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Fibrocystic Changes of the Breast (FCC)

BASICS

  • Benign epithelial lesions: nonproliferative and proliferative with/without atypia
  • FCC is not a disease but common benign epithelial histologic changes
  • Seen clinically in up to 50%, histologically up to 90% of women
  • Symptoms: cyclic pain, tenderness, swelling, fullness; often bilateral, upper outer quadrant common
  • Histology: macrocysts, microcysts, adenosis, sclerosis, apocrine metaplasia, stromal fibrosis, epithelial hyperplasia
  • Classification by epithelial hyperplasia presence: nonproliferative, proliferative without atypia, proliferative with atypia
  • Nonproliferative FCC not associated with increased breast cancer risk

EPIDEMIOLOGY

  • Occurs mostly in women aged 25-50 years
  • Rare <20 years old
  • Peaks in 4th decade (hormonal peak), decreases after menopause unless on hormone therapy

ETIOLOGY AND PATHOPHYSIOLOGY

  • Exaggerated stromal and epithelial response to estrogen, progesterone, and growth factors
  • Cyst formation via lobular acini dilatation or duct obstruction

RISK FACTORS

  • Methylxanthine-containing substances (coffee, tea, cola, chocolate) may worsen symptoms (no direct causality)
  • Diet high in saturated fats may increase risk

COMMONLY ASSOCIATED CONDITIONS

  • Proliferative FCC with atypia increases breast cancer risk

DIAGNOSIS

History

  • Personal/family history of breast disease (benign or malignant)
  • Family history of breast/ovarian cancer and known genetic mutations (BRCA1/2, PALB2, CHEK2, others)
  • Symptoms: breast pain, swelling, nipple discharge, lumps, skin changes, tenderness
  • Cyclic mastalgia common

Physical Exam

  • Inspect breast with arms at sides and overhead for asymmetry, dimpling, nipple retraction
  • Palpate breasts and axillae systematically; assess for masses, nodularity, skin changes
  • Examine opposite breast first
  • FCC breast tissue ranges from mild texture changes to dense nodularity

Differential Diagnosis

  • Causes of pain: mastitis, costochondritis, neuralgia, breast cancer, angina, GERD
  • Masses: fibroadenoma, lipoma, sebaceous cyst, phyllodes tumor, fat necrosis
  • Skin changes: eczema, Paget disease, infection

Diagnostic Tests

  • Mammography: nodular densities, cysts, calcifications; less sensitive in dense breasts <35 years
  • Ultrasound: differentiates cystic vs solid lesions; simple cysts anechoic, thin-walled
  • MRI: indicated in high-risk patients (BRCA mutation carriers, dense breasts)
  • Fine-needle aspiration: diagnostic and therapeutic; straw-colored or dark fluid; cytology for malignancy

Histopathology

  • Nonproliferative: relative risk breast cancer 1.2-1.4
  • Proliferative without atypia: risk 1.7-2.1
  • Proliferative with atypia: risk ≥4

TREATMENT

  • Often no treatment needed after ruling out malignancy
  • Symptomatic relief: cool compresses, supportive brassiere, avoid trauma
  • Dietary caffeine reduction, vitamin E, evening primrose oil (efficacy unproven)

Medication

  • First-line: analgesics/NSAIDs (oral/topical) for pain
  • Second-line: oral contraceptives may modulate symptoms
  • Severe pain: danazol (androgenic, hepatotoxic, teratogenic risks), tamoxifen (risk of thromboembolism, endometrial carcinoma)

ISSUES FOR REFERRAL

  • Women <30 years with persistent/non-simple cysts: ultrasound then surgical referral
  • Women >30 years: mammography ± ultrasound then surgical referral

SURGERY/PROCEDURES

  • Aspiration for cysts (diagnostic/therapeutic)
  • Core needle biopsy with vacuum assistance for suspicious lesions

COMPLEMENTARY & ALTERNATIVE MEDICINE

  • Vitamin E and evening primrose oil used anecdotally for mastalgia

ONGOING CARE

  • FCC is benign, chronic, recurrent
  • Follow-up individualized; US useful for differentiation in <35 years
  • Screening mammography per guidelines (USPSTF, ACOG, ACS)

DIET

  • No proven role of caffeine reduction; some patients report symptom relief

PATIENT EDUCATION

  • Patient resources: Mayo Clinic, National Cancer Institute, American Cancer Society websites

PROGNOSIS

  • Benign condition with low but variable cancer risk based on histology
  • Symptoms often improve after menopause unless hormone therapy

COMPLICATIONS

  • Increased breast cancer risk in proliferative FCC with atypia

REFERENCES

  1. Pearlman M, Griffin J, Swain M, et al. Practice Bulletin No. 164: diagnosis and management of benign breast disorders. Obstet Gynecol. 2016;127(6):e141-e156.
  2. Hartmann LC, Sellers TA, Frost MH, et al. Benign breast disease and the risk of breast cancer. N Engl J Med. 2005;353(3):229-237.
  3. Srivastava A, Mansel RE, Arvind N, et al. Evidence-based management of mastalgia: a meta-analysis of randomised trials. Breast. 2007;16(5):503-512.
  4. Bruening W, Fontanarosa J, Tipton K, et al. Systematic review: comparative effectiveness of core-needle and open surgical biopsy to diagnose breast lesions. Ann Intern Med. 2010;152(4):238-246.

CODES

  • ICD10:
  • N60.19 Diffuse cystic mastopathy, unspecified breast
  • N60.09 Solitary cyst of unspecified breast
  • N60.29 Fibroadenosis of unspecified breast

CLINICAL PEARLS

  • FCC is a spectrum of histopathologic benign breast changes common in reproductive-aged women.
  • The term "fibrocystic disease" is a misnomer.
  • Atypia increases breast cancer risk and requires further diagnostic workup.
  • NSAIDs are first-line for symptom relief; OCPs, danazol, and tamoxifen are second-line with notable adverse effects.
  • Breast specialist consultation recommended for refractory symptoms or diagnostic uncertainty.