Fibrocystic Breast Disease

Dr.Surendra Nath Panda, M.S. Professor of Obstetrics & Gynaecology M.K.C.G.Medical College Berhampur, ORISSA, INDIA

Fibrocystic Breast Disease (FBD)

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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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

Pathophysiology

Prolactin 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 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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FBD

Clinical Course
Incidence of FBD

60% 50% 40% 30% 20% 10% 0% 10% Under 21 Years

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50% 20% Menstrual years Pre-menopausal

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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

MedicalGoal 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

MedicalIneffective 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 AndrogensDanazol
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FBD

Treatment

Medical- Hormones
OC pills Users are protected from

Danazol
Remains the most

FBD Progestogen potency should be high

Progestogens To be given in the luteal

effective therapy Basis- ovarian supression Dose-200-600mg/day

phase for 9-12 months About 80% get relief but 40% require restart of therapy
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FBD

Treatment

Medical- Hormones - Danazol

Efficacy of Danazol

100% 80% 60% 40% 20% 0% 200mg

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75% 47%

81.40%

90%

400mg

100-800mg 200-400mg
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FBD

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

Treatment modality Danazol Analgesics Diuretics Local excision Bromocriptine Evening primrose oil No treatment Tamoxifen Well fitting bra
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% use 75 21 18 18 15 13 10 9 3
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THANK YOU
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