Fibrocystic Breast Disease

Introduction
Fibrocystic Changes
Fibroadenoma
Phyllodes Tumors
Intraductal Papilloma
Granular Cell Tumor
Fat Necrosis
Mastitis
Duct Ectasia

Most women experience breast changes at some time. Your age, hormone levels and medicines you take may cause lumps, bumps and discharges.

If you have a breast pain, lump, discharge or skin irritation, see your health care provider. Minor and serious breast problems have similar symptoms. Although many women fear cancer, most breast problems are not cancer.

• Fiibrocystic breast condition - lumpiness, thickening and swelling, often associated with a woman's period
• Cysts - fluid-filled lumps
• Fibroadenomas - solid, round, rubbery lumps that move easily when pushed, occurring most in younger women
• Intraductal papillomas - growths similar to warts near the nipple
• Blocked or clogged milk ducts
• Milk production when a woman is not breastfeeding
• Injury

Many different changes can be found when breast tissue affected by fibrocystic change is viewed under the microscope. Most of these changes reflect the way the woman’s breast tissue has responded to monthly hormone changes, and have little other importance. However, some changes may indicate slightly or moderately increased risk of developing breast cancer later on. By understanding some of the words doctors use to describe these changes, you can better understand how serious they are and if extra tests will be needed to check for cancer.

Fibrosis:
As the term "fibrocystic" suggests, the two main features are fibrosis and cysts. Fibrosis refers to the prominence of fibrous tissue, the same material that ligaments and scar tissues are made of. Areas of fibrosis feel "rubbery", firm, or hard to the touch. Fibrosis does not increase your breast cancer risk and does not need any special treatment.

Cysts:
Cysts are spaces filled with fluid lined by breast glandular cells. They start out as a build up of fluid inside breast glands. Microcysts are too small to feel, and are found only when tissue is looked at under the microscope. If fluid continues to build up, macrocysts are formed. These can be easily felt and may reach one or two inches across. As they grow, stretching of the surrounding breast tissue may cause pain. A round, movable lump, especially one that is tender to the touch suggests a cyst. Breast ultrasound is often used to confirm this. Fine needle aspiration can confirm the diagnosis of a cyst and, at the same time, drain the cyst fluid. Removing the fluid may reduce pressure and pain. Fluid may return, and more aspirations may be necessary. Having one or more cysts does not affect your risk of later developing breast cancer.

Epithelial hyperplasia:
Epithelial hyperplasia (also known as proliferative breast disease) is an overgrowth of the cells that line either the ducts or the lobules. When hyperplasia involves the duct, it is called ductal hyperplasia or duct epithelial hyperplasia. When it affects the lobule, it is referred to as lobular hyperplasia. Based on how it looks under the microscope, hyperplasia may be grouped as usual type (without atypia) or atypical. Usual hyperplasia indicates a very slight increase in a woman’s risk of developing breast cancer. The risk is 1 ½ to 2 times that of a woman with no breast abnormalities. Atypical hyperplasia indicates a moderate increase in risk of 4 to 5 times that of women with no breast abnormalities.

• About 1 in 10 women with atypical ductal hyperplasia will develop invasive carcinoma within 10 years of their biopsy.
• About 7 in 10 biopsies done for benign breast conditions do not contain any hyperplasia.
• About 26% have usual hyperplasia and only 4% (4 women in 100) have atypical hyperplasia

Epithelial hyperplasia is usually diagnosed with a core needle biopsy or surgical biopsy. A diagnosis of hyperplasia, particularly atypical hyperplasia, usually means you will need closer follow-up with your doctor such as more frequent breast physical examinations and a special effort to get yearly mammograms. This is because having hyperplasia increases the chance of developing a breast cancer in the future.

Adenosis:
Adenosis is a common finding in biopsies of women with fibrocystic changes. Adenosis refers to enlargement of breast lobules, which contain more glands than usual. If many enlarged lobules are found near one another, this collection of lobules with adenosis may be large enough to be felt. There are several names for this condition, including aggregate adenosis, tumoral adenosis or adenosis tumor. It is important to note that even though this term contains the word "tumor," this condition is benign and is not a cancer. Sclerosing adenosis is a special type of adenosis in which the enlarged lobules are distorted by scar-like fibrous tissue.

Fine needle aspiration biopsy of adenosis can usually show whether the lump is benign. A core needle biopsy can usually identify the mass as adenosis, but a surgical biopsy is needed in some cases to be sure cancer is not present.

Fibroadenomas are benign tumors made up of both glandular breast tissue and stromal (fibroconnective) tissue. They are most common in young women in their twenties and thirties, but they may occur at any age. Some fibroadenomas are too small to feel and can be seen only under the microscope, but some are several inches across. They tend to be round and have borders that are distinct from the surrounding breast tissue, so they often feel like a marble within the breast. Some women have only one fibroadenoma, but others may have several. Fibroadenoma can be easily diagnosed by fine needle aspiration or needle core biopsy.

