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Fibrocystic Breast Change

by Carlo Raj, MD
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    00:01 Our first topic here will be fibrocystic change, extremely important.

    00:05 Understand that we do not call this a disease and this definitely not a cancer.

    00:10 So two things that I’ve said here that is of utmost importance.

    00:13 Number one, it’s not a disease.

    00:15 It’s a change.

    00:17 Number two, it is not cancer.

    00:19 Learn that first.

    00:21 Why am I not calling it a disease? Approximately 50% of females in the reproductive age have this going on.

    00:28 Fibrocystic change.

    00:30 Thank goodness this isn’t breast cancer.

    00:32 In fact, the chance of going on to breast cancer are quite slim.

    00:37 Okay, it’s a change, not a disease.

    00:39 I’m not going to call this a tumor 50% of population.

    00:43 Young and we’ll talk about different histologic manifestations.

    00:49 Know this really well and, as a point of reference, you need to compare this with an important differential called an actual benign tumor and that will be a fibroadenoma.

    01:01 So in case your breast pathology is weak, I am going to give you the pinpoint diseases and differentials that you must know for the boards and before you walk into the wards.

    01:13 Diagnosed frequency: young female, 20 to 40.

    01:18 This would indicate reproductive age, right? Number two, what I’ll also do with you as we go through this is how we differentiate this from fibroadenoma.

    01:29 Guess what? A fibroadenoma found in a female would be pretty much in the same age range.

    01:36 So right now, there’s nothing distinguishing one from the other, but at least you have two differentials.

    01:42 Move on.

    01:43 There might be hormonal imbalances.

    01:46 You’ll find this fibrocystic change.

    01:48 You’ll find this with fibroadenoma.

    01:50 One is a tumor and one is not.

    01:52 Is fibrocystic change a tumor? No, it’s not.

    01:56 Is it a disease? No, it’s not.

    01:59 Will it go on to cancer? Not particularly.

    02:03 Hormonal imbalance.

    02:03 What does that mean to you? Every time she’s having her menstrual cycle, this change in a fibroadenoma will be responsive to the estrogen.

    02:14 So therefore, what I’m saying is, every time she’s having here menstruation, and at approximately the middle of her menstrual cycle where she is experiencing her LH surge and she has the most amount of estrogen at that point is where perhaps she might be feeling pain.

    02:30 Not always, but perhaps.

    02:32 You’ll look for menstrual following or correlation.

    02:37 Oral contraceptive pill use decreases the risk of fibrocystic change, okay? Meaning to say that now, you’re giving estrogen – Let me bring something to your attention.

    02:48 In pathology, whenever we say oral contraceptive pills, unless noted otherwise, you must understand that OCP in pathology as being part of management is going to contain estrogen.

    03:01 The last time you saw this was polycystic ovarian syndrome.

    03:04 You’re going to give a little bit of estrogen so that you can then create negative feedback.

    03:09 Is that clear? So when you know the fibrocystic change is responsive to estrogen, why not give estrogen or why not give oral estrogen in which you will then bring in about negative feedback and decreases the risk of fibrocystic change.

    03:25 I mean the change will be there, but you’re not going to have the major symptoms in the patient perhaps. Perhaps Does it work in every patient? No.

    03:34 Clinical features: It produces a palpable lump.

    03:37 You can actually feel it.

    03:39 Remember breast examination.

    03:40 You begin in the nipple and you move in a clockwise manner or whatever motion but circular.

    03:46 And you first start locally, keep moving out, keep moving out.

    03:50 And I don’t mean you just touch it lightly.

    03:52 You’re looking for a tumor, my goodness, in the breast, right? in the breast, right? So therefore you need to make that you palpate firmly and purposely.

    04:01 And as you do so, maybe perhaps you’ll feel a lump, which at this point is concerning, and then you take a proper history in your patient.

    04:09 And you start thinking about -- Well, you’re taking the exam, and so there will be enough information in the history of the stem, which will tell you as to whether not the lump is either benign such as a change or fibroadenoma or they’ll give you certain things in which you’re thinking, “ "Oh, my goodness.

