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INDICATIONS FOR SURGICAL TREATMENT OF FIBROCYSTIC CHANGES OF THE BREAST

Authors: Mihaela Avram, D. Koukoulas, I. Avram, Ana-Maria Maxim, M. Teodorescu, J. Avram, Alis Dema, Sorina Taban, Marioara Corianu

Received for publication: 2009-09-14
Revised: 2009-10-20

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INTRODUCTION

Fibrocystic changes of the breast (FCC) is a benign lesion that presents itself in various pathological, imagistic and clinical forms. The illness benefits of nutritional and medical treatments but the effectiveness of these therapies and the clear elimination of the menace of cancer did not reach yet “the gold standard“.

In the case of malignancy suspicion or in the case of cysts that reappear or do not disappear completely after fine needle aspiration the surgical treatment is recommended. In this situation the surgery is a conservative one, limited to obtaining a tissue fragment for pathological exam, its size depending upon the clinical and imagistic aspect of the lesion. The election of the surgical method depends upon the requests of the doctors that performed the imagistic diagnostic and upon the experience of the surgeon. Mainly there are “fine needle aspiration“ , “core needle biopsy“ and “excisional (open) biopsy“, “lumpectomy”. We analyzed the characteristics of the patients with fibrocystic changes of the breast in order to evaluate the possible utility of this technique. By comparing patients with FCC admitted in County Hospital Timisoara over a period of 5 years with the patients treated during the same period in one surgical clinic of this hospital we aimed to establish the right time for surgical treatment of FCC.

MATERIAL AND METHODS

A comparative retrospective study of patients with fibrocystic changes of the breast (FCC) was conducted for the patients admitted in the Timisoara County Clinical Emergency Hospital (SCJUT) in the 5 years period 2004 – 2008 and for the patients treated in the 1st Surgery Clinic of the SCJUT Hospital. The study included a number of 622 female patients having the main or secondary diagnosis of FCC. 27,65% (172 cases) were treated surgically for FCC, from these, 89 were treated in the 1st Surgery Clinic.

RESULTS

By comparing the ages of all 622 patients with FCC as main and secondary diagnosis treated in SCJUT Hospital (Fig.1) with the ages of the 89 patients treated for FCC in the 1st Surgery Clinic of the SCJUT Hospital (Fig.2) we found that:

•  In the SCJUT lot of patients FCC was most frequent in the 50-59 age group and the 40-49 age group, both age groups being almost equal as number
•  In the 1st Surgery Clinic of the SCJUT Hospital lot FCC was more frequent in the 40-49 age group
• We analyzed the symptoms accused by the patients upon admittance and we found that:
•  the SCJUT Hospital lot with FCC: 82% had no subjective symptoms upon admittance in the hospital, 10% accused permanent mastalgia, 7% had cyclical mastalgia and 1% presented a history of nipple discharge (Fig.3)
•  the 1st Surgery Clinic lot with FCC: 37% had no subjective symptoms upon admittance in the hospital, 16% accused permanent mastalgia, 43% had cyclical mastalgia and 4% presented a history of nipple discharge (Fig.4).

In the 1st Surgery Clinic imagistic investigations of the breast were performed mainly before admittance in the hospital. These exams were: breast ultrasound (all patients), mammography (72 patients), MRI of the breast (4 patients). The results of the imagistic exams, reported as BI-RADS (Breast Imaging Reporting and Data System) categories were (Fig.5):

•  BI-RADS 0 (assessment incomplete) and BI-RADS 1 (negative) – no patients
•  BI-RADS 2 – benign– 29 patients (32.58%)
•  BI-RADS 3 – probably benign (<2% malignancy chance) – 40 patients (44.94%)
•  BI-RADS 4 - suspicious abnormality (23%-34% malignancy chance) – 20 patients (22,47%)
•  BI-RADS 5 (highly suspicious of malignancy) and BI-RADS 6 ( known biopsy-proven malignancy) - no patients

The surgical treatment applied to the patients with FCC was lumpectomy or sectoral mastectomy under general i.v. anesthesia. The lesion removed was sent to frozen intraoperative pathological examination. The lesion was found to be benign in 63 patients and no further surgical treatment was performed. The result was malignancy (26 patients) mastectomy and axillary lymph node dissection was performed. The paraffin-embedded sections examinations confirmed in all cases the benign or malign characters established by the intraoperative pathological exam.

