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Fibrocystic Breast Disease

Luthfy WinartoDepartemen BedahSub Div.Onkologi

Palembang - 20!


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Fibrocystic Breast Disease

• ainful, often multiple, usually bilateral masses in t

• 'apid fluctuation in the size of the masses is comm• Fre-uently, pain occurs or worsens and size increa

premenstrual phase of cycle.

• $ost common age is #!%!. 'are in postmenopau

not recei/ing hormonal replacement.• it does not, in fact, represent a pathologic or anato

disorder

)urrent Diagnosis 0 1reatment & Surgery # Edition 2!!3"


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%

Clinical Findings

• $ay produce an asymptomatic mass

• But pain or tenderness often calls attention to it.• Discomfort often occurs or worsens during the pre

phase of the cycle, at which time the cysts tend to

• Fluctuations in size and rapid appearance or disap

of a breast mass• $ultiple or bilateral masses and serous nipple disc

atients will gi/e a history of a transient lump in th

cyclic breast pain.



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*

Diagnostic Tests

• $ammography and ultrasonography should be use

e/aluate a mass in a patient with fibrocystic condit• 4ltrasonography alone may be used in women und

years of age. Because a mass due to fibrocystic co

difficult to distinguish from carcinoma on the basis

findings, suspicious lesions should be biopsied.



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5

Diagnostic Tests

• Fine6needle aspiration FN7" cytology may be use

suspicious mass that is nonmalignant on cytologice8amination does not resol/e o/er se/eral months

be e8cised.



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• )lassification system by Dupont and age &

Nonproliferati/e lesions,roliferati/e lesions without atypia,

roliferati/e lesions with atypia atypical hyperplas

:n /arious studies, breast biopsies up to 5!; snonproliferati/e lesions.

The Oncologist & Benign Breast Diseases& )lassification, Diagnosis, and $anagement 2!!*


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3

• E8cised lesion &

• fibrocystic changeconsisting of multiple

cystically dilated duct

lobular units, some

containing featurelesseosinophilic secretions

)atherine N. )hinyama, Benign Breast Diseases& 'adiology 6 athology 'is< 7ssessmen

FBD


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ManagementFBD

Norton, Ess

FBD


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Management

FBD


• Breast pain treated by a/oiding trauma and by wearing

supporti/e brassiere during the night and day.

• Studies ha/e also demonstrated a low-fat diet inta


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Treatment

• 4S Food and Drug 7dministration FD7"

Danazol !!2!! mg 28 ="

a synthetic androgen used for patients with se/ere

1his treatment suppresses pituitary gonadotropins

androgenic effects acne, edema, hirsutism" usual

this treatment intolerable> in practice, it is rarely us



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#

Treatment modality % use

Danazol 75

Analgesics 21Diuretics 18

Local excision 18

Bromocriptine 15

Evening primrose oil 13 No treatment 10

amoxi!en "

#ell !itting $ra 3

1reatment references of 25* )onsultants 4?" Be@ieu '$,


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FBD


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*

Pathophysiology

• Aormonal basis – =estrogen 0 rogesterone

– rolactin

– 1hyroid

• $ethyle8anthiones

• 1rauma6 N=1 7 )74SE

FBD

FBD


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• =estrogen 0 rogesterone

– =estrogen predominance o/er progesterone considered causati/e

– Serum le/els of =estrogen

– @uteal phase is shortened

– rogesterone le/el decreased to C# normal

– )orp. @ut. Deficiency C 7no/ulation in 5!; – atients with re $enstrual 1ension syndrom

more li


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• rolactin6 – le/els are increased in C# of women with FDB

– robably due to =estrogen dominance onpituitary

• 1hyroid – Suboptimal le/els sensitize mammary

epithelium to rolactin stimulation

• $ethyle8anthiones6 – :ncreased inta


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Pathomorphology• Oestrogens stimulate proliferation of connective and epith

tissues.' The polymorphism of fibroeystic disease

documented by fibrosis, cyst formation, epithelial proliferatand lobular-alveolar atrophy. FBD entails simultane

progressive and regressive change. Ductular branch

intraductal epithelial proliferation(papillomatosis, lob

hyperplasia, and proliferation of intralobular connective tis

may undergo regressive changes such adenofibrosis, srlerosing adenosis, duct dilation,

formation, and calcification. !oss of parenchymal elem

(ductules, alveoli "ith intra-lobular and periductal fibros

encountered in chronic disease.

