Fibrocystic Condition, Breast

Essentials of Diagnosis

• Painful breast masses; often multiple and bilateral masses

• Rapid fluctuation in mass size is common

• Pain often worsens premenstrually

General Considerations

• Most frequent lesion of the breast

• Estrogen hormone is considered a causative factor

• Alcohol consumption may increase risk, especially in women aged 18–22 yrs

• Encompasses a wide variety of benign histologic changes in the breast epithelium

• Microscopic findings include

  • Cysts (gross and microscopic)

  • Papillomatosis

  • Adenosis

  • Fibrosis

  • Ductal epithelial hyperplasia

• Only variants with component of epithelial proliferation (especially with atypia) or increased breast density on mammogram represent true risk factor for breast cancer

Demographics

• Occurs most commonly in women age 30–50

• Rare in postmenopausal women not receiving hormonal replacement therapy

Symptoms and Signs

• Generally painful mass or masses but may be asymptomatic

• Serous nipple discharge may be present

• Rapid fluctuation in size of masses is common

Differential Diagnosis

• Breast cancer

• Fibroadenoma

• Lipoma

• Breast abscess

• Intraductal papilloma

Imaging Studies

• Mammography may be helpful but is often limited due to radiodensity of breast tissue in young women

• Breast ultrasonography is useful in differentiating cystic from solid mass

Diagnostic Procedures

• Suspicious lesions should be biopsied

• Core needle biopsy, rather than fine-needle aspiration (FNA), is the preferable technique

• Excisional biopsy is rarely necessary but should be done for lesions with atypia or where imaging and biopsy results are discordant

Medications

• Gamolenic acid, 3 g orally twice daily

• Vitamin E, 400 international units orally once daily (anecdotal data)

• Danazol, 100–200 mg orally twice daily, for severe pain, but is rarely used due to side effects (acne, hirsutism, edema)

• Tamoxifen reduces some symptoms but it is not useful in young women due to side effects, unless it is given to reduce risk of cancer

• Postmenopausal women receiving hormone replacement therapy may stop hormones to reduce pain

Surgery

• Total or subcutaneous mastectomy or extensive removal of breast tissue is rarely, if ever, indicated for fibrocystic breast disease

Therapeutic Procedures

• Aspiration of a discrete mass suggestive of a cyst is indicated in order to alleviate pain and, more importantly, to confirm the cystic nature of the mass

• Diet

  • Low-fat diet or decreasing dietary fat intake may reduce painful symptoms

  • The role of caffeine consumption remains controversial

  • Many patients report relief of symptoms after giving up coffee, tea, and chocolate

Follow-Up

• Reexamine at intervals

• Women with proliferative or atypical epithelium on biopsy should be monitored carefully by physical examination and mammography for development of breast cancer; consider tamoxifen chemoprevention

• The patient should be advised to examine her own breasts each month just after menstruation and to inform her physician if a mass appears

• Excisional biopsy should be performed

  • If no fluid is obtained or if fluid is bloody on aspiration

  • If a mass persists after aspiration

  • If at any time during follow-up a persistent lump is noted

Complications

• Risk of breast cancer in women with proliferative or atypical changes in the epithelium or papillomatosis is higher than in women in general

Prognosis

• Exacerbations of pain, tenderness, and cyst formation may occur at any time until menopause

• After menopause, symptoms usually subside, except in patients receiving hormone replacement therapy

Prevention

• Avoid trauma

• Avoid caffeine (anecdotal data)

• Wear supportive bra night and day