Fibrocystic Breast Changes

00:01 Hello there.

00:02 In this talk, we're going to cover a very common entity within the normal breast called fibrocystic change.

00:09 Back in the day, we used to call this fibrocystic disease, but it's not a disease, it is the normal proliferation regression of breast tissue.

00:18 And sometimes things don't regress completely.

00:21 And we develop these fibrous, cystic changes.

00:23 Let's talk about that.

00:25 So, during normal menstrual cycles, there's recurrent bouts or cycles of epithelial proliferation.

00:33 And then, as you have reduced estrogen levels, there's regression of that proliferative epithelium, well, sometimes it doesn't always go back completely to ground zero.

00:44 So there will be over time accumulation of some epithelial proliferation, there may be an accumulation due to secondary ductal obstruction of inflammation and fibrous tissue.

00:56 And with obstruction, you make get cyst formation.

00:59 So this is just what happens pretty much in every breast over childbearing years.

01:06 The epidemiology.

01:08 It's reported in 60 to 75% of women, but if we did a very careful evaluation, it would probably be more like 90 to 95% of women.

01:17 Again, typically develops during the childbearing years.

01:20 The pathophysiology is as I've already indicated.

01:24 Every cycle you have estrogen driven connective tissue and epithelial proliferation.

01:29 And then with the estrogen waning during the end of the menstrual cycle, you have regression.

01:35 However, you may not have complete regression.

01:40 So, dilation and obstruction of ducts may occur because of epithelium that gets into the draining areas.

01:51 With obstruction, you may actually have cyst formation and then rupturing of those cysts within with continued accumulation of material with rupturing of the cysts that will cause chronic inflammation.

02:03 With inflammation comes stromal fibrosis.

02:06 You do this over and over and over again from ages 15 to 50.

02:11 And you accumulate fibrocystic change.

02:15 The clinical presentation? Pretty much is what you would expect.

02:19 So the breast will feel firmer as a result of the fibrosis, there may be palpable breast lumps.

02:25 They're usually multifocal.

02:28 They're usually discrete and mobile, but these are the dilated cystic structures.

02:33 The changes can change, can fluctuate throughout the entire menstrual cycle.

02:38 So, these fibrocystic changes may come and go and what is present in one cycle may not necessarily be present the next cycle.

02:48 There may be cyclic breast pain.

02:50 Again, as with the proliferation and then potentially epithelial sloughing, and duct obstruction, you may get at the end of a menstrual cycle, more pain.

03:00 And the findings are tend to be similar, not identical clearly, but similar in both breasts.

03:06 Making the diagnosis.

03:07 So mammography will so typically give you the appearance of multiple cystic structures with associated fibrosis.

03:15 Ultrasound can show very similar changes overall.

03:19 And we will do a biopsy of these changes to make sure that there is not malignant potential.

03:25 So though the changes are quite common, depending on the proliferation of the epithelium, and the way that that epithelium looks, there are different risk stratification in terms of potential developing cancer.

03:38 So we definitely do want to do biopsy if there's substantial fibrocystic change.

03:44 If it is non proliferative on biopsy.

03:48 So, this is generally just an increased kind of cystic structures without much proliferation overall, you may have some apocrine change.

04:00 These are not associated with any increased risk of breast cancer.

04:05 If there's proliferation of the epithelium, but all the cells look pretty normal, there's no atypia and again, as a medical student, you don't have to worry about deciding whether something is a typical or not.

04:17 That's what's the pathologist does.

04:19 And when you become pathologist, and hopefully you all will, then you will learn how to make those distinctions.

04:25 But for you, as a medical student, you as a treating physician, you'll read your pathology report, and if they say they're proliferative breast disease, but no atypia, and you can see the different kinds of entities in there, then there are others that increases the risk, mildly, modestly, up to two fold of developing breast cancer.

04:47 And then if there's proliferative breast disease with atypical features, the cells look a little funky.

04:53 Actually, it happens in about five to 20% of breast biopsies that increases the risk up to fourfold of malignancy.

05:01 And so we want to more closely follow those patients.

05:05 So you do want to, not just ignore fibrocystic change, you want to appropriately work it up.

05:11 So you can risk stratify your patients.

05:14 How are you going to treat them? Well, it depends on what you saw on biopsy.

05:17 So on nonproliferative, disease observation and pain management, if there is pain is all you have to do.

05:24 You may want to put your patient on oral contraception to reduce the cycling of estrogen, and that may in many cases, reduce the kind of overall severity of symptoms.

05:36 You can also give androgens or tamoxifen, aspirate cysts.

05:41 There are other things you can do if the if the lesions are particularly symptomatic.

05:46 If on biopsy we're seeing proliferative disease without atypia that merits then a regular breast exam and screening mammography probably every one to two years, if not more frequently.

05:56 And if there is atypia, you definitely want to cut out things that can be identified on mammogram as being the abnormal areas to make sure there isn't malignancy in a little corner of that atypia.

06:08 You also want to increase the frequency of breast exams to every six to 12 months, and certainly with an annual mammogram.

06:15 In those patients where you already have some atypia associated with proliferative disease.

06:19 Avoid hormone replacement therapy and oral contraception.

06:24 With that we've covered fiber cystic change, very common entity.