Author Lisa Wiechmann MD

Overview

The term fibrocystic disease of the breast is commonly used to describe a group of benign breast disorders and in general refers to any deviation from perfect symmetry of the breast. It may refer to lumpiness or cysts of the breast and from mild cyclical mammary discomfort to pain and has been referred to as mammary dysplasia as well as other synonyms. Menstrual status may change the consistency of breast tissue, and “lumpiness” may vary depending on hormonal levels.  Fibrous and cystic changes increase rabidly in the 10 -15 years before menopause and they occur in approximately 50% of the immediately premenopausal population fo North-Americans at high risk for Breast Cancer. Many synonyms are used when referring to fibrocystic disease: cystic mastopathy, chronic cystic mastits, Schimmelcusch’s disease, mazoplasia, fibroadenomatosis, Cooper’s disease, fibrocystic changes and Reclus’disease.The current literature indicates that the above terminology is not clinically significant or meaningful because it attempts to describe a group of different entities that range from physiologic to pathologic. The term now used when referring to fibrocystic disease is benign breast disorder of the nonproliferative type. The term Benign Breast disorders icludes a heterogenous group of lesion that have different clinical presentation(palpable mass, radiographic abnormality, incidental finding)> Many studies at this point have indicated that termas such as Fibroscystic disease, chronic cystic mastitis and mammary dysplasia are not clinically meaningful because of the broad group of diseases that have different cancer risks. PAge and Dupont headed the seminal study evaluating benign breast disease ( Nashville, 3,000 women) and the histologic lesions present were categorized in three distinct groups as shown below.

Categorization of benign breast disease lesions according to the Criteria of Page, Dupont and Rogers                                                                                               Relative risk of breast cancer

Non Proliferative

(Cysts, papillary apocrine change, epithelial related calcifications, mild hyperplasia of the usual type)         X 1.5- 3.0

Proliferative w/o atypia

( Moderate/florid hyperplasia, Intraductal papilloma, sclerosing adenosis, fibroadenoma)                             X 1.5-2.0

Proliferative w atypia

( atypical ductal/lobular hyperplasia)                                                                                                              X  2.5- 11.0

The two major goals in the pathologic evaluation of benign breast lesions are 1) to differentiate benign from malignant and premalignant lesions and 2) to assess the risk of subsequent breast cancer associated with the benign lesion.

Risks – Nonproliferative Lesions ( Relative risk of breast cancer 1.5- 3.0 – 3.0 if postive family history)

These lesions include cysts, papillary apocrine change, epithelial – related calcifications and mild hyperplasia of the usual type

Cysts: Fluid filled , round-to ovoid structures that vary in size from microscopic to grossly evident ( gross or macroscopic cysts)

Papillary apocrine change : proliferation of ductal epithelial cells

Epithelial-related classification: Calcifications observed in breast tissue that can be seen in the normal as well as pathologic tissue

Mild hyperplasia of the usual type: Increase in the nuber of epithelial cells in a duct that is less than 4 epithelial cells in depth.

Proliferative lesions without atypia

Usual ductal hyperplasia: Intraductal epithelial proliferations greater than four epithelial cells in depth. Such cells arey cytologically benign and are often arranged in a “swirling ” pattern

Sclerosing adenosis: Usually an incidental finding. May present as a mammographic abnormality, or a mass leion. It is composed of distorted epithelial, myoepithelial and sclerotic stromal elements that arise at the end of the terminal duct.. Because of the distorted glandular pattern, this lesion may be confused with a low-grade invasive carcinoma (tubular carcinoma).

Intraductal papilloma: Tumors of the major lactiferous ducts , most frequently observed in women aged 30-50 years. They are usually less than 1 cm in diameter and only rarely measure up to 5 cm. Macroscopically they present as tan pink, friable tumors in a dilated duct or cyst. They have a delicate stalk. Microscopically, they are composed of multiple , branching papillae, each with a central fibrovascular core. Some papillomas display  areas of atypia.

Fibroadenoma:Pseudoencapsulated masses that are sharply delineated from the rest of the breast tissue. THey may be Complex, Giant, Juvenile or demonstrate infarction. Please refer to the chapter on fibroadenoma.

Risks Proliferative lesions with atypia (atypical hyperplasias)

Atypical ductal hyperplasia (ADH):  Lesion that has some architectural and cytologic features of low grade DCIS.

Atypical lobular hyperplasia: Composed of cells identical to those found in LCIS. On biopsies performed on the base of the presence of a palpable mass, 2%-4% of cases contain ALH ( atypical lobular hyperplasia). The risk associated with atypical lobular hyperplasia appears to be higher than that associated with ADH.