https://www.iheartpathology.net/post/fibrocystic-breast-disease

“Fibrocystic changes of the breast” is the wastebasket term for benign breast conditions characterized by fibrosis, cysts, inflammation, and a host of other benign changes.

Fibrocystic changes of the breast are NONPROLIFERATIVE and have NO increased risk of cancer in and of themselves.

Common Findings in Fibrocystic Changes

Irregular, cystically dilated ducts/lobules

-Cysts are lined by uniform benign cuboidal to columnar epithelial cells

Intervening stromal fibrosis

Microcalcifications

Histologic Patterns of FCC

• • Cyst formation/Duct ectasia

    • • Stromal Fibrosis

      • Pseudoangiomatous Stromal Hyperplasia (PASH)

      • Sclerosing adenosis (adenosis= increased number of acini per lobule)

      • Apocrine metaplasia (large, tall, columnar epithelial cells with abundant pink cytoplasm lining the cysts, may be vacuolated)

      • Columnar Cell Changes

  • Squamous Metaplasia

  • Fibroadenomatoid changes

  • Flat epithelial atypia

  • Collagenous spherulosis

Stromal fibrosis in the breast is a pathologic entity characterized by proliferation of stroma with obliteration of the mammary acini and ducts, which results in a localized area of fibrous tissue associated with hypoplastic mammary ducts and lobules

Stromal Fibrosis of the Breast: A Spectrum of Benign to Malignant Imaging Appearances

https://www.hindawi.com/journals/rrp/2019/5045908/

Abstract

Objectives. The aim of this study is to demonstrate the various imaging appearances of stromal fibrosis on mammography, ultrasound, and magnetic resonance imaging (MRI). Material and Methods. This study included 75 female patients who presented to the American University of Beirut Medical Center between January 2010 and October 2015 for breast imaging. 66 (88%) patients obtained a mammogram, 71 (95%) had an ultrasound, and 6 (8%) had an MRI. Patients included had stromal fibrosis proven on biopsy. Results. The most common finding on mammogram was calcifications which was present in 14 (21%) patients, while on ultrasound it was a mass which was present in 61 (86%) patients. A mass was detected on MRI in 2 (33.5%) patients. Most lesions detected had benign findings such as masses with circumscribed margins. We had a follow-up for 53 (71%) patients with an average follow-up interval of 28.5 months (range: 5 – 70). Increase in size of the index lesion was noted in only 2 patients; upon rebiopsy, pathology results read stromal fibrosis for one lesion and fibroadenoma for the other. The remaining lesions were either stable or decreased in size. The higher detection rate of a mass on ultrasound was statistically significant (p<0.001) in comparison to that of mammography. Conclusion. Stromal fibrosis can have various presentations on imaging from benign to suspicious for malignancy features. In the case of accurate targeted biopsy, when stromal fibrosis is diagnosed, the result can be considered concordant. Therefore, such lesions can be followed up by imaging to document stability and confirm benignity.

Stromal fibrosis in the breast is a benign pathologic entity. It is primarily characterized by proliferation of fibrous tissue that results in the obliteration of the mammary acini and ducts [1]. The exact etiology remains unknown. However, it has been speculated that it may be related to several conditions such as estrogen related fibroblastic proliferation, end stage of inflammatory processes, or a type of breast involution [2].

Stromal fibrosis may present as a palpable mass or a clinically occult imaging-detected abnormality [4]. On imaging, it may present with either benign or suspicious features. The major dilemma lies in the case of radiologic-pathologic discordance, for it is one of the leading causes of missed diagnosis of breast cancer [5]. Discordance may result in a second core biopsy or even a more invasive procedure such as prompting a surgical excision of the lesion in order to avoid misdiagnosing malignant lesions [6]. Literature is almost scarce regarding the eclectic radiological features this entity may present with. It is vital for radiologists to recognize that this benign entity may present as a suspicious lesion on imaging, for it will make the assessment of concordance easier. Therefore, the aim of this study is to demonstrate the various imaging appearances of stromal fibrosis on mammography, ultrasound, and magnetic resonance imaging (MRI).

