BREAST DISORDERS

FIBROCYSTIC CONDITIONS

Painful, often multiple, usually bilateral masses in the breast. Rapid fluctuation in the size of the masses is common. Frequently, pain occurs or worsens and size increases during the premenstrual phase of the cycle.
The most common age is 30-50. Rare in postmenopausal women not receiving a hormonal replacement.

General Considerations
Fibrocystic condition is the most frequent lesion of the breast. Although commonly referred to as “fibrocystic disease,” it does not represent a pathologic anatomic disorder. It is common in women 30-50 years of age but rare in postmenopausal women who are not taking hormonal replacement. Estrogen is considered a causative factor. There may be an increased risk in women who drink alcohol, especially women between 18 and 22 years of age. Fibrocystic condition encompasses a wide variety of benign histologic changes in the breast epithelium, some of which are found so commonly in normal breasts that they are probably variants of normal but have nonetheless been termed a “condition” or “disease.” The microscopic findings of the fibrocystic condition include cysts (gross and microscopic), papillomatosis, adenosis, fibrosis, and ductal epithelial hyperplasia. Although the fibrocystic condition has generally been considered to increase the risk of subsequent breast cancer, only the variants with a component of epithelial proliferation (especially with atypia) or increased breast density on mammograms represent true risk factors.

Clinical Findings
A. Symptoms and Signs

The fibrocystic condition may produce an asymptomatic mass in the breast that is discovered by accident, but pain or tenderness often calls attention to it. Discomfort often occurs or worsens during the premenstrual phase of the cycle, at which time the cysts tend to enlarge. Fluctuations in size and rapid appearance or disappearance of a breast mass are common with this condition as are multiple or bilateral masses and serous nipple discharge. Patients will give a history of a transient lump in the breast or cyclic breast pain.

B. Diagnostic Tests

Mammography and ultrasonography should be used to evaluate a mass in a patient with the fibrocystic condition. Ultrasonography alone may be used in women under 30 years of age. Because a mass due to fibrocystic condition is difficult to distinguish from carcinoma based on clinical findings, suspicious lesions should be biopsied. Fine-needle aspiration(FNA)cytology may be used, but if a suspicious mass that is nonmalignant on cytologic examination does not resolve over several months, it should be excised or biopsied by core needle. Surgery should be conservative since the primary objective is to exclude cancer. Occasionally, FNA cytology will suffice. Simple mastectomy or extensive removal of breast tissue is rarely if ever, indicated for the fibrocystic condition.

Differential Diagnosis
Pain, fluctuation in size, and multiplicity of lesions are the features most helpful in differentiating fibrocystic condition from carcinoma. If a dominant mass is present, the diagnosis of cancer should be assumed until disproved by biopsy. Mammography may be helpful, but the breast tissue in these young women is usually too radiodense to permit a worthwhile study. Sonography is useful in differentiating a cystic mass from a solid mass, especially in women with dense breasts. The final diagnosis, however, depends on the analysis of the excisional biopsy specimen or needle biopsy.

Treatment
When the diagnosis of fibrocystic condition has been established by the previous biopsy or is likely because the history is classic, aspiration of a discrete mass suggestive of a cyst is indicated to alleviate pain and more importantly, to confirm the cystic nature of the mass. The patient is reexamined at intervals thereafter. If no fluid is obtained by aspiration, if the fluid is bloody, if a mass persists after aspiration, or if at any time during follow-up a persistent or recurrent mass is noted, biopsy should be performed. Breast pain associated with the generalized fibrocystic condition is best treated by avoiding trauma and by wearing a good supportive brassiere during the night and day. Hormone therapy is not advisable, because it does not cure the condition and has undesirable side effects. Danazol(100-200 mg orally twice daily), a synthetic androgen, is the only treatment approved by the US Food and Drug Administration(FDA) for patients with severe pain. This treatment suppresses pituitary gonadotropins, but androgenic effects (acne, edema, hirsutism) usually make this treatment intolerable; in practice, it is rarely used. Similarly, tamoxifen reduces some symptoms of a fibrocystic condition, but because of its side effects, it is not useful for young women unless it is given to reduce the risk of cancer. Postmenopausal women receiving hormone replacement therapy may stop or change doses of hormones to reduce pain. Oil of evening primrose (OEP), a natural form of gamolenic acid, has been shown to decrease pain in 44-58% of users. The dosage of gamolenic acid is six capsules of 500 mg orally twice daily. Studies have also demonstrated a low-fat diet or decreasing dietary fat intake may reduce the painful symptoms associated with the fibrocystic condition. Further research is being done to determine the effects of topical treatments such as topical nonsteroidal anti-inflammatory drugs as well as topical hormonal drugs such as topical tamoxifen.
The role of caffeine consumption in the development and treatment of the fibrocystic condition is controversial. Some studies suggest that eliminating caffeine from the diet is associated with improvement while other studies refute the benefit entirely. Many patients are aware of these studies and report relief of symptoms after giving up coffee, tea, and chocolate. Similarly, many women find vitamin E (400 international units daily) helpful; however, these observations remain anecdotal.

Prognosis
Exacerbations of pain, tenderness, and cyst formation may occur at any time until menopause, when symptoms usually subside, except in patients receiving a hormonal replacement. The patient should be advised to examine her breasts regularly just after menstruation and to inform her practitioner if a mass appears. The risk of breast cancer developing in women with fibrocystic conditions with a proliferative or atypical component in the epithelium or papillomatosis is higher than that of the general population. These women should be monitored carefully with physical examinations and imaging studies.