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Fibrocystic Breast Changes, Emergency Medicine

Basics

Description

- Most common in women 30-50 yr old - Pain is most likely caused by rapid expansion of simple cysts - Symptoms may continue into menopause secondary to hormone replacement therapy - Incidence is decreased in women taking oral contraceptives - Risk factors include: - Family history of fibrocystic changes - Oral contraceptives - Hormone replacement therapy - Increasing age - Diet (high fat intake; caffeine/methylxanthines)

- Mastalgia and tenderness: - Persistent or intermittent - Often occurs during premenstrual phase of normal menstrual cycle - Usually bilateral - Pain may radiate to shoulders and upper arms

- Ultrasound if <30 yr old - Mammography if >30 yr old - Ultrasound: - Can differentiate cystic from solid masses - Benign cysts: - Typically demonstrate a uniform outer margin without asymmetry or irregular thickness of the cyst wall - Have no central echoes - Posterior wall enhancement is normal

- Fine needle aspiration: - Usually performed by a specialist - May be performed therapeutically for symptomatic or large masses - Allows differentiation between cystic and solid masses - Obtain cytology studies to evaluate for malignancy

  • Generalized term for benign breast changes that are poorly defined
  • No longer considered a pathologic disease process as they are found in the majority of healthy women
  • Most common of all benign breast conditions
  • Changes include:Benign cystsBreast pain (mastalgia or mastodynia), which may or may not be cyclicDiffuse and focal nodularityPalpable fibroadenomasNipple discharge-may be green or brownish, though usually nonbloody
  • Spontaneous, persistent discharge warrants further evaluation
  • Occurs in ~60% of women
  • Symptoms of pain and tenderness become progressively worse until menopause
  • Pain is often most prominent during the premenstrual phase and improves with the onset of mensesBreast pain alone is a rare symptom of cancer and accounts for only 0.2-2% of cases
  • Synonyms: Adenosis, benign breast disease, cystic mastitis, cystic disease of the breast, fibroadenosis, fibrocystic disease, mammary dysplasia.

Etiology

  • Mechanism of development not well understood
  • Likely an enhanced or exaggerated reaction of breast tissue to cyclic levels of female reproductive hormones:May be caused by imbalance of the estrogen to progesterone ratioMay occur secondary to increased daily prolactin production
  • Most common in women 30-50 yr old
  • Pain is most likely caused by rapid expansion of simple cysts
  • Symptoms may continue into menopause secondary to hormone replacement therapy
  • Incidence is decreased in women taking oral contraceptives
  • Risk factors include:Family history of fibrocystic changesOral contraceptivesHormone replacement therapyIncreasing ageDiet (high fat intake; caffeine/methylxanthines)

Diagnosis

Signs and Symptoms

History

  • Mastalgia and tenderness:Persistent or intermittentOften occurs during premenstrual phase of normal menstrual cycleUsually bilateralPain may radiate to shoulders and upper arms
  • Lumpiness, nodularity:May be localized or generalized
  • Increased engorgement and breast density:Breasts described as being dull and heavyCaused by fluctuations in the size of the cystic areas
  • Spontaneous or expressible nipple discharge
  • Abnormal nipple sensations, including pruritis
  • Family history of cysts is common

Physical Exam

  • Palpate the 4 breast quadrants while patient is sitting and then while lying down
  • Note any changes from normal, including overlying erythema and warmth that may suggest an alternative diagnosis
  • Examine for regional nodes (axillary, clavicular, etc.)
  • Fibrocystic changes feel doughy with vague nodularity
  • Nodules are typically discrete and mobile
  • Usually more marked in the superior and lateral quadrants
  • Small groups of cysts often described as palpating a "plate full of peas"пїЅ
  • Large cysts have consistency of a balloon filled with water
  • Breast exam is most sensitive 7-9 days after 1st day of menses when the breasts are least congested

Diagnosis Tests & Interpretation

Lab

  • A detailed lab evaluation is usually not necessary in the emergency department
  • Prolactin and thyroid-stimulating hormone may be helpful if galactorrhea is present

Imaging

  • Ultrasound if <30 yr old
  • Mammography if >30 yr old
  • Ultrasound:Can differentiate cystic from solid massesBenign cysts:Typically demonstrate a uniform outer margin without asymmetry or irregular thickness of the cyst wallHave no central echoesPosterior wall enhancement is normalCan assist in aspiration of deep and nonpalpable cystsAlso used to conservatively follow cyst sizePerformed at a specialized breast center with trained techs and interpreting radiologists
  • Mammography:Benign changes may falsely appear malignantDifficult to interpret in women <30 yr old due to breast tissue densityShould be performed either before aspiration or 7-10 days afterward to avoid artifact

Diagnostic Procedures/Surgery

  • Fine needle aspiration:Usually performed by a specialistMay be performed therapeutically for symptomatic or large massesAllows differentiation between cystic and solid massesObtain cytology studies to evaluate for malignancy
  • Excisional biopsy:Performed by surgeonIndicated for solid lumps that are not proven benign

Differential Diagnosis

  • Benign breast masses:Breast abscessDuct ectasiaMastitisSimple fibroadenomasSolitary papillomas
  • Malignant breast masses:Atypical hyperplasiaComplex fibroadenomasDiffuse papillomatosisDuctal hyperplasia without atypiaSclerosing adenosis

