Hyperplastic Cystic Disease, Breast Pain | mastalgia, Biopsy


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Fibroadenosis - What Is It and How To Treat It?

Fibroadenosis or fibrocystic disease was previously known by many other terms such as mammary dysplasia, chronic cystic mastitis or hyperplastic cystic disease. The plethora of names for this condition reflects controversy over its aetiology and confusion over the lack of correlation between its clinical findings and its pathological features.

Women with fibroadenosis generally complain of breast pain (mastalgia) or a lump in the breast. At surgery instead of a definite lump, an indurated area is often found. The typical microscopic features of such a biopsy (fibrosis, adenosis, epitheliosis and cyst formation) are commonly found in normal women at autopsy. Hence, some pathologists have questioned whether fibroadenosis can be called a disease.

From the clinical view point, such women need treatment as their mastalgia may be severe enough to interfere with their work or social life. The uncertainty over the presence of a lump or induration (nodularity) of the breast can be frightening to a woman and needs proper clinical assessment.

To resolve this debate, fibroadenosis is now thought to be a more severe form of the cyclical changes that take place in the woman's breasts monthly. This is due to the influence of her sex hormones which varies with her menstrual cycle. This would explain why fibroadenosis is common in women during her reproductive age (25 to 35 years old), and why there is similarity in the symptoms of pain and nodularity which a woman often has premenstrually, and finally why there is a lack of distinct pathological features. This new concept is termed Aberrations of Normal Development and Involution (ANDI) and was proposed to cover the whole spectrum of benign breast disorders.

Is Fibroadenosis Associated With Increased Risk of Malignancy?

Dupont and Page assessed the risk of breast cancer in patients with fibroadenosis and found no significantly increased risk. However, a subtype of fibroadenosis, namely atypical ductal or lobular epithelial hyperplasia (ADH or ALH) is associated with a significant increased risk of breast cancer.

Patients with ADH have a four times increased risk of breast cancer compared to the general population and this risk increases to eight times if the patient also has a positive family history of breast cancer. Such women need close monitoring with yearly reviews and mammograms. Recently it was reported that women with ADH benefited from treatment with Tamoxifen (for a 5-year duration), with significant reduction (of 50%) in their breast cancer risk.

In summary, two broad approaches are needed to treat a patient with fibroadenosis. Firstly, one needs to assess her mastalgia and treat if necessary. Secondly, her complaint of a breast lump should be assessed carefully. A detailed history is helpful to assess the severity of her mastalgia. Equally important is a careful physical examination to decide whether there is a breast lump. Mammogram and ultrasound scan are performed to exclude any lesion. Finally fine needle aspiration (FNA), core needle biopsy or tru-cut biopsy, and excision may be required to rule out malignancy on doubtful breast lumps.


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