Distinguishing between fibroadenoma and fibrocystic changes

[ChessMaster3000]

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This is apparently a lot harder than it seems. I know the Fibrocystic changes are the most common, and a hormonally influenced. I know that fibroadenoma is hormonally influenced as well. From reading a UW explanation and other sources, the only discernable difference is that fibroadenoma is more likely in pregnancy, whereas both fibroadenoma and FCC can occur with relation to the menstrual cycle. Anyway, I missed a question where the patient was pregnant and the mass had increased and then resolved after birth. Based on THAT, apparently we were supposed to select fibroadenoma over fibrocystic change.

So, I guess my question is essentially two-fold:

1. Do we really have to know and distinguish among the histology of fibroadenoma and the multiple types of fibrocystic change (including sclerosis adenosis, cystic blue dome, etc)
OR
2. Is it an unspoken secret that these types of questions are basically always "fibroadenoma"? Come to think of it, of all the questions I have done, I dont think any of them were ever fibrocystic change.

 

[Apoplexy__]

I think it comes down to "defined, mobile mass" versus "lumpy-bumpy masses". I mean, you're unlikely to get those exact key words but you can probably draw a conclusion based on the adjectives. Plus, coming and going during pregnancy is totally classical of fibroadenoma, as you said. If a woman notices bumps in her breasts they were tender around menses, that's definitely more indicative of fibrocystic change.

1. I wouldn't expect that...have you had any questions that imply they wanted you to be able to? If you had to, I think the biggest tip-off you'd look for is a sharp demarcation between the pathology and normal breast, indicative of fibroadenoma.
2. Not sure...haven't had enough experience with these questions.

 

[ChessMaster3000]

I think it comes down to "defined, mobile mass" versus "lumpy-bumpy masses". I mean, you're unlikely to get those exact key words but you can probably draw a conclusion based on the adjectives. Plus, coming and going during pregnancy is totally classical of fibroadenoma, as you said. If a woman notices bumps in her breasts they were tender around menses, that's definitely more indicative of fibrocystic change.

1. I wouldn't expect that...have you had any questions that imply they wanted you to be able to? If you had to, I think the biggest tip-off you'd look for is a sharp demarcation between the pathology and normal breast, indicative of fibroadenoma.
2. Not sure...haven't had enough experience with these questions.

I have had a few questions where it wasn't an absolute requirement but it would have helped knowing the histology.

I guess a generalization could be made that fibrocystic change(s) are truly multiple, while fibroadenoma is more singular (that's why it's "defined", makes it sound like a discrete mass)? If that's the case, that will probably be easy enough to distinguish. I really didnt know the pregnancy thing though, which is annoying, because I dont see why FCC wouldn't be increased in pregnancy with the estrogen stimulation (is there something else to it, or is it just straight up classical?)

 

[thehundredthone]

Like you already know, fibrocystic changes involve areas of existing breast tissue. Fibroadenomas are ANDI, and are usually single hyperplastic lumps. Although both are hormonally influenced, you are unlikely to have fibrocystic changes that exaggerate only during pregnancy and not during normal menstrual cycles. Conversely, fibroadenomas are not really affected very greatly by the hormonal changes in normal menstrual cycles, but a small, previously undetected fibroadenoma may grow large enough to become detectable during pregnancy.

 

[Transposony]

Fibroadenoma: Single, discrete, highly mobile mass in a younger women <35 yrs of age. Increases in size during later part of menstrual cycle & pregnancy. Short history.

Fibrocystic changes: Multiple (lumpy bumpy), often bilateral masses in relatively older women >35 yrs of age. Symptoms worse before menstruation and better afterwards. History of breast symptoms (tenderness) prior to development of mass(es). Longer history.

D/D: Fat necrosis: H/o trauma to breast. Histology. Calcification.

 

[targ489]

Fibroadenoma: Single, discrete, highly mobile mass in a younger women <35 yrs of age. Increases in size during later part of menstrual cycle & pregnancy. Short history.

Fibrocystic changes: Multiple (lumpy bumpy), often bilateral masses in relatively older women >35 yrs of age. Symptoms worse before menstruation and better afterwards. History of breast symptoms (tenderness) prior to development of mass(es). Longer history.

D/D: Fat necrosis: H/o trauma to breast. Histology. Calcification.

This!

 

[Apoplexy__]

I guess a generalization could be made that fibrocystic change(s) are truly multiple, while fibroadenoma is more singular (that's why it's "defined", makes it sound like a discrete mass)?

Yeah, I think that's a really big point.

is there something else to it, or is it just straight up classical?

Not that I know of, but thehundredthone's post sounds like good logic.

Transposony's post was money, but I thought I'd also chime in the reply from a pathologist (who runs this blog: http://www.pathologystudent.com/ ) who I e-mailed your question to:

-Palpation: "Lumpy-bumpy" masses = fibrocystic change; "Mobile, discrete mass" = fibroadenoma
-Presentation: Masses are tender during menses = fibrocystic change; Woman slowly develops mass during pregnancy that disappears after delivery = fibroadenoma
-Histology: Varied appearance pervasive throughout normal tissue = fibrocystic change; Sharply demarcated nodule of glands and stroma = fibroadenoma

So, basically what you already knew. She also added some "real-world" insight on how the clinical management works:
Fibroadenomas basically present as moveable masses - and with any breast mass, you just have to biopsy it and go from there. Fibrocystic change can sometimes present as a mass too - so you may need to biopsy that as well. In the real world, there is some overlap between the two - so it basically boils down to this: if it's a mass, biopsy it. (perhaps ultrasound it first - then if it's not cystic, biopsy it).

 

[ChessMaster3000]

Yeah, I think that's a really big point.



Not that I know of, but thehundredthone's post sounds like good logic.

Transposony's post was money, but I thought I'd also chime in the reply from a pathologist (who runs this blog: http://www.pathologystudent.com/ ) who I e-mailed your question to:

-Palpation: "Lumpy-bumpy" masses = fibrocystic change; "Mobile, discrete mass" = fibroadenoma
-Presentation: Masses are tender during menses = fibrocystic change; Woman slowly develops mass during pregnancy that disappears after delivery = fibroadenoma
-Histology: Varied appearance pervasive throughout normal tissue = fibrocystic change; Sharply demarcated nodule of glands and stroma = fibroadenoma

So, basically what you already knew. She also added some "real-world" insight on how the clinical management works:
Fibroadenomas basically present as moveable masses - and with any breast mass, you just have to biopsy it and go from there. Fibrocystic change can sometimes present as a mass too - so you may need to biopsy that as well. In the real world, there is some overlap between the two - so it basically boils down to this: if it's a mass, biopsy it. (perhaps ultrasound it first - then if it's not cystic, biopsy it).

Yeah ive seen that blog before, it is solid. I think the tender thing that she mentioned is an important addition to what we have already established. I didnt realize that fibroadenomas are typically painless even when they enlarge. I was equating enlarge during menses/pregnancy with "painful", which is an all-too-easy mistake to make. With all of this there are clearly tons of differences between the two, more than enough to distinguish any in a test question.