2. Fibrocystic Breast Change Dr. Atif Ali Bashir, M.D. Assistant Professor of Pathology Medical College Majma’ah University

3. 08/06/2016 2 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

4. Breast lumps

5. 08/06/2016 4 Pathophysiology Hormonal basis – Oestrogen & Progesterone – Prolactin – Thyroid Methylexanthiones Trauma- NOT A CAUSE

6. 08/06/2016 5 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 Pathophysiology

7. 08/06/2016 6 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 Pathophysiology

8. 08/06/2016 7 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.

9. 08/06/2016 8 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. Pathomorphology

10. 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

11. 08/06/2016 10 Histopathological sections of breast showing FCC Pathomorphology

12. FCC Epithelial ↑ plasia AdenosisCystFibrosis A C F

13. 08/06/2016 12 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.

14. 08/06/2016 13 Clinical Course

15. 08/06/2016 14 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 Clinical Course

16. 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

17. 08/06/2016 16 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. Diagnosis Symptoms and Signs -

18. 08/06/2016 17 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). Diagnosis

19. Physical Exam Findings “plateful of peas” palpable lumpiness water-filled balloons

20. Diagnostic Aids for Fibrocystic Change Imaging techniques Fine needle aspiration cytology Histopathologic evaluation (core needle biopsy or excision biopsy)

21. 08/06/2016 20 Mammography – 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. Diagnosis

22. 08/06/2016 21 Mammography – Diagnosis 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.

23. 08/06/2016 22 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. Diagnosis

24. 08/06/2016 Fibrocystic Breast Disease - Prof.S.N.Panda23

25. 08/06/2016 24 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. Diagnosis

26. 08/06/2016 25 Treatment 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 Intervention indicated when- – Fibroadenoma is increasing in size – Serous / Serosanguineous / bloody discharge occurs – Patients are pshychologicaly disturbed  Medical-  Surgical-

27. 08/06/2016 26 Ineffective modalities – Diet therapy-Caffeine restriction – Diuretics – Iodine containing agents – Thyroid hormone – Evening Primrose oil – Vitamin E & B6 – Dihydroergotamine – Antiprolactin drugs – Analgesics Hormones- – Low Oestrogen Combined OC pills – Progestogens in the luteal phase – Antioestrogens- Tamoxifen – Androgens- Danazol Treatment  Medical-

28. 08/06/2016 27 OC pills- – Users are protected from FBD – Progestogen potency should be high Progestogens - – To be given in the luteal phase for 9-12 months – About 80% get relief but 40% require restart of therapy Danazol – Remains the most effective therapy – Basis- ovarian supression – Dose-200-600mg/day Hormones Treatment  Medical-

29. 08/06/2016 28 Treatment - Danazol  Medical- Hormones

30. 08/06/2016 29 Treatment Preferences of 276 Consultants (UK) – BeLieu RM,1994 Treatment modality% use Danazol75 Analgesics21 Diuretics18 Local excision18 Bromocriptine15 Evening primrose oil13 No treatment10 Tamoxifen9 Well fitting bra3

31. BENIGN TUMOURS  Fibroadenoma  Most common benign tumour  Circumscribed lesion composed of both proliferating glandular and stromal elements

32. 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

33. Fibroadenoma Common (20-30) yrs Common (20-30) yrs Free moble ( mouse), oval, firm Free moble ( mouse), oval, firm Gross : Microscopically ↑↑duct and periductal CT ↑↑duct and periductal CT (fibromyxomatous stroma) (fibromyxomatous stroma) Intracanalicular pattern: Intracanalicular pattern: Pericanalicular pattern:. Pericanalicular pattern:.

36. Diagnostic Aids for Fibroadenomas Breast sonography Mammography (may not be done for <35 years old) Fine needle Surgical excision

37. Treatment of Fibroadenomas Surgical Excision (in those <35: nonoperative approach possible upon meeting THREE clinical parameters to establish the diagnosis- 1.clinical exam 2.ultrasound, mammography 3.cytology (FNA)

38. Phylloides ( leaf –like) Tumors

39. Past name: Cystosarcoma Phylloid. It can become malignant Usually a big tumor Contain mainly stromal component. Morphologically has a “ leaf like” appearance.

40. Morphologically has a “ leaf like” appearance

41. Phylloides tumor High-grade lesion behave aggressively and exhibit recurrence.

42. Fibroadenoma Vs Phylloides tumor Low cellularity High cellularity, bulky stroma. Rare mitosis High mitosis No Pleomorphism Pleomorphism Present Well circumscribed Infiltrative border

43. 08/06/2016 42 THANK YOU 