For so many years, I have been looking for a document to support my stand on giving out a diagnosis of fibrocystic breast changes despite the presence of reports of solid nodules on ultrasound by the ultrasonographer. These are in patients with no palpable dominant breast masses. TODAY (MAY 13, 2016), I FOUND A STRONG DOCUMENT THAT SUPPORTS MY STAND (see below, bottom of page).
I know very well that many patients have been operated on as a result of such reports which usually end in a histopath diagnosis of fibrocystic changes. Fibrocystic changes are hormonal changes on the breast which do not need to be operated on.
My usual explanation to patients has been like this (especially in those with reports of concomitant cystic masses).
My primary clinical diagnosis is FIBRO-CYSTIC changes of the breast after correlating my physical examination findings with the ultrasound report of presence of subcentimeter solid and cystic nodules. The presence of cystic nodules on ultrasound jibe with the CYSTIC in my FIBRO-CYSTIC diagnosis. The solid nodules on ultrasound are compatible with the FIBRO in my FIBRO-CYSTIC diagnosis. The FIBRO in my FIBRO-CYSTIC diagnosis can be seen on ultrasound as “solid nodules”, a term commonly used by ultrasonographer, but in reality they are not real masses, in the parlance of clinicians and pathologists. Real masses usually are 3-dimensional and dominant.
After this explanation on the clinical diagnosis, I just advise monitoring and check-up.
Below are examples of such reports. There are no associated palpable dominant breast masses. My primary clinical diagnosis has been FIBROCYSTIC CHANGES of the breast. Patients are just advised regular monitoring and follow-up. There is no need to have the solid masses biopsied or removed.
In 2012, I came across this document that more or less support my stand. It shows that ultrasound picks up very strongly fibrous signals which may be reported as a nodule.
Today, May 13, 2016, I decided to search the literature again. Initially, I used the following search words: false positivity of ultrasound of the breast; positive findings of mass on ultrasound despite negative dominant mass; etc. There were no good articles until I used sonographic findings of fibrocystic changes. Lo and behold, there was this 2002 article which showed good supporting evidences on my stand.
Ultrasound Q. 2002 Mar;18(1):35-40.
Sonographic findings in focal fibrocystic changes of the breast.
From Baylor College of Medicine and Woman’s Hospital of Texas
In 58 patients, there were 60 lesions with a pathologic diagnosis of focal fibrocystic changes (FC). Sonographically, focal FC appeared as solid mass in 28 cases (46.6%) and as cysts in eight (13.3%). In nine cases (15%), heterogeneously echogenic tissue was seen, and in the remaining 15 (25%) cases, there was no sonographically visible focal change.
There you are – my strongest supporting evidence.
To repeat: On ultrasound, focal fibrocystic changes appeared as a solid mass in 47%, as heterogeneous echogenic tissue in 15%, as cysts in 13%, and in 25% of cases was not visible on ultrasound.
Below is the abstract:
The purpose of this study was to identify the spectrum of sonographic appearances in histologically proven focal fibrocystic changes (FC) of the breast to enhance understanding of imaging findings in this commonly encountered benign condition of the breast. During a 28-month period, the pathology database at two breast centers was searched to identify all patients with a pathologic diagnosis of focal FC resulting from biopsy of a focal mammographic, sonographic, or palpable abnormality and who had undergone sonographic evaluation before biopsy. The authors included lesions with a pathologic diagnosis of FC with or without a specific histologic subtype, such as stromal fibrosis, sclerosing adenosis, and apocrine metaplasia. In 58 patients, there were 60 lesions with a pathologic diagnosis of focal FC. Sonographically, focal FC appeared as solid mass in 28 cases (46.6%) and as cysts in eight (13.3%). In nine cases (15%), heterogeneously echogenic tissue was seen, and in the remaining 15 (25%) cases, there was no sonographically visible focal change. Thirteen of the 28 (46.4%) masses were classified as sonographically indeterminate. One mass was classified as probably malignant, and 14 masses were sonographically benign. A significant number of focal FC appear as solid masses. The sonographic features are not specific enough to differentiate between those that have a dominant component of focal fibrosis, sclerosing adenosis, or apocrine metaplasia from FC without a specific histologic subtype. Many of these solid masses may appear indeterminate, based on published criteria. An understanding of the imaging findings also helps to avoid repeat biopsy for discordant histologic and imaging findings.
FC is defined as “a condition in which there are palpable lumps in the breast, usually associated with pain and tenderness, that fluctuate with the menstrual cycle and that become progressively worse until menopause. Histologically, FC includes macrocysts, microcysts, adenosis, apocrine change, fibrosis, or ductal hyperplasia.”