Breast

Fibrocystic changes

Nonproliferative fibrocystic changes



Last author update: 15 February 2022
Last staff update: 15 February 2022

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PubMed Search: Fibrocystic breast disease[TI]

Apeksha N. Agarwal, M.B.B.S., M.D.
Daniel D. Mais, M.D.
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Cite this page: Agarwal AN, Mais DD. Nonproliferative fibrocystic changes. PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/breastfcc.html. Accessed July 3rd, 2022.
Definition / general
  • Nonspecific, general term to describe a range of common and benign breast conditions, which may occur together or in isolation
  • Cause clinical, radiographic (e.g. calcifications, mass or architectural distortion) or histologic changes of the breast tissue that may result in concern for malignancy
  • Nonproliferative and nonatypical fibrocystic changes are not associated with increased risk of subsequent breast carcinoma
  • Some proliferative fibrocystic changes are associated with a slightly increased risk of subsequent breast carcinoma
Essential features
  • Histologically benign structural alterations in epithelial and stromal elements
Terminology
ICD coding
  • ICD-10: N60.19 - diffuse cystic mastopathy of unspecified breast
Epidemiology
Sites
  • Breast
  • Can occur in axilla from the accessory breast tissue
Pathophysiology
  • Excess estrogen leads to proliferation of epithelium in terminal duct lobular units and induces stromal fibrosis
  • Fibrosis and epithelial proliferation may lead to obstruction of ducts and acini, leading to involution or cyst formation
  • Some cysts may rupture, inducing adjacent fibroinflammatory stromal reactions
  • Reference: J Adv Sci Res 2020;11:30
Etiology
Diagrams / tables

Images hosted on other servers:

Breast tissue with cysts

Clinical features
  • Breast pain, tenderness, lumpiness, cysts or mass
  • Manifestations may be cyclic, reflecting menstrual cycle
  • Associated with polycystic ovary syndrome (Arch Gynecol Obstet 2009;280:249)
  • Usually bilateral, although one breast may be affected more than the other
  • Symptoms tend to abate after menopause
    • Nonproliferative lesions are the most common finding in breast cancer screening biopsies, accounting for about 70% of all cases (N Engl J Med 2005;353:275)
Diagnosis
  • Needle biopsy, needle aspiration or excisional biopsy
Radiology description
  • Ultrasound: may be a solid mass, cyst, heterogeneous echogenic tissue or no visible abnormality (Invest Radiol 2005;40:436)
  • MRI: mass or a nonmass-like regional enhancing lesion with benign enhancement kinetics (Invest Radiol 2005;40:436)
  • Can also present as densities with associated calcifications, areolar skin thickening alone or normal dense fibroglandular tissue with no abnormality on mammogram (Invest Radiol 2005;40:436)
Radiology images

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Increased fibroglandular density

Prognostic factors
  • Risk of breast cancer (Am J Surg Pathol 2003;27:836)
    • Nonproliferative lesions: no increased risk
    • Proliferative lesions without atypia: 1.5 - 2 fold risk
Case reports
Treatment
Gross description
  • Breast tissue is heterogeneously fibrous and indurated
  • Cysts ranging from 1 - 20 mm, clear or blue domed, may be seen
Gross images

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Cysts surrounded by fibrous tissue

Irregular fibrosis and small cysts

Fibrosis and dilated ducts

Microscopic (histologic) description
  • Nonproliferative fibrocystic changes; characterized by 3 features: adenosis, fibrosis and cyst formation
    • Adenosis:
      • Increased number of acini per lobule
      • Acini are lined by columnar cells, which may be benign or have atypia
      • Adenosis is frequently seen in pregnancy and may be focal in nonpregnant women
    • Fibrosis:
      • Stromal fibrosis
      • Cyst rupture may result in chronic inflammation, prominent histiocytic reaction and fibrosis
      • Causes increased density observed on imaging and nodularity observed on palpation
    • Cyst formation:
      • Cystically dilated ducts or lobules
      • May contain eosinophilic secretions, foamy macrophages and calcifications
      • Lined by cuboidal epithelium or may have apocrine metaplasia
      • Outer myoepithelial layer present but may be attenuated
    • Apocrine metaplasia: single or multilayered ductal epithelium with abundant granular eosinophilic cytoplasm, apical snouts, enlarged nuclei and prominent nucleoli
    • Columnar cell changes / columnar cell hyperplasia: enlargement of terminal duct lobule with variably dilated lumens and irregular contours, lined by cuboidal to columnar cells, lacking cytologic atypia, frequently with apical snouts
Microscopic (histologic) images

Contributed by Apeksha N. Agarwal, M.B.B.S., M.D.
Fibrocystic change

Fibrocystic change

Apocrine metaplasia

Apocrine metaplasia

Fibrosis, cysts and microcalcifications

Fibrosis, cysts and microcalcifications

Cysts

Cysts

Cytology description
  • Nonproliferative breast lesions
    • Apocrine cells, foam cells and small, uniform, evenly spaced ductal epithelial cells
  • Proliferative breast lesions
    • Sheets and tight clusters of cells without significant nuclear overlap
  • Reference: Clin Lab Med 2005;25:713
Cytology images

Contributed by Areej M. Al Nemer, M.D.
Fibrocystic change

Fibrocystic change

Fibrocystic change

Apocrine metaplasia

Sample pathology report
  • Breast, 12:00, microcalcifications, stereotactic core needle biopsy:
    • Benign breast parenchyma with fibrocystic changes, including florid usual type ductal hyperplasia and apocrine metaplasia
    • Microcalcifications associated with apocrine metaplasia
Differential diagnosis
  • Proliferative lesions without atypia:
    • Mild usual ductal hyperplasia:
      • Proliferation of ductal epithelium no more than 3 or 4 cell layers in thickness
    • Moderate to severe (florid):
      • Proliferation of ductal epithelium more than 4 cell layers in thickness that may fill and extend the luminal space
      • Arrangement of nuclei is haphazard, with cellular heterogeneity, oval nuclei with grooves and small indistinct nucleoli
    • Sclerosing adenosis:
      • Lobulocentric proliferation of acini within dense hyaline sclerotic stroma
      • Intraluminal calcifications may be present
  • Cystic fibroadenoma:
  • Pseudoangiomatous stromal hyperplasia:
    • Stroma with prominent slit-like spaces lined by bland spindle cells; the slit-like spaces are empty and have an anastomosing appearance
Board review style question #1
Which of the following is true about proliferative fibrocystic changes in the breast?

  1. Apocrine metaplasia is considered a proliferative fibrocystic change
  2. Duct ectasia is considered a proliferative fibrocystic change
  3. Proliferative fibrocystic change has no associated increased lifetime risk of breast cancer
  4. Proliferative fibrocystic change without atypia has an associated 1.5 - 2 fold increased lifetime risk of breast cancer
Board review style answer #1
D. Proliferative fibrocystic change without atypia has an associated 1.5 - 2 fold increased lifetime risk of breast cancer

Comment Here

Reference: Fibrocystic changes
Board review style question #2

A 40 year old woman presents with heterogeneous echogenic tissue in the breast on ultrasound. Which of the following is shown in the biopsy above?

  1. Atypical ductal hyperplasia
  2. Columnar cell change
  3. Duct ectasia
  4. Flat epithelial atypia
Board review style answer #2
B. Columnar cell change. The biopsy shows classic findings of fibrosis, cystic changes and microcalcifications along with the lining epithelium in a couple of cysts lined by columnar epithelium.

Comment Here

Reference: Fibrocystic changes
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