Essentials of Diagnosis

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

General Considerations

Fibrocystic condition is the most frequent lesion of the breast. Although commonly referred to as “fibrocystic disease,” it does not, in fact, represent a pathologic or anatomic disorder.

It is common in women 30-50 years of age but rare in postmenopausal women who are not taking hormonal replacement medications. Estrogen hormone 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 histologic changes. These lesions are always associated with benign changes in the breast epithelium, some of which are found so commonly in normal breasts that they are probably variants of normal breast histology but have nonetheless been termed a “condition.”

The microscopic findings of fibrocystic condition include cysts (gross and microscopic), papillomatosis, adenosis, fibrosis, and ductal epithelial hyperplasia. Although fibrocystic condition has generally been considered to increase the risk of subsequent breast cancer, only the variants in which proliferation (especially with atypia) of epithelial components is demonstrated represent true risk factors.

Clinical Findings

A. Symptoms and Signs

Fibrocystic condition may produce an asymptomatic lump in the breast that is discovered by accident, but pain or tenderness often calls attention to the mass. There may be discharge from the nipple. In many cases, discomfort occurs or is increased during the premenstrual phase of the cycle, at which time the cysts tend to enlarge. Fluctuation in size and rapid appearance or disappearance of a breast mass are common with this condition. Multiple or bilateral masses are common, and many patients will give a history of a transient lump in the breast or cyclic breast pain.

B. Diagnostic Tests

Because a mass due to fibrocystic condition is frequently indistinguishable from carcinoma on the basis of clinical findings, suspicious lesions should be biopsied. Fine-needle aspiration cytology may be used, but if a suspicious mass that is nonmalignant on cytologic examination does not resolve over several months, it must be excised. Surgery should be conservative, since the primary objective is to exclude cancer. Occasionally, core needle biopsy will suffice. Simple mastectomy or extensive removal of breast tissue is rarely, if ever, indicated for 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. Final diagnosis often depends on excisional 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 from a solid mass.

Treatment

When the diagnosis of fibrocystic condition has been established by 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 or if fluid is bloody, if a mass persists after aspiration, or if at any time during follow-up a persistent lump is noted, biopsy is performed.

Breast pain associated with generalized fibrocystic condition is best treated by avoiding trauma and by wearing (night and day) a brassiere that gives good support and protection. A topical nonsteroidal anti-inflammatory gel may be of value. Hormone therapy is not advisable, because it does not cure the condition and has undesirable side effects. Danazol (100-200 mg twice daily orally), a synthetic androgen, has been used 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 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 hormones to reduce pain.

The role of caffeine consumption in the development and treatment of fibrocystic condition is controversial. Some studies suggest that eliminating caffeine from the diet is associated with improvement. 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 the menopause, when symptoms usually subside, except in patients receiving hormonal replacement therapy. The patient should be advised to examine her own breasts each month just after menstruation and to inform her physician if a mass appears. The risk of breast cancer in women with fibrocystic condition showing proliferative or atypical changes in the epithelium is higher than that of women in general. These women should be followed up carefully with physical examinations and mammography.

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