Cystic hyperplasia of breast is a disease characterized by highly dilated cysts in the lobules, small ducts and terminal ducts of the breast, accompanied by structural malformations of the breast. It is also known as chronic cystic breast disease, cystic dermoid mastopathy, and fibrocystic breast disease. In contrast to simple mastopathy, this disease is distinguished by the coexistence of mammary hyperplasia and atypical hyperplasia, with the risk of malignant transformation. It should be considered as a precancerous lesion.
Pathogenesis
The pathological changes of cystic hyperplasia of the breast are characterized by
1. Gross morphology There are cystic nodules or masses of different sizes and uneven softness in the breast tissue on one side or both sides. The cysts vary in size, with large cysts up to 1-5 cm in diameter, grayish or blue in color, also known as blue domed cysts or blue-topped cysts. Small cysts are mostly seen around large cysts, only 2mm in diameter, not even visible to the naked eye, only visible under the microscope. Incision of large cysts reveals the cyst contents as clear, colorless, plasma or brownish-yellow fluid, sometimes bloody. It contains proteins, hormones (lactogen, estrogen, androgens, human chorionic gonadotropin, human growth hormone, follicle stimulating hormone, luteinizing hormone, etc.), sugars, minerals and cholesterol. The cystic wall is thick and lustrous, and there may be granular or papillary neoplasms protruding into the cystic cavity.
2.Histological morphology Five different kinds of lesions can be seen.
(1) Cyst: terminal duct and alveolar hyperplasia, small duct dilatation and extension, terminal duct cyst formation. The terminal duct epithelium proliferates abnormally to form multiple layers and grows papillary from the duct wall to the lumen, occupying most of the duct lumen so that the lumen is obstructed and the secretions are retained and expanded, and cysts are formed. Cysts can be divided into simple cysts, which are only cystic expansion without epithelial proliferation; and another kind of papillary cysts, which have papillary epithelial proliferation.
(2) Epithelial hyperplasia of milk duct: epithelium in dilated ducts and cysts shows different degrees of hyperplasia, with increased epithelial layers in mild cases and papillary protrusions in severe cases, or connected with each other in a reticular or sieve-like, solid, or glandular pattern. If the cyst epithelium is actively proliferating, atypical hyperplasia or interstitial changes are common and may develop into cancer. (3) Papillomatosis: that is, on the basis of the cystic expansion of papillary cysts, the epithelial cells of the cyst wall show papillary proliferation in many places, forming papillomatosis. According to the extent of papillomatosis involvement, the density of papillae and the degree of epithelial cell proliferation, papillomatosis can be classified as mild, moderate and severe, which has practical significance in clinical practice.
(4) Glandular duct type adenopathy: lobular duct or alveolar duct chemosis and hyperplasia, solid masses of proliferating epithelial cells, varying degrees of proliferation of fibrous tissue, and inconspicuous duct dilation and cyst formation, called adenopathy formation.
(5) Sweat gland-like metaplasia: the cyst wall is covered with epithelial metaplasia in a high columnar shape, rich in cytoplasm, which has eosinophilic granules, resembling sweat gland cells, the appearance of such cells is often a benign sign. In addition, fibrous tissue around the cyst wall, ducts and alveoli proliferate and form fibrous cords to squeeze the surrounding ducts to produce obstruction, resulting in secretion retention and then cause duct distortion or dilatation.
3, pathological diagnostic criteria Cystic hyperplasia of the breast with the above five lesions, they do not exist at the same time. Among them, papillomatosis, ductal adenopathy and cysts are the main lesions. The rate of occurrence of each lesion is related to the site of tissue sampling and the amount of tissue taken. The diagnosis is made if three of the five lesions or two of the three major lesions can be seen in the section. Among the 5 lesions cystic ductal epithelial hyperplasia, papillomatosis, and atypical hyperplasia due to adenoidal adenopathy are prone to carcinogenesis. Pathogenesis
The development of this disease is associated with endocrine stimulation of the ovaries. coormaghtigi and Amerlinck have shown in 1930 that oophorectomized house mice injected with estrogen can produce cystic mammary gland disease. In humans, estrogen not only stimulates mammary epithelial hyperplasia, but also causes dilation of the ducts and the formation of cysts. Recent studies indicate that hyperprolactinemia is an important cause of cystic hyperplasia of the breast, and foreign scholars have reported that postmenopausal women with cystic hyperplasia of the breast are often the result of inappropriate application of estrogen replacement therapy. Symptoms and signs
1. Lumps Lumps in the breast are often the main symptom, and can occur in one breast or both breasts, but the left breast is more prominent. The lump can be single or multiple, and its shape varies from a single nodule to multiple nodules. The nodules are often spherical, with poorly defined borders, and can be freely pushed, with a cystic sensation; multiple nodules often involve both breasts or the whole breast, with nodules of varying sizes, often with limited cystic activity, moderately hard and tough, with a cystic sensation often palpable when the larger cysts are located near the surface; there are also distribution along the milk ducts in the form of cords, with nodules or cords mostly 0.5 to 3 cm in diameter, and according to the extent of distribution of the masses can be divided into diffuse type The lumps are distributed throughout the breast, or mixed, i.e. several different forms of lumps, such as lamellar, nodular, lacunar, or granular, are scattered throughout the breast.
