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Fibrocystic Breast Disease (Proliferative Breast Changes, Fibrocystic Changes)

Nodularity in the breasts of most adolescents and young adults is associated with benign, proliferative breast changes or, in less-preferable terminology, fibrocystic changes. Although the prevalence in adolescents is unknown, the prevalence of this condition, if breasts were examined carefully, is probably more than 50% in women of reproductive age. As many as 90% of women of all ages have histologic changes consistent with "fibrocystic disease" at autopsy. This condition is so common that it is considered by some authorities to be a "nondisease." Benign breast changes is a better term than fibrocystic disease.

Although the precise cause of benign proliferative breast changes is unknown, an imbalance between estrogen and progesterone has been implicated. Estrogen induces proliferation of breast tissue, which includes ductal alveolar epithelium and stroma, whereas progesterone counteracts these proliferative effects, leading to epithelial differentiation and a reduction of mitoses. With a higher estradiol-to-progesterone ratio, connective and epithelial tissue proliferation occurs. Some women with proliferative breast changes also have obstruction and persistent secretory material in the alveoli and terminal ducts. Over time, this can lead to alveolar enlargement and cyst formation.

Proliferative breast changes in women usually correlate with an individual's age. In adolescents and young women, most clinical manifestations involve minimally symptomatic fibrotic changes that usually involve the upper, outer quadrants of the breasts.

In most instances, proliferative breast changes are discovered as painless lumps during examination or because of a complaint of pain or discomfort. The symptoms usually are most

Although adolescents may be concerned about the risk for breast cancer, the risk does not seem to be high in adolescents; however, in rare women with proliferative lesions with atypia, a fivefold increased risk for breast cancer exists.

Patients with proliferative breast changes have been treated with many modalities. In most adolescents, the symptoms are sufficiently mild not to require aggressive therapy. Supportive measures include well-padded brassieres in addition to mild analgesics. Hormonal modalities have included oral contraceptive pills (OCPs) and medroxyprogesterone acetate (Provera). OCPs have been reported to help 70% to 90% of women, whereas medroxyprogesterone, 10 mg on days 15 to 25 of the menstrual cycle, has had success in as many as 85%.

Fibroadenomas involve a benign neoplasm of the mammary gland that microscopically has stromal proliferation surrounding aggregates of compressed or uncompressed, elongated, and distorted ducts. Although fibroadenomas are classified as benign neoplasms, they can almost be considered an aberration of normal development. Four types of fibroadenomas exist: (1) common fibroadenomas, (2) giant fibroadenomas, (3) juvenile fibroadenomas, and (4) phyllodes tumors. Common fibroadenomas are the most prevalent breast tumor found in adolescents on surgical reports. Extensive reviews of fibroadenomas in adolescents have been published.

Adolescents commonly discover fibroadenomas while bathing or during self-examination. Usually, no other associated symptoms exist; however, some adolescents have breast discomfort during menstruation or pregnancy. The average duration of symptoms before diagnosis is 5 months.

Fibroadenomas usually have a firm, rubbery feel on examination, are mobile, nontender, and have well-demarcated borders. These lesions are usually easy to differentiate from the surrounding breast tissue. Usually, only one fibroadenoma is present, although 10% to 25%.

Diagnosis usually can be made with a combination of clinical examination; sonography; and fine-needle aspiration (FNA) cytology, core biopsy, or excisional biopsy. Treatment for fibroadenomas involves elective surgical excision or careful follow-up, especially when a diagnosis has been confirmed by FNA cytology. The decision about surgery in adolescents with fibroadenomas diagnosed by examination, sonography, FNA, or core biopsy is based on size and breast cancer concerns of the adolescent and family.

Some fibroadenomas, juvenile and giant fibroadenomas, have a much more rapid growth with a greater degree of stromal cellularity and the potential to grow to a large size, usually more than 5 cm in diameter. Giant fibroadenomas, although uncommon, are more common in young and black adolescents. Compression of adjacent breast tissue may occur because of the rapid and asymmetric growth pattern. In addition, the area may feel warm because of the increased blood supply of the tumor and may be associated with dilated superficial veins and thinning.

Phyllodes tumors (cystosarcoma phyllodes) are the least prevalent cause of massive breast lesions in adolescents, with a prevalence of 0.4% in the author's review. Adolescents with this condition usually present with bulky breast masses.

Phyllodes tumors in female adolescents have been reviewed by Briggs et al. In this series of nine adolescents, the chief complaint in all teens was of recent onset of a rapidly growing.