Fibrocystic Breast Disease

Luthfy Winarto
Departemen Bedah
Sub Div.Onkologi
Palembang - 2016

Fibrocystic Breast Disease

Fibrocystic breast disease is a generalized process of
microscopic cyst formation, often accompanied by breast
nodularity, with stromal proliferation.

Norton, Essential practice of Surgery (2002)

Fibrocystic Breast Disease

Most benign breast condition
premenopausal women between 20 and 50 years of age
Synonyms :
fibrocystic disease,cystic mastopathy, chronic cystic disease,
mazoplasia, Recluss disease

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The Oncologist : Benign Breast Diseases: Classification, Diagnosis, and Management
(2006)

Fibrocystic Breast Disease

Painful, often multiple, usually bilateral masses in the breast.
Rapid fluctuation in the size of the masses is common.
Frequently, pain occurs or worsens and size increases during
premenstrual phase of cycle.
Most common age is 3050. Rare in postmenopausal women
not receiving hormonal replacement.
it does not, in fact, represent a pathologic or anatomic
disorder
Current Diagnosis & Treatment : Surgery 13 Edition (2009)

Clinical Findings
May produce an asymptomatic mass
But pain or tenderness often calls attention to it.
Discomfort often occurs or worsens during the premenstrual
phase of the cycle, at which time the cysts tend to enlarge.
Fluctuations in size and rapid appearance or disappearance
of a breast mass
Multiple or bilateral masses and serous nipple discharge.
Patients will give a history of a transient lump in the breast or
cyclic breast pain.
Current Diagnosis & Treatment : Surgery 13 Edition (2009)

Diagnostic Tests
Mammography and ultrasonography should be used to
evaluate a mass in a patient with fibrocystic condition.
Ultrasonography alone may be used in women under 30
years of age. Because a mass due to fibrocystic condition is
difficult to distinguish from carcinoma on the basis of clinical
findings, suspicious lesions should be biopsied.

Current Diagnosis & Treatment : Surgery 13 Edition (2009)

Diagnostic Tests
Fine-needle aspiration (FNA) cytology may be used, but if a
suspicious mass that is nonmalignant on cytologic
examination does not resolve over several months, it should
be excised.

Current Diagnosis & Treatment : Surgery 13 Edition (2009)

 Classification system by Dupont and Page :

Nonproliferative lesions,
Proliferative lesions without atypia,
Proliferative lesions with atypia (atypical hyperplasia).
In various studies, breast biopsies up to 70% show
nonproliferative lesions.

8
The Oncologist : Benign Breast Diseases: Classification, Diagnosis, and Management
(2006)

 Excised lesion :
fibrocystic change
consisting of multiple
cystically dilated duct
lobular units, some
containing featureless
eosinophilic secretions

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Catherine N. Chinyama, Benign Breast Diseases: Radiology - Pathology Risk Assessment
(2003)

FBD

Management

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Norton, Essential practice of Surgery

FBD

Management

Breast pain treated by avoiding trauma and by wearing a good,

supportive brassiere during the night and day.
Studies have also demonstrated a low-fat diet intake may reduce the
painful symptoms associated with fibrocystic condition.
Some studies suggest that eliminating caffeine from the diet is
associated with improvement. Many patients are aware of these
studies and report relief of symptoms after giving up coffee, tea, and
chocolate.

Current Diagnosis & Treatment : Surgery 13 Edition (2009)

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Treatment
US Food and Drug Administration (FDA)
Danazol (100200 mg 2x PO)
a synthetic androgen used for patients with severe pain.
This treatment suppresses pituitary gonadotropins, but
androgenic effects (acne, edema, hirsutism) usually make
this treatment intolerable; in practice, it is rarely used.

Current Diagnosis & Treatment : Surgery 13 Edition (2009)

Treatment modality
Danazol
Analgesics
Diuretics
Local excision
Bromocriptine
Evening primrose oil
No treatment
Tamoxifen
Well fitting bra

% use
75
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18
15
13
10
9
3

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Treatment Preferences of 276 Consultants (UK) BeLieu
RM,1994

FBD

Pathophysiology
Hormonal basis
Oestrogen & Progesterone
Prolactin
Thyroid

Methylexanthiones
Trauma- NOT A CAUSE

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FBD

Pathophysiology
Oestrogen & Progesterone
Oestrogen predominance over progesterone is
considered causative
Serum levels of Oestrogen >
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 FBD
Women with progesterone deficiency carry a
five fold risk of premenopausal breast cancer
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FBD

Prolactin-

Pathophysiology

levels are increased in 1/3 of women with FDB

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
FDP
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FBD

Pathomorphology
Oestrogens stimulate proliferation of connective and epithelial
tissues.' The polymorphism of fibroeystic disease is
documented by fibrosis, cyst formation, epithelial proliferation,
and lobular-alveolar atrophy. FBD 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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FBD

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 (>1 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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FBD

Pathomorphology
Histopathological sections of breast showing FBD

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FBD

Clinical Course

FBD

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

Early

with early menarche and late menopause.

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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FBD

Clinical Course

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FBD

Clinical Course

Clinically, three phases of fibrocystic disease

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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FBD

Diagnosis
Symptoms and Signs Fibroeystic disease has a history of many months
to several years.
Fibroeystic disease is rare in ovulating women,
multiparous women, and patients using oral
contraceptives.
Breast pain (mastodynia) and/or tenderness is
observed in the majority of patients.
In 40% to 60% of patients these are associated with
irregular menses, dysmenorrhea, menometrorrhagia, or
ovarian cysts.
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FBD

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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FBD

Diagnosis
Nipple secretion In one third of patients with FBD, discharge is spontaneous
or secretion can be expelled from the nipple. The
cytological features may include amorphous material (fat,
proteins), ductal cells, erythrocytes, andlor foam cells. 7he
fluid is straw yellow, green- ish, 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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FBD

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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FBD

Diagnosis
Mammography
Nodular changes are reflected in the
mammogram by darker specks amid
dense white areas appear- ing as
"buckshot" breast".
Wolfel ob- 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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FBD

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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FBD

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 disease, 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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FBD

Treatment

Medical-

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

Surgical Intervention indicated

when Fibroadenoma is
increasing in size
Serous /
Serosanguineous /
bloody discharge
occurs
Patients are
pshychologicaly
disturbed
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FBD

Treatment

Medical-

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

Hormones Low Oestrogen

Combined OC pills
Progestogens in the
luteal phase
AntioestrogensTamoxifen
Androgens-Danazol

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FBD

Treatment

Medical- Hormones

OC pills Users are protected from

FBD
Progestogen potency
should be high

Progestogens -

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

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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FBD

Treatment

Medical- Hormones - Danazol

Fibrocystic Breast Disease - Prof.S.N.Panda

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