2, breast pain The breast pain in this disease is not obvious and not closely related to the menstrual cycle. Occasionally, there are multiple manifestations of pain, such as hidden pain, stabbing pain, chest and back pain and upper limb pain. In some patients, the lump becomes larger, harder and more painful when they are sad, sorrowful or in a bad mood, as well as when they are tired or in bad weather, and the lump becomes softer and smaller after the menstrual cycle or when they are in a better mood. Clinical experience suggests that this change is mostly benign. If the lump increases rapidly and has a hard texture, it suggests the possibility of malignant transformation.
3, nipple overflow About 5% to 15% of patients may have nipple overflow, mostly spontaneous nipple drainage. It is often straw yellow plasma, brown plasma, plasma blood or bloody overflow. If the overflow is plasmacythematous or bloody it often signals the presence of an intraductal papilloma. Tests
Laboratory tests.
1. Fine needle aspiration cytology of the masses The masses of cystic hyperplasia of the breast are mostly bilaterally, multi-mass, and the progression of each mass lesion varies. Taking multi-point fine needle aspiration cytology examination can often fully reflect the lesion situation or nature of each lump. It can provide early diagnosis especially in cases suspected of cancer. Sometimes the final diagnosis should also depend on pathological biopsy.
2.Papillary overflow cytology examination A few patients have papillary overflow, which is mostly seen as plasma, plasma blood or blood by naked eyes. Smear microscopy can see ductal epithelium, foam cells, red blood cells, a few inflammatory cells and fat, protein and other invisible material. Other ancillary examinations.
1.Molybdenum target radiography The molybdenum target radiograph shows the lesion area presenting a cotton ball or hairy glass shape with blurred edges of increased density shadow, or see strips of connective tissue traversing between them. In the presence of cysts, round translucent shadows in irregular enhancing shadows are seen. The former does not have malignant signs such as increased blood flow, skin thickening and burr; if there are calcifications, they are scattered and not as dense as breast cancer (Figure 4).
Ultrasound examination In recent years, ultrasound diagnostic technology has developed rapidly and the diagnostic rate has been increasing. The examination of this disease often shows uneven hypoechoic areas and echogenic cystic areas without masses (Figure 5).
3.Near-infrared breast scan examination This disease is shown on the near-infrared breast scan screen as scattered dotted or lamellar gray shadows, or striated or cloudy gray shadows, with increased vascularity, thickening, reticulation, dendritic and other changes based on the common foveal inhomogeneous translucent areas.
4.Magnetic resonance imaging (MRI) typically shows dilated breast ducts with irregular morphology and unclear borders, and the signal intensity of dilated ducts is lower than that of normal glandular tissue on Tl-weighted images; the lesion is confined to a certain area, or can be diffusely distributed throughout the region or in the whole breast (Figure 6). The MRI images of this disease are usually characterized by symmetric changes. Differential diagnosis of disease
1. Breast pain Most often seen in young women aged 20 to 30 years, older unmarried or married without children, with poorly developed small breasts. Periodic swelling and pain in the breast bilaterally. The lumps in the breast are mostly inconspicuous or only limitedly thickened or finely granular, also known as finely granular small mammary glands.
2, breast adenopathy Most commonly seen in women aged 30 to 35. Breast pain and lumps are more periodic, lumps are more nodular, multiple scattered, more uniform in size, no cystic sensation, and generally no nipple discharge.
3.Fibroadenoma of the breast Most often seen in young women, often painless lumps, mostly solitary, a few are multiple. The lumps have obvious boundaries, move well and are not painful to touch. However, sometimes cystic hyperplasia of the breast can coexist with fibroadenoma, which is not easy to distinguish.
The diagnosis can be confirmed by X-ray mammography, which shows the filling defect.
5.Breast cancer is common in middle-aged and elderly women, and there is often a single painless lump in the breast. The lump is often a single painless lump. A fine needle aspiration cytology examination of the lump can mostly find cancer cells. Sometimes, it is not easy to distinguish between cystic hyperplasia and atypical hyperplasia and cancer. Pathological biopsy is required to confirm the diagnosis. Treatment with medication
1.Medication
(1) Chinese medicine treatment: For those with obvious pain and diffuse hyperplasia, Chinese medicine treatment can be taken. It can be used to relax the liver and Qi, activate blood circulation and remove blood stasis, and soften the knots. Such as breast fetish elimination tablets, breast node elimination granules, breast health tablets, etc.
