Fibrocystic breast changes

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Fibrocystic breast changes is a nonspecific term that includes a heterogeneous spectrum of breast conditions. Women between 20 and 50 years of age are most commonly affected. Histologically, fibrocystic changes are divided into nonproliferative breast lesions (e.g., simple breast cysts, apocrine metaplasia) and proliferative breast lesions (e.g., ductal epithelial hyperplasia, sclerosing adenosis). Patients typically present with premenstrual bilateral multifocal breast pain with or without palpable nodules, which may be tender. The diagnosis is made during the workup of symptoms (e.g., mastalgia, palpable breast mass, nipple discharge) or incidentally on clinical breast examination and/or imaging. Tissue biopsy, usually a core-needle biopsy, is indicated if there is a clinical suspicion of malignancy. Management of breast lesions without cellular atypia is primarily symptomatic. Proliferative breast lesions with cellular atypia require surgical excision as they are associated with an increased risk of breast cancer.

• Most common benign lesion of the breast
• Peak age: 20–50 years
• Up to 50% of women are affected during their lifetime.

Epidemiological data refers to the US, unless otherwise specified.

• Premenstrual bilateral multifocal breast pain (cyclic mastalgia)
• Tender or nontender breast nodules
• Clear, greenish, or slightly milky nipple discharge; often multiductal ^[2]

Nonproliferative breast lesions ^[3][4][5]

• Simple breast cysts: circumscribed fluid-filled lesions (blue dome cysts)
• Stromal fibrosis (no malignant potential)
• Apocrine metaplasia

Proliferative breast lesions (with or without cellular atypia) ^[3][5]

• Sclerosing adenosis
  • Proliferation of small ductules and acini in the lobules
  • Stromal fibrosis ^[6]
  • Calcifications (slightly increased risk of breast cancer)
• Ductal epithelial hyperplasia (ductal hyperplasia)
  • Epithelial hyperplasia of terminal duct cells and lobular epithelium
  • The presence of atypical cells is associated with an increased risk of breast cancer.
  • Papillary proliferation (papillomatosis) is a type of ductal hyperplasia that has a papillary histopathological appearance.
• Radial scar
• Fibroadenoma
• Intraductal papilloma

General principles ^[3][7]

• Obtain a thorough medical history and perform a CBE in all patients.
• Diagnostic workup should be guided by clinical findings.
• See also “Breast mass,” “Mastalgia,” “Nipple discharge,” and “Breast cysts” as needed.

All patients with a palpable breast mass should be evaluated appropriately, even those with suspected fibrocystic breast changes. ^[3]

Imaging

Follow age-appropriate diagnostic workup for a palpable breast mass. The imaging findings in fibrocystic breast changes are heterogeneous and include the following.

Breast ultrasound

• Scattered calcifications
• Clustered microcysts ^[8][9]
• Simple or complicated cysts (see “Breast cysts” for details). ^[10][11]
• Distorted breast parenchyma ^[11][12]

Mammography ^[12][13]

• Focal asymmetry
• Architectural distortion
• Round or oval masses with circumscribed borders
• Calcifications

MRI breast with and without contrast (not routinely obtained) ^[5]

• Nonmass enhancement
• Isointense or hypointense masses with fluid components
• Low-intensity T1 weighted round or oval masses

Biopsy

In patients with suspicious clinical and/or imaging findings, a tissue biopsy is indicated to rule out malignancy.” See “Histologic subtypes” for findings ^[5][14]

• Core needle biopsy (CNB): preferred for most lesions ^[14]
• Excisional biopsy: Consider in the following situations ^[3]
  • CNB findings suggestive of radial scar, atypical hyperplasia ^[3]
  • Imaging and needle biopsy findings are discordant.

Nonproliferative breast lesions or proliferative breast lesions without atypia

• Symptomatic management ^[7]
  • Proper breast support (i.e., a well-fitting bra)
  • Consider topical NSAIDs, tamoxifen; , or danazol for moderate to severe symptoms.
  • See “Management of mastalgia” for details.
• Management of breast cysts (e.g., surveillance, FNAC, or excision)
• Age-appropriate routine breast cancer surveillance is sufficient. ^[3]

Proliferative breast lesions with atypia (specifically atypical ductal hyperplasia) ^[3]

• Surgical excision, followed by close surveillance for breast cancer with CBE and imaging ^[3]
• Chemoprevention (e.g., tamoxifen, raloxifene, or aromatase inhibitors) can be considered for further risk reduction. ^[3]

Atypical ductal hyperplasia is associated with an increased risk of breast cancer in both the affected and contralateral breast. ^[3]

• Nonproliferative breast lesions are not associated with an increased risk of breast cancer.
• Proliferative breast lesions with atypical cells (e.g., ductal epithelial hyperplasia) are associated with an increased risk of cancer.