocystic change confer an increased risk for breast cancer:
  • Nonproliferative changes: relative risk of 1.2 to 1.4
  • Proliferative disease (PD) without atypia: relative risk of 1.7 to 2.1
  • PD with atypia: relative risk ≥4 (3)[B]
image TREATMENT
  • After ruling out malignancy by means of examination and/or imaging and diagnostic procedures, FCC may not require treatment and often resolves with time.
  • Cool compresses, avoiding trauma, and around-the-clock wearing of a well-fitting, supportive brassiere may be useful for symptom relief.
MEDICATION
First Line
For cyclic pain and swelling: NSAIDs:
  • Ibuprofen 400 mg QID/PRN
  • Naproxen 500 mg BID/PRN
Second Line
  • Oral contraceptives may be useful in modulating symptoms or in preventing the development of new changes.
  • For severe pain, consider the following (4,5)[B]:
    • Danazol (Danocrine) 100 to 400 mg/day divided in 2 doses for 4 to 6 months
    • Bromocriptine 1.25 to 2.5 mg BID for 3 months
    • Tamoxifen 10 mg/day for 3 to 6 months
    • These medications are not without serious side effects and thorough counseling is required. Consultation with a breast specialist may be considered.
  • Bromocriptine, danazol, and tamoxifen all significantly reduced pain. Tamoxifen was found to have the fewest adverse effects (4)[A].
ISSUES FOR REFERRAL
  • If discrete palpable lesion in a woman ≥35 years: US, then refer to a surgeon.
  • If discrete palpable lesion in a woman >35 years: Diagnostic mammography ± US, then refer to surgeon.
SURGERY
  • Breast cyst aspiration can be both diagnostic and therapeutic.
  • Core-needle biopsies performed under stereotactic guidance with vacuum assistance has similar accuracy in distinguishing between malignant and benign lesions compared to open surgical biopsy (6)[A].
COMPLEMENTARY & ALTERNATIVE MEDICINE
  • The use of vitamin E has shown effectiveness in treating breast pain due to FCC (3)[B].
  • Evening primrose oil and pyridoxine have not been shown to reduce mastalgia (4)[A],(7)[B].
image ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Condition is benign, chronic, and recurrent.
Patient Monitoring
  • Follow-up times are variable, depending on the clinical situation and pertinent family history.
  • US is useful to differentiate cysts from solid lesions and in evaluating women <35 years of age for FCC but is not useful for screening.
  • Screening mammograms should be obtained after age 40 to 50 years. Refer to the USPSTF, ACOG, or ACS recommendations for screening schedules.
DIET
The role of caffeine consumption in the development and treatment of FCC has never been proven; however, some patients report relief of symptoms after abstinence from coffee, tea, and chocolate.
PATIENT EDUCATION
  • Patient information on fibrocystic breasts from the Mayo Foundation for Medical Education and Research: http://www.mayoclinic.org/diseases-conditions/fibrocystic-breasts/basics/definition/con-20034681
  • Information on breast cancer prevention from the National Cancer Institute: http://www.cancer.gov/
  • Information on fibrocystic breasts from the American Cancer Society: http://www.cancer.org/healthy/findcancerearly/womenshealth/non-cancerousbreastconditions/non-cancerous-breast-conditions-finding-benign-br-cond
REFERENCES
1. Barton MB, Harris R, Fletcher SW. The rational clinical examination. Does this patient have breast cancer? The screening clinical breast examination: should it be done? How? JAMA. 1999;282(13):1270-1280.
2. Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353(3):229-237.
3. Parsay S, Olfati F, Nahidi S. Therapeutic effects of vitamin E on cyclic mastalgia. Breast J. 2009;15(5): 510-514.
4. Srivastava A, Mansel RE, Arvind N, et al. Evidence-based management of mastalgia: a meta-analysis of randomised trials. Breast. 2007;16(5):503-512.
5. Mousavi SR, Mousavi SM, Samsami M, et al. Comparison of tamoxifen with danazol in the management of fibrocystic disease. Int J Med Sci. 2011;2:329-331.
6. Bruening W, Fontanarosa J, Tipton K, et al. Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 2010;152(4): 238-246.
7. Horner NK, Lampe JW. Potential mechanisms of diet therapy for fibrocystic breast conditions show inadequate evidence of effectiveness. J Am Diet Assoc. 2000;100(11):1368-1380.
Additional Reading
&NA;
  • Amin AL, Purdy AC, Mattingly JD, et al. Benign breast disease. Surg Clin North Am. 2013;93(2):299-308.
  • Griffin JL, Pearlman MD. Breast cancer screening in women at average risk and high risk. Obstet Gynecol. 2010;116(6):1410-1421.
  • Jatoi I. Screening clinical breast examination. Surg Clin North Am. 2003;83(4):789-801.
  • Klein S. Evaluation of palpable breast masses. Am Fam Physician. 2005;71(9):1731-1738.
  • Meisner AL, Fekrazad MH, Royce ME. Breast disease: benign and malignant. Med Clin North Am. 2008;92(5):1115-1141.
  • Morris EA. Diagnostic breast MR imaging: current status and future directions. Magn Reson Imaging Clin N Am. 2010;18(1):57-74.
  • Rinaldi P, lerardi C, Costantini M, et al. Cystic breast lesions: sonographic findings and clinical management. J Ultrasound Med. 2010;29(11):1617-1626.
  • Santen RJ, Mansel R. Benign breast disorders. N Engl J Med. 2005;353(3):275-285.
  • Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for breast screening with MRI as an adjunct to mammography. CA Cancer J Clin. 2007;57(2):75-89.
Codes
&NA;
ICD10
  • N60.19 Diffuse cystic mastopathy of unspecified breast
  • N60.09 Solitary cyst of unspecified breast
  • N60.29 Fibroadenosis of unspecified breast
Clinical Pearls
&NA;
  • FCC of the breast comprise a spectrum of histopathologic changes are a common finding in reproductive-aged women. The former term of fibrocystic disease is a misnomer.
  • Atypia, as demonstrated histopathologically, confers an increased cancer risk.
  • NSAIDs are the first-line treatment. OCPs, Danazol, Bromocripine, and Tamoxifen are second-line treatments, though not without considerable adverse effects. Caution should be used and consultation with a breast specialist is recommended.