Fibrocystic Breast Change

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Fibrocystic Breast Change

• Dr. Atif Ali Bashir, M.D.
• Assistant Professor of Pathology
• Medical College
• Majmaah University

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Fibrocystic Change (FCC)

• Most benign breast condition
• Incidence-varying, related to age
• Menstruating years-20
• 30-50 in premenopausal years
• Synonyms-
• Mammary dysplasia,
• Cystic disease,
• Cyclic Mastopathy,
• Cystic Hyperplasia

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Breast lumps
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Pathophysiology

• Hormonal basis
• Oestrogen Progesterone
• Prolactin
• Thyroid
• Methylexanthiones
• Trauma- NOT A CAUSE

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Pathophysiology

• Oestrogen Progesterone
• Oestrogen predominance over progesterone is
  considered causative
• Serum levels of Oestrogen gt
• Luteal phase is shortened
• Progesterone level decreased to 1/3 normal
• Corp. Lut. Deficiency / Anovulation in 70
• Patients with Pre Menstrual Tension syndrome
  more likely to develop FCC
• Women with progesterone deficiency carry a five
  fold risk of premenopausal breast cancer

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Pathophysiology

• Prolactin-
• levels are increased in 1/3 of women with FCC
• Probably due to Oestrogen dominance on pituitary
• Thyroid
• Suboptimal levels sensitize mammary epithelium to
  Prolactin stimulation
• Methylexanthiones-
• Increased intake of coffee, tea, cold drinks
  chocolate is associated with development of FCC

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Pathomorphology

• Oestrogens stimulate proliferation of connective
  and epithelial tissues.' The polymorphism of
  fibroeystic change is documented by fibrosis,
  cyst formation, epithelial proliferation, and
  lobular-alveolar atrophy. FCC entails
  simultaneous progressive and regressive change.
  Ductular branching, intraductal epithelial
  proliferation(papillomatosis), lobular
  hyperplasia, and proliferation of intralobular
  connective tissue may undergo regressive
  changes such as. adenofibrosis,
  srlerosing adenosis, duct dilation, cyst
  formation, and calcification. Loss of parenchymal
  elements (ductules, alveoli) with intra-lobular
  and periductal fibrosis is encountered in chronic
  disease.

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Pathomorphology

• Cyst formation as a consequence of obstruction by
  stromal fibrosis and per- sisting ductular
  alveolar secretion, whereby material is retained,
  leading to dilation of terminal ducts (duct
  ectasia) and alveoli with cyst formation. In 20
  to 40 of patients with fibroeystic dis- ease,
  gross cyst formation is observed.
• Macrocysts (gt1 em in diameter) rep- resent an
  advanced form of fibrocystic disease. They
  develop in women mainly in their forties and,
  depending on the degree of fluid filling and
  pericystic fi- brosis, appear softer or harder.

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Histopathology of Fibrocystic Change

• Epithelial proliferation
• Fibrous tissue proliferation
• Histologic variants (cysts, adenosis,
  fibroplasias, duct ectasia, apocrine metaplasia,
  ductal epithelial hyperplasia,papillomatosis)
• Ductal epithelial hyperplasia and atypia and
  apocrine metaplasia

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Pathomorphology

• Histopathological sections of breast showing FCC

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C
A
F
Epithelial ?plasia
Adenosis Cyst Fibrosis
FCC
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Clinical Course

• FCC represents a clinical problem in
  approximately 30 of patients.
• Predominantly afflicted are
• women with menstrual abnormalities
• nulliparous women
• patients with a history of spontaneous abortions
• nonusers of oral contraceptives and
• women with early menarche and late menopause.
• Early fibrocystic manifestations may occur
  between the age of 20 and 25 years, but most
  patients (70 to 75) are in their mid 30s and
  40s.

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Clinical Course
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Clinical Course

• Clinically, three phases of fibrocystic change
  can be recognized-
• Phase I-Moderate stromal fibrosis, beginning
  hardness of breast tissue and premenstrual breast
  tenderness
• Phase II- Progressive fibrosis leading to
  increased hardening and tenderness, cyst
  formation, moderate modularity
• Phase III- Pronounced fibrosis and tenderness,
  macrocyst formation

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Fibrocystic Change Signs and Symptoms

• Cyclic bilateral breast pain-Classic symptom
• Signs- Increased engorgement and density,
  excessive nodularity, rapid changes in cystic
  sizes, tenderness, spontaneous nipple discharge
• Prominent premenstrually

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Diagnosis

• Symptoms and Signs -

• Breast pain (mastodynia) and/or tenderness is
  observed in the majority of patients.
• Mastodynia may start a few days or 1 to 2 weeks
  before menstruation it usually eases or subsides
  with the onset of or during menses.
• In more than half of the patients with
  mazoplasia, pre- menstrual breast swelling,
  mastodynia, and irregular menses, are observed.
  In approximately 20 of patients, axillary
  tenderness and enlarged lymph nodes are observed.

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Diagnosis

• Nipple secretion-
• In one third of patients with FCC, discharge is
  spontaneous or secretion can be expelled from the
  nipple. The cytological features may include
  amorphous material (fat, proteins), ductal cells,
  erythrocytes, and foam cells. The fluid is straw
  yellow, greenish, or bluish. In 2-3 carcinoma is
  diagnosed
• Bloody Nipple secretion- when present
• 50-60 due to intra ductal proliferation
  (Papilloma)
• 30-40 due to carcinoma ( 64 after age 50).