Treatment

Ed Treatment/Procedures

  • Majority of women will not require any medical treatment
  • Conservative therapy:Support bra:Reduces tension on supporting ligaments of the breastMay reduce inflammatory response and edemaLow dose diuretic for 2-3 days before onset of mensesNSAIDs
  • Dietary changes are somewhat controversial:Restricting dietary fat (to 25% of total calories) and eliminating caffeineIncreasing vitamin E and vitamin B6Herbal preparations such as primrose oil
  • Hormonal therapy:Should be initiated by PCP to enable follow-up during course of treatmentOral contraceptives:May decrease symptoms, particularly after 1 yr of useDanazol (synthetic androgen) and Tamoxifen (partial estrogen antagonist):Shown to be equally effective for treatment of severe cyclical mastalgiaUse may be limited by side effects (acne, hirsutism, weight gain, teratogenicity)Bromocriptine (inhibits prolactin production):Use also limited by side effects (headache, dizziness, nausea, constipation, weakness)
  • Surgical intervention:If a persistent nodule exists, excision is recommended regardless of findings on diagnostic imagingIf a large cyst recurs after aspiration on 2 occasions, it should be excised and sent for pathology

Medication

  • Bromocriptine: 2.5-5 mg/d BID
  • Danazol: 100-400 mg/d BID for 6 mo
  • Tamoxifen: 10-20 mg/d
  • Oral contraceptive pills (vary)

Follow-Up

Disposition

Discharge Criteria

  • Patients with fibrocystic changes are appropriate for discharge with outpatient follow-up
  • Encourage patient to keep a breast pain record to determine whether pain is cyclic
  • The importance of follow-up should be stressed to ensure patient health, disease prevention, and patient satisfaction
  • Encourage regular breast self-exam, annual physical exams, and annual mammograms when appropriate

Issues for Referral

  • Practically speaking, all breast masses evaluated in the ED need referral to a primary provider or specialized breast clinic
  • Further investigation with imaging and possible biopsy are required for masses that persist throughout menses and are not cyclical
  • Referral to a general surgeon may be required in certain cases where tissue biopsy is necessary

Pearls and Pitfalls

  • Breast cancer may coexist with benign breast disease and fibrocystic changes:Consider all cancer risk factorsConfirm follow-up plan
  • Mastitis in a nonlactating patient should be treated as inflammatory carcinoma until proven otherwise
  • Fibrocystic changes are usually bilateral; unilateral changes are suspicious for cancer
  • Fear of breast cancer is high in all patients:Give reassurance that fibrocystic breast changes are not cancerousHave a low threshold for referral to a specialist

Additional Reading

  • Grube пїЅBJ, Giuliano пїЅAE. Benign breast disease. In: Berek пїЅJS, ed. Berek & Novaks Gynecology. 14th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:652-654.
  • Institute for Clinical Systems Improvement (ICSI). Diagnosis of Breast Disease. Bloomington, MN: Institute for Clinical Systems Improvement; 2005.
  • Katz пїЅVL, Dotter пїЅD. Breast diseases: Diagnosis and treatment of benign and malignant disease. In: Lentz пїЅGM, Lobo пїЅRA, Gershenson пїЅDM, et al., eds. Comprehensive Gynecology. 6th ed. Philadelphia, PA: Elsevier; 2012:304-306.
  • Marchant пїЅDJ. Benign breastdisease. Obstet Gynecol Clin North Am. 2002;29:1-20.
  • Parikh пїЅJR. ACR appropriateness criteria on palpable breast masses. J Am Coll Radiol. 2007;4:285-288.
  • Parikh пїЅJR, Evans пїЅWP, Bassett пїЅL, et al. Expert Panel on Women's Imaging-Breast. Palpable Breast Masses. Reston, VA: American College of Radiology (ACR);2006.
  • Rastelli пїЅA. Breast pain, fibrocystic changes, and breast cysts. Probl Gen Surg. 2003;20:17-26.
  • Santen пїЅRJ, Mansel пїЅR. Benign breast disorders. N Engl J Med. 2005;353:275-285.

Codes

ICD9

  • 610.1 Diffuse cystic mastopathy
  • 610.2 Fibroadenosis of breast
  • 610.9 Benign mammary dysplasia, unspecified

ICD10

  • N60.19 Diffuse cystic mastopathy of unspecified breast
  • N60.29 Fibroadenosis of unspecified breast
  • N60.99 Unspecified benign mammary dysplasia of unspecified breast
  • N60.11 Diffuse cystic mastopathy of right breast
  • N60.12 Diffuse cystic mastopathy of left breast
  • N60.1 Diffuse cystic mastopathy
  • N60.21 Fibroadenosis of right breast
  • N60.22 Fibroadenosis of left breast
  • N60.2 Fibroadenosis of breast
  • N60.91 Unspecified benign mammary dysplasia of right breast
  • N60.92 Unspecified benign mammary dysplasia of left breast
  • N60.9 Unspecified benign mammary dysplasia

SNOMED

  • 27431007 fibrocystic breast changes (finding)
  • 23260002 Fibroadenosis of breast (disorder)
  • 57993004 Benign mammary dysplasia (disorder)