(2) Hormone therapy: If the effect of Chinese medicine treatment is not good, hormone therapy can be considered to achieve the purpose of treatment through the adjustment of hormone level. Commonly used drugs include progesterone 5-10mg/d, taken 5-10 days after menstruation; Dantazol 200-400mg/d, taken for 2-6 months; bromocriptine 5mg/d, for 3 months; for those who test positive for estrogen receptors with hyperplastic glands, oral tamoxifen (triamcinolone) 20mg/d, for 2-3 months. Hormone therapy should not be applied for a long time to avoid adverse reactions such as menstrual disorders.
2.Surgical treatment
(1) Purpose of surgery: To clarify the diagnosis and avoid breast cancer underdiagnosis and delayed diagnosis.
(2)Indications: Patients who have not obvious efficacy after drug treatment, whose lumps are increasing, enlarging and firm in texture; those with active ductal epithelial cell proliferation and atypical hyperplasia as seen by needle aspiration cytology of lumps; those who are over 40 years old and have family history of breast cancer should choose surgery.
(3) Surgical plan selection: Different surgical methods are adopted according to the size of lesion and the number of masses.
(①Lump excision: for lump class or family members with high incidence of cancer and lump diameter <3cm, lump excision including some normal tissues is feasible.
②Mastectomy: If the lesion is limited to a certain local area, the pathological result shows a high degree of epithelial cell proliferation and interstitial changes, and the age is above 40 years, mastectomy is feasible.
(3) Simple percutaneous mastectomy: those with high epithelial cell hyperplasia and a family history of similar disease, especially those with first-degree relatives with breast cancer, should undergo simple mastectomy at the age of 45 years or older.
④ Radical mastectomy: Isolated lumps of different types of moderate hardness under the age of 35 years, which have been treated for a long time with good and bad results, should undergo multi-point fine-needle aspiration cytology, and those who are positive should undergo radical mastectomy. For negative cases, lump excision for pathology is feasible and additional surgical scope will be performed according to the pathology results. Diet and health care
Health care.
1, good mood: in a good mood, the normal ovulation of the ovaries will not be obstructed by bad mood, progesterone secretion will not be reduced, the mammary glands will not be enlarged by the unilateral stimulation of estrogen, and the enlarged mammary glands will gradually recover under the care of progesterone.
Pregnancy and breastfeeding: Pregnancy and breastfeeding are good ways to combat mammary gland hyperplasia. Sufficient secretion of progesterone can effectively protect and repair the mammary glands; and breastfeeding can make the mammary glands fully develop and degenerate well after weaning, so that hyperplasia is not easy to occur.
3, regulate menstruation: clinical findings show that women with disrupted menstrual cycles are more prone to mastopexy than others, and by regulating endocrine regulation of menstruation, you can also prevent and treat mastopexy.
4, low-fat, high-fiber diet: follow the “low-fat, high-fiber” diet principle, eat more whole-grain foods, beans and vegetables to increase the body’s metabolic pathways and reduce the adverse stimulation of the mammary glands. Also, control the intake of animal protein to avoid excessive estrogen, resulting in breast enlargement.
5, sleep regular regular: sleep not only helps balance endocrine, but also provides a good environment for the various hormones in the body to play a balanced health effect. The power of unity is great, and various hormones work together naturally to defeat mastocytosis.
6, harmonious sex life: harmonious sex life can first regulate endocrine, stimulate progesterone secretion, increase the strength of protection and repair of the mammary glands. Of course, sex will also stimulate estrogen secretion, but under the supervision of progesterone, estrogen can only be good breast enlargement, there is no chance to make breast enlargement. In addition, orgasmic stimulation can also accelerate blood circulation to avoid breast enlargement due to poor blood and Qi flow.
7, supplemental vitamins, minerals: If the body lacks B vitamins, vitamin C or calcium, magnesium and other minerals, the synthesis of prostaglandin E will be affected, and the breast will appear or aggravate hyperplasia under the excessive stimulation of other hormones. Preventive care
Cystic hyperplasia of the breast is a precancerous lesion and should be closely monitored after diagnosis and treatment: monthly breast self-examination; annual mammography; clinical breast examination every 4-6 months, etc. A complete set of follow-up monitoring plan should be established for each 1 patient. In clinical practice, efforts are made to explore more valuable diagnostic and treatment techniques to improve the prediction of malignant tendency of precancerous disease for early detection of breast cancer. Prognosis In recent years, the research on cystic hyperplasia of breast has been deepened to the molecular biology level, and the relationship between various precancerous lesions and the occurrence of breast cancer has been explored by many parties. The study of whole breast large section technique combined with CEA, C-erbB-2 gene product, DNA content, S-phase cell ratio and cell proliferation index by combined detection of several indexes in Tianjin Medical University Cancer Hospital confirmed that ductal epithelial severe atypical hyperplasia and moderate papillomatosis are closely related precancerous lesions of breast cancer, suggesting that only malignant tumors are more frequent, with high levels of 1 to 2 indexes If two or more indicators are highly expressed, it should be considered as early stage cancer. This study suggests the basis for the evolution of cystic hyperplasia of the breast to cancer from the molecular level.