Many doctors recommend removing fibroadenomas, especially if they continue to grow or if they change the shape of the breast. Sometimes (especially in middle aged or elderly women) these tumors will stop growing or even shrink on their own, without any treatment. In this case, as long as the doctors are certain the masses are really fibroadenomas and not breast cancer, surgery to remove them may not be needed. This approach is useful for women with many fibroadenomas that are not growing. In such cases, removing them all might mean removing a lot of nearby normal breast tissue, causing scarring that would change the shape and texture of the breast. This could also make future physical examination and mammograms harder to interpret. But, it is important for women who do not have fibroadenomas removed to have a breast physical exam at regular intervals to make sure the mass is not continuing to grow. Sometimes one or more new fibroadenomas will grow after one is removed. This simply means that another fibroadenoma has formed and not that the old one has come back.

Phyllodes (also spelled phylloides) tumors are a rare type of breast tumor that, like a fibroadenoma, contains two types of tissue -- stromal (connective) breast tissue and glandular breast tissue. In contrast, carcinomas (the usual type of breast cancer) develop in the ducts or lobules of the breast’s glandular tissue. The difference between phyllodes tumors and fibroadenomas is that there is an "overgrowth" of the fibroconnective tissue in the phyllodes tumor. The cells that make up the fibroconnective tissue part can look abnormal under the microscope. Depending on how they look under the microscope, phyllodes tumors may be classified as benign, malignant, or of uncertain malignant potential (the chance of the tumor becoming cancer is uncertain).

Phyllodes tumors are usually benign but on very rare occasions may be malignant, rarely having the chance to metastasize (spread). In the past, both benign and malignant phyllodes tumors were referred to as cystosarcoma phyllodes. Benign phyllodes tumors are treated by removing the mass and a 2 cm (about 1 inch) area of normal breast tissue from around the tumor. A malignant phyllodes tumor is treated by removing it along with a wider margin of normal tissue, or by mastectomy (removing the entire breast) if needed. Malignant phyllodes tumors do not respond to hormone therapy and are less likely than most breast cancers to respond to chemotherapy or radiation therapy.

Intraductal papillomas are wartlike growths of gland tissue and fibrovascular tissue (fibrous tissue and blood vessels). Papillomas often involve the large milk ducts near the nipple. These result in a bloody nipple discharge. Papillomas may also be found in small ducts in areas of the breast further from the nipple. In this case there will often be several growths and may also have epithelial hyperplasia. Although papillomas may be suspected in a nipple discharge exam, many doctors do not feel the test is useful. If the papilloma is large enough to be felt, a needle biopsy can be done. The usual treatment is to remove the papilloma and a part of the duct it is found in, usually through an incision at the edge of the areola (the darker colored area around the nipple).

Granular cell tumors are rare in the breast. Most are found in the skin or the mouth, but they are uncommon even in those places. They are almost always benign.

Most granular cell tumors of the breast can be felt as a movable, firm lump. They are usually about ½ to 1 inch across. Their firmness may raise the possibility of cancer, but a fine needle or core needle biopsy can tell them apart from cancers.

This tumor is usually cured by removing it and a small area of normal breast tissue. Granular cell tumors do not increase a woman’s risk of developing breast cancer later in life.

Fat necrosis happens when an area of the fatty breast tissue is damaged. This is usually the result of injury to the breast. It can also occur after surgery or radiation therapy. Because the body is trying to repair the damaged tissue, the area becomes replaced by firm scar tissue. Because most breast cancers are also firm, areas of fat necrosis with scarring can be difficult to distinguish from cancers by a breast physical exam. A needle biopsy, or sometimes a surgical excision, will be needed to decide if cancer is present.

Some areas of fat necrosis will respond differently to injury. Instead of forming scar tissue, the fat cells die and release their contents. This will form a sac-like collection of greasy fluid called an oil cyst. Oil cysts can be diagnosed by fine needle aspiration, which also serves as a treatment.

Mastitis is an infection that most often affects women who are breast-feeding or who have had a break or crack in the skin. Cracking of the skin around the nipple allows bacteria from the skin surface to enter the breast duct where they grow and cause inflammation (redness). The inflammatory cells release substances that fight the infection, but also cause tissue swelling and increased blood flow. These changes cause the surrounding area to be painful and the overlying breast skin to be red and warm to the touch. This condition is treated with antibiotics. Some cases of mastitis lead to a breast abscess or collection of pus (inflammatory cells and fluid). Abscesses are treated by surgically draining the pus.

Inflammatory breast cancer has symptoms that are similar to mastitis. Because of this it can be misdiagnosed or have a delay in diagnosis. If antibiotic treatment does not help, and inflammatory breast cancer has not been ruled-out, then a biopsy of the skin may be needed to make sure it is not cancer.

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Duct Ectasia

Duct ectasia is a common condition that tends to affect women in their 40s and 50s. The most common symptom is a green or black, often thick, sticky discharge. The nipple and the surrounding breast tissue may be tender and red. Sometimes scar tissue around the abnormal duct causes a hard lump that may be confused with cancer. This condition sometimes improves without any treatment, or with warm compresses and antibiotics. If the symptoms do not go away, the abnormal duct is removed through an incision at the border of the areola.