Approach
Fibrocystic change refers to a variety of benign alterations and is a diagnosis of exclusion. It is felt to be an exaggerated physiologic phenomenon rather than a disease. Characteristic history and examination findings are often sufficient to diagnose the condition. Common clinical criteria used are breast pain, nodularity upon palpation, and imaging studies that suggest the presence of breast cyst formation or fibrosis.[1][2][13] Biopsy is usually reserved for cases in which physical examination or imaging studies demonstrate the presence of a mass, in order to exclude a diagnosis of breast cancer.[1][2]
History
Symptoms typically arise between the third and fifth decades of life.[4] It is most often characterized by breast pain, which is often bilateral and associated with the menstrual cycle, preceding menses by a few days and stopping shortly thereafter. The pain is described as constant and dull in nature, although it can throb and cause a burning sensation. It is generally diffuse and bilateral but may be localized to an area of the breast often associated with a ruptured cyst. In 30% to 40% of cases, the pain is constant in nature and not related to the menstrual cycle. In these cases it is important to differentiate other causes of pain, such as pain arising from chest wall structures.[1][2][14] Though most patients experience relief of symptoms with initial management, pain tends to be recurrent and patients may suffer recurrences over long periods of time (average 12 years), requiring intermittent bouts of intervention.[15]
Patients may also present with nipple discharge. Nonsuspicious nipple discharge is scant, milky, green, gray, or black, is either unilateral or bilateral, and may be expressed from several ducts. Suspicious nipple discharge is bloody or watery, profuse, and emanates from a single nipple duct. This clinical scenario is most often caused by an intraductal papilloma (70%), breast cancer (5%), or ductal ectasia (25%), which is part of the fibrocystic disease spectrum and also known as nonpuerperal mastitis.
Physical examination
Diffuse symmetric lumpiness through both breasts is a common finding and should not be regarded as a disease.[8][13] Patients may also have a focal area of asymmetry or a dominant mass on palpation. The mass is often discovered incidentally by the patient or during routine physical examination. Less frequently, the patient may notice a tender mass that often correlates with an enlarged or ruptured cyst.[1][2][13] Patients with focal asymmetry or a dominant mass require further evaluation with imaging studies or a biopsy to exclude other pathology, most significantly breast cancer.
Imaging
Imaging studies are requested based on the clinical presentation. Extensive workup of patients who present only with mastalgia is not indicated, other than age-appropriate screening mammography. Patients who have a history of a persistent breast mass or are suspected to have a mass on breast examination should undergo diagnostic mammography and breast ultrasound.[1][2][13] In patients with suspicious nipple discharge, evaluation with mammography and breast ultrasound may define abnormalities as a target for biopsy. A cyst may be suspected on physical examination or mammography, but must be confirmed by breast ultrasound. Breast pain alone is not an indication for imaging in the absence of other physical findings suggestive of an anatomic cause for the pain, such as a cyst or mass.[16][17][Figure caption and citation for the preceding image starts]: Ultrasound image of a breast cyst (note the characteristic smooth and sharp margins of the anechoic lesion with posterior acoustic enhancement)Courtesy of Limin Yang, MD, and Justin Boatsman, MD, Department of Radiology, University of Iowa Hospital and Clinics; used with permission [Citation ends].
Cyst aspiration
Cyst aspiration is indicated for women who have symptomatic breast cysts. Asymptomatic or small breast cysts require no intervention. If fluid aspirated is straw-colored and the cyst is completely aspirated there is no need for cytologic studies. If the fluid aspirated is bloody, cytology of the fluid or biopsy of the cyst is recommended.[1][2][13]
Biopsy
Most patients do not require biopsy; it is usually reserved for cases in which physical examination or imaging studies demonstrate the presence of a mass and is used to exclude breast cancer.[1][2] Histologic findings that confirm fibrocystic breasts are apocrine metaplasia and hyperplasia, gross and microscopic cysts, and fibrosis.[1][2] Other alterations include certain stromal alterations, mild epithelial hyperplasia, and mild degrees of adenosis.
Diagnostic biopsy, to exclude breast cancer or an intracystic papilloma, is indicated in cysts demonstrating sonographically complex characteristics, such as a solid component, mural growth, wall thickening, or thick septa.
Patients with suspicious nipple discharge and normal mammography and breast ultrasound still require a tissue diagnosis and an excisional biopsy of the secreting duct and underlying breast tissue. This takes the form of a microductectomy (selective excision of the secreting duct) or central duct excision (excision of the entire ductal complex). Ductoscopy can also play a role in evaluation of nipple discharge, but is not widely performed.[18]
Use of this content is subject to our disclaimer