Benign Breast Disease

BREAST CYSTS

Many women (approximately 7%) present at some time during their lives to their doctor with a palpable breast cyst. Cysts are most common in the perimenopausal age group, declining in incidence after the menopause.

It is possible that cystic disease has a hormonal aetiology. It is very often bilateral in nature and the relationship to the menopause and response of cystic disease to endocrine treatment provide indirect evidence that this is the case. They start usually in the small terminal ducts probably by excessive secretion and progressive dilatation resulting in microcysts. The lining cells of the cyst wall secrete fluid, which makes up the fluid in the cyst. Some studies have suggested that essential fatty acid levels in the plasma of patients with cysts may be lower than in the general population. However, the exact aetiology as to the relationship with the development cysts is unknown.

Pathogenesis:
They develop as result of involution of breast tissue which starts in the late 20's and and early 30's and may last for over 20 years. Involution is the process where the tissue between the lobules (stromal tissue) is replaced by fibrous tissue and the regression of the cells lining the lobules. Lobules are the basic unit of tissue, which make up breast. When there is a minor aberration in this normal process it leads to the formation of microcysts. They result from the kinking or compression of the ducts by this fibrous tissue or by the active secretion of fluid from the cells. The enlargement of microcysts leads to the development of macrocysts.

Clinical presentation:
They often do not cause any symptoms in many women. Patients become aware of breast lump accidentally. In other cases they can cause pain probably increase in size or leakage fluid into the surrounding tissues causing secondary irritation. Even a small increase in volume for unknown reasons has disproportionate effect in pressure inside the cyst resulting in pain. This explains the fact that symptoms improve after aspiration of fluid from it. Multiple cysts are frequently not felt due to the laxity of the cyst and they easily merge with the surrounding breast tissue. When one or few of the cyst increase in size they can be so tense they feel hard to feel on occasion simulating carcinoma. Clinically, may be fluctuate. Occasionally, non-fluctuant cysts may resemble a carcinoma. Pain can be a presenting symptom and the history is of short and rapid onset. The total number of palpable breast cysts varies greatly between individual women, the majority however developing only a single cyst, 30% having between two and five cysts and the remainder more than this number.

Click here to see Management protocol for Breast cysts

Clinical Management:
All patients over the age of thirty-five years should have a mammogram prior to aspiration because a small percentage of patients may have an incidental carcinoma. Fine needle aspiration also has the potential to distort radiographic images and make interpretation of films difficult. If the mammogram shows no suspicious abnormality, then cysts may be aspirated with a wide bore needle to dryness. They are commonly performed under ultrasound guidance. It can also be performed in the clinic once a diagnosis is established and the cyst is palpable. There is little value in sending the fluid to cytology unless it is bloodstained. The clinician must make sure that there is no mass present following aspiration and, if this is the case, further assessment will be necessary. In those circumstances the fluid is sent for microscopic testing and a core biopsy may also be performed to rule out cancer. It is useful to review the patient six weeks after aspiration to make sure that there is no re-accumulation and if so a repeat aspiration may be performed. Repeated accumulation should be viewed with suspicion and the patient may need excision.

Cysts and Cancer:
There is a small but perceptible increased risks of patients with breast cysts developing carcinoma and debate continues concerning more regular screening of these patients. It is not the cysts per se pre malignant but the entire breast is said to be at risk and the cyst being a marker of high risk. However they are invalidated reports and it is reasonable to conclude that at present there is no indication for regular follow up of patients with breast cysts.

Follow up:
Once cancer is ruled out the patients are reassured with all the information about cysts. If a cyst is aspirated then patient is reassessed again for re aspiration if it is causing symptoms. They are then discharged with the advice to come back if new lumps appear. They are also advised to do self-examination regularly so that they familiarise what is normal for them. They are also advised to be in the national screening programme if they are in the appropriate age group.
Regular follow up in the breast clinic is usually not done unless the patient has

1. History of breast cancer in the family.
2. A solitary cyst rather than multiple cysts.
3. Other risks of breast cancer

Patients with multiple cysts may be helped occasionally with Danazol particularly if there is mastalgia associated with the cyst formation but the majority of patients with multiple cysts probably do not need regular treatment or aspiration unless there are symptoms.

Nodularity:
Nodularity in the breasts may be diffuse or focal. Premenstrual nodularity is so common a clinical finding that it is considered normal and patients under the age of thirty-five years should be reassured whilst those patients over the age of thirty-five years should have a mammogram which, if normal, will provide reassurance for the majority of women. Focal nodularity is one of the most common presenting symptoms to the breast clinic in women up to the age of fifty. Most of the changes that occur are part of normal breast involution and there may be areas of fibrosis or adenosis, cyst formation or epocrine change, all of which are entirely benign. Only rarely is focal pathology discovered, for example, sclerosis, epithelial hyperplasia or cancer. Patients should have an ultrasound of the lesion if they are under the age of thirty-five and fine needle aspiration cytology should be undertaken if a discrete lesion is found. For patients over the age of thirty-five, a mammogram is also essential and fine needle aspiration cytology of the area should also be taken whether there is a discrete mass or not. If all the investigations are normal, the patient may be discharged with confidence but an open appointment for review should be offered.

If you require further advice or information please contact the
Macmillan Breast Care Nurses, Hazel Ricard and Hilary Rickwood on 020 8565 5885

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