We had a follow-up for 53 (71%) patients with an average follow-up interval of 28.5 months (range: 5 – 70). 46 patients (87%) had a stable lesion with no interval history of malignancy. Four (7.5%) patients had a decrease in the size of the lesion, while 2 (4%) other patients had an increase in size. Finally, we had one patient who had a total ipsilateral mastectomy in another hospital before presenting back to us 5 months later. The indication that led the patient to undergo a surgery and the resulting pathology are unknown. As for the patients who had an increase in lesion size, their lesions were biopsied once again. The pathology report read fibroadenoma for one patient and stromal fibrosis for the other.

The pathogenesis of stromal fibrosis remains unknown. However, the theory of a hormonal role has gained support by previous studies whereby patients were almost exclusively premenopausal [3, 8]. However, similar to Taskin et al. [9] who reported a high percentage of 33% of postmenopausal women with stromal fibrosis, 25% of patients in our study were postmenopausal. This does not rule out a possible hormonal role; nevertheless, other explanations ought to be pursued.

On ultrasound, though a well-defined mass was the most common finding, a big proportion of lesions presented as irregular masses with irregular, microlobulated, or angular margins.

The imaging features of stromal fibrosis are not specific and variable. On mammography, the most common finding in our study was calcifications

Our study has the second longest follow-up for stromal fibrosis lesions in the literature to date with a mean of 28.5 months (range: 5–70). No false negatives are to be reported. None of the patients had an interval history of malignancy. On follow-up, only 2 patients had an increase in lesion size which upon rebiopsy had pathology results that read stromal fibrosis for one and fibroadenoma for the other. Jai Kyung et al. have also demonstrated lesion size stability and/ or decrease over a 2-year follow-up period with no false negatives [12]. Similarly, no false negatives were noted by Rosen et al. [4] and Harvey et al. [3] who reported rebiopsy of lesions increasing in size, proven again to be benign (focal fibrosis and fibroadenoma respectively). No false negatives were reported by Lee et al. [11] in his series of 40 cases of stromal fibrosis detected on MRI. The false negatives reported in the literature are related to either sampling error as noted by Sklair-Levy et al. [1] who describe two cases of invasive carcinoma mistakenly labeled as stromal fibrosis and to radiological-pathological discordance according to Malik et al. [13] who reported a false negative rate of 7%.

Conclusion

Although stromal fibrosis is most likely to occur as an ultrasound detected mass, this study has not identified a characteristic imaging appearance. In fact, stromal fibrosis may demonstrate a wide array of radiological phenotypes on mammography, ultrasound, and MRI, displaying features ranging from benign to suspicious for malignancy. In the case of accurate targeted biopsy, when stromal fibrosis is diagnosed, the result can be safely considered concordant. It is currently recommended that these patients undergo a follow-up ultrasound for documentation of benignity. Our study parallels several others that show no false negative results upon follow-up. In light of this reproducible finding across several studies, larger studies are needed in order to reconsider the need for short-term follow-up ultrasound after diagnosis of stromal fibrosis.

Fibrosis refers to a large amount of fibrous tissue, the same tissue that ligaments and scar tissue are made of. Areas of fibrosis feel rubbery, firm, or hard to the touch.

Because breast swelling toward the end of the menstrual cycle is painful for some women, some doctors recommend over-the-counter pain relievers such as acetaminophen or ibuprofen, or other medicines. It’s been suggested that some types of vitamin or herbal supplements might relieve symptoms, but so far none have been proven to be helpful, and some may have side effects if taken in large doses. Some doctors prescribe hormones, such as oral contraceptives (birth control pills), tamoxifen, or androgens. But these are usually given only to women with severe symptoms because they also can have serious side effects.

https://www.cancer.org/cancer/breast-cancer/non-cancerous-breast-conditions/fibrosis-and-simple-cysts-in-the-breast.html

ROJ@20apr3