Breast Cysts & Fibrocystic Disease

Yesterday in the breast clinic I also saw two patients with fibrocystic disease. One was an extremely anxious woman, the type of anxious someone would be if you told them to act anxious, because although she has a diagnosis of fibrocystic disease, she had noticed some new lumps and yes, I do have cysts but I just want to be sure that it isn’t something else, something worse. She had a palpable cluster of cysts in one breast, with pain and tenderness over the area and had previously had cysts aspirated.

Another woman who had also noticed a new lump came in to get it investigated. She gets very bad pain in her breasts before her period and her nipples get very painful. Her fibrocystic lumps get bigger with her period and then practically disappear when not on her period.

On the whole, it was a really a good clinic- I got to do at least 6 breast examinations. I examined a re-constructed breast, a carcinoma with skin tethering, as well as the two cases of fibrocystic disease.


Breast Cysts

Definition: usually benign, fluid filled lump in the breast

Aetiology/ risk factors:

-may be less common in those on OCP

-often associated with fibrocystic disease

Epidemiology: common in > 35yrs (40-50 yrs), especially perimenopausal (shortly before menopause)

Symptoms: lump is occasionally painful

Signs:

-fluid filled round, symmetrical lump, not fixed to surrounding tissue

-may be discrete or multiple

-Features of malignancy are absent (skin tethering, dimpling, peau ‘orange skin changes, enlarged axillary lymph nodes)

Investigations:

Triple assessment:

1) History and clinical examination

2) Imaging: mammogram (Mediolateral Oblique & Craniocaudal view +/- spot compression & magnification view) and U/S if > 35 yrs (40 in the hospital I’m at), U/S if < 35 yrs- will not usually see calcification in benign breast disease.

-Cysts are confirmed on U/S.

Image result for breast cysts ultrasound

3) Cytology/ histology: by Fine Needle Aspiration cytology or core biopsy

-If the fluid aspirated is straw-coloured and the cyst is completely aspirated there is no need for cytological studies, but if it is bloody, cytology of the fluid or biopsy of the cyst is recommended.

Management:

→If the lump is cystic, it can be aspirated (though simple cysts do not need aspiration unless clinically indicated)

→Typical fluid is returned (green/yellow, milky, brown)

→On aspiration, cyst should disappear completely

→If there is a residual mass or recurrent cysts you would do further investigations to exclude an associated tumour e.g. a mammogram if you went straight for aspiration without imaging or cytology

→Hormone manipulation is occasionally useful for multiple recurrent cysts.

Complications: Pain, recurrence

Prognosis: Prognosis is good, although recurrence is common


Fibrocystic Disease

Definition: combination of localised fibrosis, inflammation, cyst formation, and hormone-driven breast pain

Aetiology/ risk factors:

Risk factors: obesity, late menopause, never having given birth (nulliparity), later age at first childbirth

-Increased incidence with use of oestrogen-replacement therapy

Epidemiology: occurs almost exclusively between menarche and menopause (15-55 yrs)

-Peak incidence of symptoms in 20s and 30s with a higher prevalence of cysts as women approach menopause.

Symptoms:

-cyclical (rarely may be non-cyclical) breast pain (Mastalgia) and swelling

-cyclical pain often precedes onset of menses by a few days and ceases shortly thereafter

-pain usually constant and dull, can occasionally be throbbing with burning sensation

-pain generally diffuse and bilateral but may be localised, often associated with a ruptured cyst

Signs:

-Lumpy breasts- diffuse symmetrical lumpiness through both breasts

-Multiple breast cysts (fluid filled round, symmetrical lumps, not fixed to surrounding tissue)

-Palpable breast mass (uncommon)

-May have nipple discharge (non-suspicious discharge = scant; milky, green, grey or black; unilateral or bilateral; may be expressed from several ducts)

-Features of malignancy are absent (skin tethering, dimpling, peau ‘orange skin changes, enlarged axillary lymph nodes)

Investigations:

Triple assessment (even if they already have a diagnosis of fibrocystic disease, new lumps should still be investigated as any woman can get breast cancer):

1) History and clinical examination

2) Imaging: mammogram (Mediolateral Oblique & Craniocaudal view +/- spot compression & magnification view) and U/S if > 35 yrs (40 in the hospital I’m at), U/S if < 35 yrs- will not usually see calcification in benign breast disease.

-Cysts are confirmed on U/S.

3) Cytology/ histology: by Fine Needle Aspiration cytology or core biopsy

-If the fluid aspirated is bloody, cytology is recommended.

-Biopsy of breast if palpable mass: apocrine metaplasia and hyperplasia, gross and microscopic cysts and fibrosis

Management:

Image result for evening primrose oil→Re-assurance (very important as women get really worried when it comes to breast lumps)

→NSAIDs (e.g. Ibuprofen)

→Hormone or ‘cellular manipulation’: e.g. Gamma-linolenic acid found in Evening Primrose Oil, combined oral contraceptive pill, Danazol and occasionally Tamoxifen (anti-oestrogen)

In clinic, evening primrose oil was suggested a lot for breast pain. Also, reducing caffeine and alcohol intake, going on a low fat diet and getting specially fitted for a bra with good support.

→Cyst aspiration (see Breast Cysts above)

Complications: Pain

-In a minority of patients, a progression to a high-risk and malignant phenotype is associated with the accumulation of genetic mutations.

Prognosis: breast pain is usually recurrent or chronic, but may be acute isolated episode

References: Cheese & Onion (+surgery version), Rapid Medicine, BMJ Best Practice

 

 

 

 

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