FBD


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2!

• #yst formation as a conse$uence of obstruction by stro

fibrosis and per- sisting ductular alveolar secretion, "hermaterial is retained, leading to dilation of terminal ducts (ectasia and alveoli "ith cyst formation. %n & to )patients "ith fibroeystic disease, gross cyst formatioobserved.

• *acrocysts (+ em in diameter represent an advanform of fibrocystic disease. They develop in "omen maintheir forties and, depending on the degree of fluid filling pericystic fibrosis, appear softer or harder.

Pathomorphology

FBD


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Aistopathological sections of breast showing FBD

Pathomorphology


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FBD


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2#

Clinical Course

FBD


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2+

• Clinically, three phases of fibrocystic disease

can be recognized- – hase :6$oderate stromal fibrosis, beginning

hardness of breast tissue and premenstrualbreast tenderness

– hase ::6 rogressi/e fibrosis leading to

increased hardening and tenderness, cystformation, moderate modularity

– hase :::6 ronounced fibrosis and tendernemacrocyst formation

Clinical Course


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FBD


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• Nipple secretion6

– :n one third of patients with FBD, discharge is sponta

or secretion can be e8pelled from the nipple. 1he

cytological features may include amorphous material

proteins", ductal cells, erythrocytes, andlor foam cells

fluid is straw yellow, green6 ish, or bluish. :n 26#;

carcinoma is diagnosed

• Bloody Nipple secretion6 when present

– %!6*!; due to intra ductal proliferation apilloma"

– #!6+!; due to carcinoma *+; after age %!".

Diagnosis


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FBD


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• *ammography

Diagnosis

Nodular changes are reflected in tmammogram by dar


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#!

• Ultrasonography -

– Particularly useful in delineating solid from cysticbreast masses.

– Ultrasound of cystic masses characteristicallydefines a mass with a uniform outer margin

demonstrating no asymmetry or unusual thicknesthe wall. The central part of the mass shows noechoes, and there is posterior wall enhancement.

Diagnosis

FBD

Di i


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#

• Needle aspiration biopsy – !ndicated in patients with breast mass, a lump like

structure,, a hard dense area or any abnormal tissueareas, as defined by clinical e"amination,mammography or U#$.

– !n patients at high risk of breast cancer, needleaspiration should be performed when the slightest

suspicion arises. – !n women with fibrocystic disease, ductal epitheliumconsists of cohesi%e cells with a scant rim ofcytoplasm and round or o%al small, slightly hyperchromatic nuclei. Connecti%e &fibrous' tissue is usupredominant.

Diagnosis

T t tFBD


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#2

Treatment

•

Goal6 – 1o stop progression

– 1o relie/e pain

– 1o re/erse changes

– Soften breast tissue

• :ndicated when6

– Fibroadenoma is notincreasing in size

– No nipple discharge

– No psychological effect

•

:nter/ention indicatedwhen6

– Fibroadenoma is

increasing in size

– Serous C

Serosanguineous C

bloody dischargeoccurs

– atients are

pshychologicaly

disturbed

Medical- Surgical6

FBD

1 t t


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##

• Ineffectie modalities – Diet therapy-Caffeine

restriction – Diuretics – Iodine containing

agents – Thyroid hormone

– !ening Primrose oil – "itamin ! # B$ – Dihydroergotamine – %ntiprolactin drugs – %nalgesics

• &ormones-

– 'ow (estrogenCombined (C pills

– Progestogens in th

luteal phase

– %ntioestrogens-

Tamo)ifen – %ndrogens-Dana*o

1reatment Medical-

FBD

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#+

• (C pills- – Users are protected from

)*+

– Progestogen potencyshould be high

• Progestogens - – To be gi%en in the luteal

phase for - months

– /bout 012 get relief but312 re4uire restart oftherapy

• Dana*ol – +emains the most

effectie therapy

– Basis- oarian

supression

– Dose-,-$mg.d

&ormones

1reatment Medical-


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