Fibrocystic Breast Change
Dr. Atif Ali Bashir, M.D.
Assistant Professor of Pathology
Medical College
Majma’ah University
Fibrocystic Change (FCC)

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
01/07/2016
2
Breast lumps
Pathophysiology

Hormonal basis
– Oestrogen & Progesterone
– Prolactin
– Thyroid

Methylexanthiones
 Trauma- NOT A CAUSE
01/07/2016
4
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 FCC
Women with progesterone deficiency carry a five
fold risk of premenopausal breast cancer
01/07/2016
5
Pathophysiology

Prolactin– levels are increased in 1/3 of women with FCC
– 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 FCC
01/07/2016
6
Pathomorphology

Oestrogens stimulate proliferation of connective and epithelial
tissues.' The polymorphism of fibroeystic change is
documented by fibrosis, cyst formation, epithelial proliferation,
and lobular-alveolar atrophy. FCC 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.
01/07/2016
7
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.

01/07/2016
8
Histopathology of Fibrocystic
Change

Epithelial proliferation
 Fibrous tissue proliferation
 Histologic variants (cysts, adenosis,
fibroplasias, duct ectasia, apocrine
metaplasia, ductal epithelial
hyperplasia,papillomatosis)
 Ductal epithelial hyperplasia and atypia
and apocrine metaplasia
Pathomorphology
Histopathological sections of breast showing FCC
01/07/2016
10
C
A
F
FCC
Adenosis
Cyst
Fibrosis
Epithelial ↑pla
Clinical Course

FCC 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.
01/07/2016
12
Clinical Course
01/07/2016
13
Clinical Course

Clinically, three phases of fibrocystic change 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
01/07/2016
14
Fibrocystic Change: Signs and
Symptoms

Cyclic bilateral breast pain-Classic
symptom
 Signs- Increased engorgement and density,
excessive nodularity, rapid changes in
cystic sizes, tenderness, spontaneous nipple
discharge
 Prominent premenstrually
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.
01/07/2016
16
Diagnosis

Nipple secretion– In one third of patients with FCC, discharge is spontaneous
or secretion can be expelled from the nipple. The
cytological features may include amorphous material (fat,
proteins), ductal cells, erythrocytes, and foam cells. The
fluid is straw yellow, greenish, 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).
01/07/2016
17
Physical Exam Findings
“plateful of peas”
 palpable lumpiness
 water-filled balloons

Diagnostic Aids for Fibrocystic
Change

Imaging techniques
 Fine needle aspiration cytology
 Histopathologic evaluation (core needle
biopsy or excision biopsy)
Diagnosis

Mammography –
01/07/2016
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.
20
Diagnosis

Mammography –
Nodular changes are reflected in the
mammogram by darker specks amid
dense white areas appearing as
"buckshot" breast".
- 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.
01/07/2016
21
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.
01/07/2016
22
01/07/2016
Fibrocystic Breast Disease - Prof.S.N.Panda
23
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 change, 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.
01/07/2016
24
Treatment

Medical-

Goal– 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

01/07/2016
 Surgical
Intervention indicated
when– Fibroadenoma is
increasing in size
– Serous /
Serosanguineous /
bloody discharge occurs
– Patients are
pshychologicaly
disturbed
25
Treatment

Medical-

Ineffective modalities
– Diet therapy-Caffeine
restriction
– Diuretics
– Iodine containing
agents
– Thyroid hormone
– Evening Primrose oil
– Vitamin E & B6
– Dihydroergotamine
– Antiprolactin drugs
– Analgesics
01/07/2016

Hormones– Low Oestrogen
Combined OC pills
– Progestogens in
the luteal phase
– AntioestrogensTamoxifen
– AndrogensDanazol
26
Treatment

Medical- Hormones

OC pills– Users are protected from
FBD
– Progestogen potency
should be high

Progestogens – To be given in the luteal

Danazol
– Remains the most
effective therapy
– Basis- ovarian
supression
– Dose-200-600mg/day
phase for 9-12 months
– About 80% get relief but
40% require restart of
therapy
01/07/2016
27
Treatment

Medical- Hormones - Danazol
Efficacy of Danazol
100%
80%
75%
60%
40%
81.40%
90%
47%
20%
0%
200mg
01/07/2016
400mg
100-800mg 200-400mg
28
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
01/07/2016
% use
75
21
18
18
15
13
10
9
3
29
BENIGN TUMOURS
Fibroadenoma
 Most common benign tumour
 Circumscribed lesion composed
of both proliferating glandular
and stromal elements
BENIGN TUMOURS
Fibroadenoma
 Patients usually present < 30 years
 Classic presentation is that of a firm,
mobile lump (“breast mouse”)
 Giant forms can occur, especially in
younger patients
Fibroadenoma
Common (20-30) yrs
 Free moble ( mouse) , oval , firm
Gross :
Microscopically
 ↑↑duct and periductal CT
(fibromyxomatous stroma)
 Intracanalicular pattern:
 Pericanalicular pattern:.

Diagnostic Aids for
Fibroadenomas




Breast sonography
Mammography (may not be done for
<35 years old)
Fine needle
Surgical excision
Treatment of Fibroadenomas

Surgical Excision
(in those <35: nonoperative approach
possible upon meeting THREE clinical
parameters to establish the diagnosis1.clinical exam
2.ultrasound, mammography
3.cytology (FNA)
Phylloides ( leaf –like)
Tumors
Phylloides ( leaf –like)
Tumors





Past name: Cystosarcoma Phylloid.
It can become malignant
Usually a big tumor
Contain mainly stromal
component.
Morphologically has a “ leaf like”
appearance.
Morphologically has a “ leaf
like” appearance
Phylloides tumor

High-grade lesion behave aggressively
and exhibit recurrence.
Fibroadenoma Vs Phylloides tumor
Low cellularity
High cellularity, bulky
stroma.
Rare mitosis
High mitosis
No Pleomorphism
Pleomorphism
Present
Well circumscribed
Infiltrative border
A
THANK YOU
01/07/2016
42