Fibrocystic Breast Disease

BASICS

DESCRIPTION

Fibrocystic breast disease is a generalized term for benign breast disorders such as lumps and pain. The term benign breast disease is preferred. Benign lumps are usually smooth, regular, and mobile. The following classifications are useful:

Lumps:
- Physiologic nodularity - lumps vary with the phase of the menstrual cycle, common in young women
- Mastoplasia - a ropy, thickening of the breast tissue, most common in the upper outer quadrant, persists throughout the menstrual cycle
- Cysts - distended, fluid-filled masses caused by an imbalance between secretion and absorption in the breast lobule, common in the decade preceding menopause
- Fibroadenoma - benign solid tumor, smooth margins, mobile, most common tumor in teenagers and young women, may occur at any age after thelarche
- Phyllodes tumors - painless, solid, smooth, lobular, bulky; stromal hyperplasia; 10% are malignant
Nipple discharge
- Although considered one of the warning signs for breast cancer, 90% of patients with nipple discharge have benign disease
- Bilateral duct ectasia - most common cause of nipple discharge; benign inflammatory condition; bilateral, sticky, multicolored discharge; usually has to be expressed
- Bilateral galactorrhea - prolactin-secreting pituitary tumors (usually with amenorrhea); drugs (isoniazid, methyldopa, thiazides, reserpine, tricyclic antidepressants, BCPs); trauma; hypothyroidism
- Unilateral intraductal papilloma - spontaneous discharge from one duct; carcinoma must be excluded
Pain
- Cyclical mastodynia - hormonal, an exaggeration of normal premenstrual tenderness
- Non-cyclical - sclerosing adenosis, cysts, chest wall muscle spasm, costochondritis, fibromyalgia, neuritis, stress, referred pain
Inflammatory conditions
- Fat necrosis - a solid lump with or without pain that can mimic carcinoma
- Superficial phlebitis of the thoracoepigastric vein (Mondor's disease) - local tenderness and induration
- Mastitis/abscess - exquisite pain and tenderness, erythema (common), not always a definite mass; common with lactation and squamous metaplasia of lactiferous ducts (Zuska's disease); usually caused by staphylococcal organisms
Growth disorders
- Accessory nipples (polythelia)
- Absence of the breast (amastia)
- Absence of the nipple (athelia)
- Hypoplasia (often associated with hypoplasia of the thorax and pectoral muscles, and abnormalities of the hand—Poland's syndrome)
- Gigantomastia: occurs during puberty and pregnancy
- Gynecomastia: occurs in men in association with puberty, senescence, liver disease, testicular tumors, and medications such as digoxin and cimetidine
System(s) affected: Skin/Exocrine
Genetics:
- Little is known about the genetic aspects of benign breast disease
- Family history of cysts common
Incidence/Prevalence in USA: Unknown. It is estimated that at least 50% of women have benign breast symptoms during their lifetime.
Predominant age:
- Symptoms tend to occur in menstruating women
- Mastoplasia - most common in women from mid 20's to 55 years of age
- Cysts - usually seen in women in their 40's
- Cyclical mastodynia - common in menstruating women
- Non-cyclical pain - can occur at any age after breast development
Predominant sex: Female > Male (almost exclusively)

SIGNS AND SYMPTOMS

Asymptomatic
Breast pain
Breast tenderness
Pain subsides after menses
Smooth masses
Tense masses
Fluctuant masses
Bilateral masses
Breast engorgement
Breast thickening
Nipple discharge

CAUSES

The etiology of benign breast disease is unknown
Possible causes:
- Luteal phase defect in progesterone
- Increased estrogen (17 beta estradiol)
- Hyperprolactinemia
- End organ hypersensitivity to estrogen
- Sensitivity to methylxanthines
- Dietary fat intake

RISK FACTORS

Unknown
The effect of consumption of methylxanthine-containing substances, e.g., coffee, tea, cola, and chocolate is controversial

DIAGNOSIS

LABORATORY

Prolactin, TSH (if galactorrhea), aspiration cytology or biopsy of discrete mass

Drugs that may alter lab results: N/A
Disorders that may alter lab results: N/A

PATHOLOGICAL FINDINGS

Hyperplasia of breast epithelium or stroma, adenosis, microcysts, macrocysts, duct ectasia (plasma cell mastitis), apocrine metaplasia

SPECIAL TESTS

N/A

IMAGING

Mammography
- Signs of malignancy include irregular mass, clustered masses, calcifications, architectural distortion, dilated duct
- May be normal in presence of malignancy; mammograms are difficult to interpret in women less than age 35 due to dense breast tissue
Ultrasonography
- Useful for differentiating cystic from solid lesions
Thermography (available at a few institutions)

DIAGNOSTIC PROCEDURES

Fine needle aspiration and biopsy - allows differentiation of cystic and solid lesion. Cells sent for cytology can diagnose cancer with a relatively high degree of accuracy. Low morbidity. If mass disappears, no further evaluation is necessary.
Core needle biopsy - usually not indicated for fibrocystic disease. Useful in diagnosis of a large cancer.
Excisional biopsy - indicated for all solid lumps that are not clearly benign.

TREATMENT

APPROPRIATE HEALTH CARE

Outpatient. May be inpatient for biopsy or surgery.

GENERAL MEASURES

Evaluate to be certain there is no malignancy by means of imaging and diagnostic procedures
Pain rarely severe or disabling
Frequently resolves spontaneously
Reassure patient there is no malignancy
Cold compresses may be helpful
Well fitting, supportive brassiere (worn night and day)

SURGICAL MEASURES

Possibly excision (under local anesthesia) of benign fibroadenoma or phyllode tumors, and fat necrosis lesions

ACTIVITY

No restrictions. Avoid activities that may cause trauma to the breasts.

DIET

Abstention from methylxanthines (coffee, tea, caffeine-containing soda and chocolate)

PATIENT EDUCATION

American College of Obstetricians & Gynecologists, 409 12th St., SW, Washington, DC 20024-2188, (800)762-ACOG
Booklet on Breast Self Examination from Primary care and Care and Cancer, 17 Prospect St., Huntington, NY 11743, (516)424-8900
National Cancer Institute, (800)4-CANCER
American Cancer Society; http://www3.cancer.org/cancerinfo/documents/bbreast.asp?ct=5

FOLLOW UP

PREVENTION/AVOIDANCE

Avoiding caffeine may reduce breast pain

POSSIBLE COMPLICATIONS

Fibrocystic change can make physical examination and mammograms difficult to interpret
Atypical hyperplasia may lead to cancer

EXPECTED COURSE AND PROGNOSIS

Benign, chronic, recurring, intermittent

MISCELLANEOUS

ASSOCIATED CONDITIONS

Breast carcinoma

AGE-RELATED FACTORS

Pediatric: Biopsy in children should be avoided since a developing breast bud may be inadvertently removed
Geriatric: Not as common in this age group
Others: Prophylactic mastectomy for pain is rarely indicated since many patients have underlying psychiatric problems

PREGNANCY

N/A

OTHER NOTES

N/A

ABBREVIATIONS

N/A

Clinical Investigations

ROLE OF HOMOEOPATHY

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