    04:28 Is my breast tumor or this palpable structure that I’m feeling malignant?” Now, let’s go on.

    04:35 It may produce mammographic densities or calcifications.

    04:38 Stop here.

    04:40 Fibrocystic change.

    04:41 Is this a disease? No.

    04:43 Is this a cancer? No.

    04:46 If you find calcification, yes, you’re concerned about cancer.

    04:50 But the history so far, reproductive age, young estrogen sensitive they’ll have to give you something about histology, which I have not touched yet, but I need to in greater detail.

    05:02 It may produce nipple discharge and that nipple discharge, well, it could be clear, very rarely would it be bloody, but just keep that in mind.

    05:10 Some type of fluid coming out of the nipple and I’ll talk to you more about nipple discharges.

    05:15 Could it be bloody? Could it be milk? Galactorrhea, okay? Or could it be just fluid? Or could it be purulent.

    05:21 Remember, acute mastitis? The baby biting on the nipple, introducing organism, acute mastitis.

    05:29 There, you would have a purulent type of discharge.

    05:32 That discharge from the nipple tells you quite a bit.

    05:35 Discharge in general.

    05:37 Firbrocystic change and morphology.

    05:39 Now here, I’ll walk you through a table which will give you the details, but allow the name to speak to you.

    05:47 Fibrocystic change.

    05:50 Right off the bat, it gives you two major differentials, fibrosis or cystic.

    05:57 I’ll talk to you more about the cystic.

    05:59 A cyst.

    06:01 What’s the definition of a cyst? Fluid accumulation.

    06:05 You’re never going to find this in fibroadenoma.

    06:08 And fibroadema is a tumor. It’s solid.

    06:12 And, well, fibroadenoma will be located way back in the stroma.

    06:16 Now at some point I’ll walk you through, as I told you, the clinical anatomy for breast so that you’re clear about what you’re looking for.

    06:23 At this point, a cyst formation could be possible.

    06:26 And if there’s fluid in here, with your naked eye, gross examination.

    06:30 If you take a look at the breast, which has fluid accumulation, it looks like – “ "Hey, doc. I think I got a bruise on my breast.” So it looks blue, okay? It looks like a bruise.

    06:41 You call this a blue dome cyst, but you’ll know better.

    06:43 It might be a fibrocystic change.

    06:46 Epithelial changes especially -- now, this cyst in which it’s accumulating fluid, you must know the details.

    06:54 Meaning to say that within the cyst and epithelial cells, remember this is a true cyst.

    06:59 What’s the definition of a true cyst? It’s a structure that is lined by epithelium.

    07:05 In this case, it’s going to secrete fluid.

    07:08 So what type of epithelium is then here going to secrete fluid? This is called apocrine metaplasia.

    07:15 Commit that to memory.

    07:17 Apocrine or those type of cells that are responsible for secreting the fluid here in the cystic type of histology of fibrocystic change.


    About the Lecture

    The lecture Fibrocystic Breast Change by Carlo Raj, MD is from the course Breast Disease. It contains the following chapters:

    • Fibrocystic Change
    • Clinical Features of Fibrocystic Change
    • Morphology of Fibrocystic Change

    Included Quiz Questions

    1. Mid-cycle LH surge
    2. Menstruation
    3. Luteal phase
    4. Secretory phase
    5. Proliferative phase
    1. Negative feedback for endogenous estrogen production
    2. Increased circulating levels of estrogen
    3. Suppression of lactation
    4. Suppression of ovulation and resulting progesterone release
    5. Increased circulating levels of progesterone
    1. Purulent nipple discharge
    2. Palpable lumps
    3. Clear nipple discharge
    4. Mammographic calcification
    5. Bloody nipple discharge
    1. Cysts are always filled with fluid.
    2. They are true cysts.
    3. Cysts may resemble a bruise on the breast.
    4. They are lined by epithelium.
    5. They are associated with apocrine metaplasia.

    Author of lecture Fibrocystic Breast Change

     Carlo Raj, MD

    Carlo Raj, MD


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