Fi Bro Cystic Breast Disease
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Fibrocystic Breast Disease
Dr.Surendra Nath Panda, M.S.
Professor of Obstetrics & Gynaecology
M.K.C.G.Medical College
Berhampur, ORISSA, INDIA
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Fibrocystic Breast Disease (FBD)
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
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Pathophysiology
Hormonal basis
– Oestrogen & Progesterone
– Prolactin
– Thyroid
Methylexanthiones
Trauma- NOT A CAUSE
FBD
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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 morelikely to develop FBD
– Women with progesterone deficiency carry a fivefold risk of premenopausal breast cancer
FBD
Pathophysiology
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Prolactin-
– levels are increased in 1/3 of women with FDB
– 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 FDP
FBD
Pathophysiology
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Pathomorphology Oestrogens stimulate proliferation of connective and epithelial
tissues.' The polymorphism of fibroeystic disease is
documented by fibrosis, cyst formation, epithelial proliferation,
and lobular-alveolar atrophy. FBD 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, cystformation, and calcification. Loss of parenchymal elements
(ductules, alveoli) with intra-lobular and periductal fibrosis is
encountered in chronic disease.
FBD
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Histopathological sections of breast showing FBD
FBD
Pathomorphology
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Clinical CourseFBD
FBD represents a clinical problem inapproximately 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 mostpatients (70% to 75%) are in their mid 30s and40s.
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Clinically, three phases of fibrocystic diseasecan be recognized-
– Phase I-Moderate stromal fibrosis, beginninghardness of breast tissue and premenstrual breasttenderness
– Phase II- Progressive fibrosis leading to increasedhardening and tenderness, cyst formation, moderatemodularity
– Phase III- Pronounced fibrosis and tenderness,macrocyst formation
FBD
Clinical Course
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Diagnosis
Fibroeystic disease has a history of many months
to several years.
Fibroeystic disease is rare in ovulating women,
multiparous women, and patients using oralcontraceptives.
Breast pain (mastodynia) and/or tenderness is
observed in the majority of patients. – In 40% to 60% of patients these are associated with
irregular menses, dysmenorrhea, menometrorrhagia, or
ovarian cysts.
FBD
Symptoms and Signs -
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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 onsetof or during menses.
In more than half of the patients with mazoplasia,
pre- menstrual breast swelling, mastodynia, and
irregular menses, are observed. In approximately20% of patients, axillary tenderness and enlarged
lymph nodes are observed.
FBD
Diagnosis Symptoms and Signs -
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Nipple secretion- – In one third of patients with FBD, discharge is spontaneous
or secretion can be expelled from the nipple. The
cytological features may include amorphous material (fat,
proteins), ductal cells, erythrocytes, andlor foam cells. 7hefluid is straw yellow, green- ish, 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).
FBD
Diagnosis
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Mammography –
FBD
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 diseaseprogresses, 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
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Mammography –
FBD
Diagnosis
Nodular changes are reflected in the
mammogram by darker specks amid
dense white areas appear- ing as
"buckshot" breast".
Wolfel ob- 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.
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Ultrasonography -
– Particularly useful in delineating solid from cysticbreast masses.
– Ultrasound of cystic masses characteristicallydefines a mass with a uniform outer margindemonstrating no asymmetry or unusual thickness of the wall. The central part of the mass shows noechoes, and there is posterior wall enhancement.
FBD
Diagnosis
FBD
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Needle aspiration biopsy – – Indicated in patients with breast mass, a lump like
structure,, a hard dense area or any abnormal tissueareas, as defined by clinical examination,mammography or USG.
– In patients at high risk of breast cancer, needleaspiration should be performed when the slightestsuspicion arises.
– In women with fibrocystic disease, ductal epitheliumconsists of cohesive cells with a scant rim of cytoplasm and round or oval small, slightly hyper chromatic nuclei. Connective (fibrous) tissue is usuallypredominant.
FBD
Diagnosis
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FBD
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Ineffective modalities
– Diet therapy-Caffeinerestriction
– Diuretics
– Iodine containingagents
– 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
FBD
Treatment
Medical-
FBD
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OC pills-
– Users are protected fromFBD
–Progestogen potencyshould 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
FBD
Hormones
Treatment
Medical-
FBD
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Efficacy of Danazol
47%
75%81.40%
90%
0%
20%
40%
60%
80%
100%
200mg 400mg 100-800mg 200-400mg
FBD
Treatment
- Danazol Medical- Hormones
FBD
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Treatment Preferences of 276 Consultants
(UK) – BeLieu RM,1994
FBD
Treatment modality % use Danazol 75
Analgesics 21
Diuretics 18Local excision 18
Bromocriptine 15
Evening primrose oil 13 No treatment 10
Tamoxifen 9
Well fitting bra 3
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THANK YOU
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