Fi Bro Cystic Breast Disease

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Fibrocystic Breast Disease

Dr.Surendra Nath Panda, M.S.

Professor of Obstetrics & Gynaecology

M.K.C.G.Medical College

Berhampur, ORISSA, INDIA



11/07/2013 Fibrocystic Breast Disease - Prof.S.N.Panda 2

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




Pathophysiology

Hormonal basis

– Oestrogen & Progesterone

– Prolactin

– Thyroid

Methylexanthiones

Trauma- NOT A CAUSE

FBD




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 morelikely to develop FBD

– Women with progesterone deficiency carry a fivefold risk of premenopausal breast cancer

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

FBD

Pathophysiology




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, cystformation, and calcification. Loss of parenchymal elements

(ductules, alveoli) with intra-lobular and periductal fibrosis is

encountered in chronic disease.

FBD




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Histopathological sections of breast showing FBD

FBD

Pathomorphology



Clinical CourseFBD

FBD represents a clinical problem inapproximately 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 mostpatients (70% to 75%) are in their mid 30s and40s.





Clinically, three phases of fibrocystic diseasecan be recognized-

– Phase I-Moderate stromal fibrosis, beginninghardness of breast tissue and premenstrual breasttenderness

– Phase II- Progressive fibrosis leading to increasedhardening and tenderness, cyst formation, moderatemodularity

– Phase III- Pronounced fibrosis and tenderness,macrocyst formation

FBD

Clinical Course



Diagnosis

Fibroeystic disease has a history of many months

to several years.

Fibroeystic disease is rare in ovulating women,

multiparous women, and patients using oralcontraceptives.

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.

FBD

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 onsetof or during menses.

In more than half of the patients with mazoplasia,

premenstrual breast swelling, mastodynia, and

irregular menses, are observed. In approximately20% of patients, axillary tenderness and enlarged

lymph nodes are observed.

FBD

Diagnosis Symptoms and Signs -



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. 7hefluid 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).

FBD

Diagnosis



Mammography –

FBD

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 diseaseprogresses, 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.

Diagnosis



Mammography –

FBD

Diagnosis

Nodular changes are reflected in the

mammogram by darker specks amid

dense white areas appear- ing as

"buckshot" breast".

Wolfel observed 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.




Ultrasonography -

– Particularly useful in delineating solid from cysticbreast masses.

– Ultrasound of cystic masses characteristicallydefines a mass with a uniform outer margindemonstrating no asymmetry or unusual thickness of the wall. The central part of the mass shows noechoes, and there is posterior wall enhancement.

FBD

Diagnosis

FBD




Needle aspiration biopsy – – Indicated in patients with breast mass, a lump like

structure,, a hard dense area or any abnormal tissueareas, as defined by clinical examination,mammography or USG.

– In patients at high risk of breast cancer, needleaspiration should be performed when the slightestsuspicion arises.

– In women with fibrocystic disease, ductal epitheliumconsists of cohesive cells with a scant rim of cytoplasm and round or oval small, slightly hyper chromatic nuclei. Connective (fibrous) tissue is usuallypredominant.

FBD

Diagnosis



FBD




Ineffective modalities

– Diet therapy-Caffeinerestriction

– Diuretics

– Iodine containingagents

– Thyroid hormone

– Evening Primrose oil

–Vitamin E & B6

– Dihydroergotamine

– Antiprolactin drugs

– Analgesics

Hormones-

– Low Oestrogen

Combined OC pills

– Progestogens in

the luteal phase

– Antioestrogens-

Tamoxifen – Androgens-

Danazol

FBD

Treatment

Medical-

FBD




OC pills-

– Users are protected fromFBD

–Progestogen potencyshould be high

Progestogens -

– To be given in the luteal

phase for 9-12 months – About 80% get relief but

40% require restart of therapy

Danazol

– Remains the most

effective therapy

– Basis- ovarian

supression

– Dose-200-600mg/day

FBD

Hormones

Treatment

Medical-

FBD




Efficacy of Danazol

47%

75%81.40%

90%

0%

20%

40%

60%

80%

100%

200mg 400mg 100-800mg 200-400mg

FBD

Treatment

- Danazol Medical- Hormones

FBD




Treatment Preferences of 276 Consultants

(UK) – BeLieu RM,1994

FBD

Treatment modality % use Danazol 75

Analgesics 21

Diuretics 18Local excision 18

Bromocriptine 15

Evening primrose oil 13 No treatment 10

Tamoxifen 9

Well fitting bra 3



11/07/2013 Fib i B Di P f S N P d 24

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