By comparing the pathological exams results with the preoperative imagistic diagnosis we observed that:

•  BI-RADS 2 category -29 patients. Postoperatory pathological findings: 16 were FCC and 13 associated fibroadenoma
•  BI-RADS 3 category -40 patients. Postoperatory pathological findings: 33 were FCC and 7 (17.5% ) were FCC and breast cancer
•  BI-RADS 4 category - 20 patients. Postoperatory pathological findings: 1 was FCC and the other 19 (95%)were FCC and breast cancer

DISCUSSIONS

The treatment of FCC is not well settled by guidelines. The medical treatment uses a vast arsenal of drugs in order to relieve the mastalgia as well as the lumpy consistency of the breast. The drugs used are various: topical progesterone gel (although the success rate of this therapy is not known), topical anti-inflammatory drugs which are efficient in reducing mastalgia (1) Danazol (7-alfa-etinil testosterone) which treats mastalgia and reduces the size of cysts (2), Bromocriptine which reduces mainly the breast tenderness but does not influence the clinical symptoms(3), Oenothera Biennis extract which reduces mastalgia with 50% (4), Tamoxifene, which treats mastalgia in up to 100% cases, improves clinical features and prevents recurrence of FCC (5).

The question is when the time is and which is the place for the surgical treatment of FCC? Should it only be used as a diagnostic mean or are there times in which it is required as a treatment? Invasive diagnostic measures for FCC vary from fine needle aspiration, to open biopsy and lumpectomy. In the last years new methods were introduced for interventional treatment of FCC (Advanced Breast Biopsy Instrumentation –ABBI-and minimally Invasive Breast Biopsy -MIBB-), to guide with stereotaxic control the surgical instruments (large core needle or cannula) and even to remove lesion up to 20mm in size. Useful in nonpalpable breast lesions, the indications of these techniques are still controversial, as some of the patients who underwent these methods required further surgical treatment. Also the post interventional rate of complications is superior to the rate of complications after open surgery.(6)

In the lot we have studied we noticed that the patients who received surgical treatment were younger than those treated conservatory. This raises the question if FCC in younger patients needs to be treated surgically more often than FCC in older patients. In order to solve this problem we should also take into consideration the fact that in recent years breast cancer in women under 40 years seems to be a different entity than cancer in older women, as it has genetic and prognosis particularities. (7)

Comparing the two lots we noticed that breast pain was more frequent in women receiving surgical treatment for FCC compared to all women with FCC admitted in SCJUT Hospital, leading to the conclusion that mastalgia resistant to medical treatment determined the choice of surgical treatment.

In the 1st Surgery Clinic lot intraoperative frozen section pathological examination was performed in all cases and the diagnosis corresponded, in all cases, with the paraffin embedded pathological diagnosis. Frozen section intraoperatory examination is not accepted by all for FCC, due to a lack of concordance with the paraffin embedded pathological diagnosis. (8) In our lot the concordance between the two types of diagnosis was 100% .

We also observed the fact that the rate of carcinoma in patients with FCC in 1st Surgical Clinic was greater than expected taking into consideration the BI-RADS preoperatory category. This fact is probably due to the characteristics of FCC, as the fibrosis present might imagistic hide breast cancer (9).

CONCLUSIONS

In conclusion, the surgical treatment of FCC was mainly applied in younger patients, with mastalgia but also for diagnostic reasons in patients without a certain diagnosis of benignity after clinical and imagistic examinations. The concordance between the intraoperative frozen section pathological examination and the paraffin embedded pathological diagnosis, performed by The Pathology Department of SCJUT, was 100% in the 1st Surgical Clinic lot. For the FCC patients in the 1st Surgical Clinic, in the category BI-RADS 3 lesions 17,5% had breast cancer and in the category BI-RADS4 lesions 95% had breast cancer, these figures show the difficulties in diagnosing breast cancer in patients with FCC which might lead to the delay of diagnosis of breast cancer.

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