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Physical Exam Findings

• plateful of peas
• palpable lumpiness
• water-filled balloons

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Diagnostic Aids for Fibrocystic Change

• Imaging techniques
• Fine needle aspiration cytology
• Histopathologic evaluation (core needle biopsy or
  excision biopsy)

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Diagnosis

• Mammography

Patients with early fibrocystic change show small
areas of increased density on the mammographic
film.These are irregular and scattered, with
varying degrees of density. As disease
progresses, dark areas may occur along with the
whitish grey areas, and microcalcifications may
also become prominent. These calcifications can
be single or multiple small flecks located in
intraductal or periductal stroma or in entire
lobules.
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Diagnosis

• Mammography

Nodular changes are reflected in the mammogram by
darker specks amid dense white areas appearing as
"buckshot" breast". - served a dense pattern in
approximately 20 of women between age 39 and 49,
in 5 between age 50 and 59 and in 0.5 of
patients of age 60 or above.
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Diagnosis

• Ultrasonography -
• Particularly useful in delineating solid from
  cystic breast masses.
• Ultrasound of cystic masses characteristically
  defines a mass with a uniform outer margin
  demonstrating no asymmetry or unusual thickness
  of the wall. The central part of the mass shows
  no echoes, and there is posterior wall
  enhancement.

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Diagnosis

• Needle aspiration biopsy
• Indicated in patients with breast mass, a lump
  like structure,, a hard dense area or any
  abnormal tissue areas, as defined by clinical
  examination, mammography or USG.
• In patients at high risk of breast cancer, needle
  aspiration should be performed when the slightest
  suspicion arises.
• In women with fibrocystic change, ductal
  epithelium consists of cohesive cells with a
  scant rim of cytoplasm and round or oval small,
  slightly hyper chromatic nuclei. Connective
  (fibrous) tissue is usually predominant.

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Treatment

• Medical-

• Surgical-

• Goal-
• To stop progression
• To relieve pain
• To reverse changes
• Soften breast tissue
• Indicated when-
• Fibroadenoma is not increasing in size
• No nipple discharge
• No psychological effect

• Intervention indicated when-
• Fibroadenoma is increasing in size
• Serous / Serosanguineous / bloody discharge
  occurs
• Patients are pshychologicaly disturbed

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Treatment

• Medical-

• Hormones-
• Low Oestrogen Combined OC pills
• Progestogens in the luteal phase
• Antioestrogens- Tamoxifen
• Androgens-Danazol

• Ineffective modalities
• Diet therapy-Caffeine restriction
• Diuretics
• Iodine containing agents
• Thyroid hormone
• Evening Primrose oil
• Vitamin E B6
• Dihydroergotamine
• Antiprolactin drugs
• Analgesics

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Treatment
Hormones

• Medical-

• Danazol
• Remains the most effective therapy
• Basis- ovarian supression
• Dose-200-600mg/day

• OC pills-
• Users are protected from FBD
• Progestogen potency should be high
• Progestogens -
• To be given in the luteal phase for 9-12 months
• About 80 get relief but 40 require restart of
  therapy

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Treatment
- Danazol

• Medical-

Hormones
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Treatment Preferences of 276 Consultants (UK)
BeLieu RM,1994
Treatment modality use
Danazol 75
Analgesics 21
Diuretics 18
Local excision 18
Bromocriptine 15
Evening primrose oil 13
No treatment 10
Tamoxifen 9
Well fitting bra 3
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BENIGN TUMOURS

• ? Fibroadenoma
• Most common benign tumour
• Circumscribed lesion composed
• of both proliferating glandular
• and stromal elements

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BENIGN TUMOURS

• ? Fibroadenoma
• Patients usually present lt 30 years
• Classic presentation is that of a firm,
• mobile lump (breast mouse)
• Giant forms can occur, especially in
• younger patients   

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Fibroadenoma

• Common (20-30) yrs
• Free moble ( mouse) , oval , firm
• Gross
• Microscopically
• ??duct and periductal CT
• (fibromyxomatous stroma)
• Intracanalicular pattern
• Pericanalicular pattern.

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Diagnostic Aids for Fibroadenomas

• Breast sonography
• Mammography (may not be done for lt35 years old)
• Fine needle
• Surgical excision

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Treatment of Fibroadenomas

• Surgical Excision
• (in those lt35 nonoperative approach possible
  upon meeting THREE clinical parameters to
  establish the diagnosis-
• 1.clinical exam
• 2.ultrasound, mammography
• 3.cytology (FNA)

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Phylloides ( leaf like) Tumors
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Phylloides ( leaf like) Tumors

• Past name Cystosarcoma Phylloid.
• It can become malignant
• Usually a big tumor
• Contain mainly stromal component.
• Morphologically has a leaf like appearance.

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Morphologically has a leaf like appearance
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Phylloides tumor

• High-grade lesion behave aggressively and exhibit
  recurrence.

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Fibroadenoma Vs Phylloides tumor
Low cellularity High cellularity, bulky stroma.
Rare mitosis High mitosis
No Pleomorphism Pleomorphism Present
Well circumscribed Infiltrative border
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THANK YOU
A