Can benign cysts become cancerous later?

A spectrum of benign breast problems exists and ranges from normal to aberrant to disease, depending on the degree of stromal and ductal changes. In fact, the term “fibrocystic breast disease” has now been replaced by “fibrocystic changes” because of the frequency of this histologic appearance in normal women (Santen 2000).

Breast lumps are usually caused by either fibrocystic changes in breast tissues or the presence of cysts and are relatively common among pre-menopausal women. Fibrocystic changes are most often diagnosed based on symptoms such as lumpy breasts, swelling and tenderness and these symptoms usually become worse a week before the period starts.

Fibrocystic breast tissue usually consists of distinct components such as fluid-filled round or oval sacs known as breast cysts, scar-like fibrous tissue (fibrosis), an overgrowth of cells (hyperplasia) lining the milk ducts or milk-producing tissues (lobules) of the breast or enlarged breast lobules (adenosis) (http://www.mayoclinic.org/diseases-conditions/fibrocystic-breasts/symptoms-causes/dxc-20194996)

Breast cysts are typically fluid-filled sacs and they may get bigger and one can feel them during breast self-examination (BSE). Cysts may enlarge and become tender right before menstruation. They tend to be round and movable. Usually ultrasound is used to tell the difference between a cyst and a solid mass.  

Another benign but common condition is the presence of fibroadenoma, solid mass made up of glandular breast tissue and stromal (connective) tissues. More information about fibroadenomas can be found at various websites such as American Cancer Society and MayoClinic.

Most fibroadenomas look the same under a microscope and thus, called simple fibroadenomas. But some fibroadenomas have more complicated histology and thus, are called complex fibroadenomas.

In a recent study, where women who had fibroadenoma were compared to women who did not have fibroadenoma, some noteworthy observations were made. Women with complex fibroadenoma were more likely to have other, concomitant high-risk histologic characteristics (Nassar et al. 2015).  

In another cohort of 1667 female patients who was enrolled in the Clinical Breast Care Project, another interesting observation was made. Although not without controversy, the general consensus has been that simple fibroadenoma is not a risk for invasive breast cancer but complex fibroadenoma is; non-proliferative fibrocystic change are not a risk but proliferative fibrocystic change are (Chen et al. 2015).

A total of 1,406 benign breast disease biopsies from African American women were included in a study with a median follow-up of 10.1 years. The majority (68%) showed nonproliferative disease, 29% had proliferative disease without atypia, and 3% had proliferative disease with atypia. By the way, atypia is a pathologic term for a structural abnormality in a cell. Subsequent incident breast cancers occurred in 55 women (3.9%). Women whose biopsies showed proliferative disease with atypia were more than three-fold more likely to develop breast cancer as compared with women who had nonproliferative disease (Cote et al. 2012). Does this finding suggest that all benign disease should be assessed despite the low percentages of women who may have proliferative disease? I supposed I may be under this overlooked category.  

Apparently, atypical hyperplasia (Carter et al. 1988, Hartmann et al. 2005, London et al. 1992)(1–3) and high breast density (Boyd et al. 2007, Cummings et al. 2009, Ziv et al. 2003) are two of the strongest risk factors for breast cancer.  

Another study of 42818 women aged 30 years and older who had at least one biopsy with a benign diagnosis on pathology and had a mammographic measurement of breast density concluded that women with high breast density and proliferative benign breast disease are at very high risk for future breast cancer. Women with low breast density are at low risk, regardless of their benign pathologic diagnosis (Tice et al. 2013). The authors suggest that these women may benefit from more-intensive approaches to screening for breast cancer or interventions to lower their risk for breast cancer.

According to American Cancer Society, most women with fibrocystic changes and without bothersome symptoms do not need treatment, although they might be monitored closely. Some women may get relief from well-fitted, supportive bras, applying heat, or using over-the-counter pain relievers. Cutting caffeine and other stimulants found in coffee, tea, chocolate, and soft drinks were some offered solutions, although there were no specific evidences. Salt reduction, some vitamins or herbal supplements are other alternatives but none have been proven helpful (http://www.cancer.org/healthy/findcancerearly/womenshealth/non-cancerousbreastconditions/non-cancerous-breast-conditions-women-at-inc-br-cancer-risk).

The exact cause of fibrocystic breast changes isn't known although hormones produced in the ovaries especially estrogen play a role. Painful or sensitive breasts just prior to menstruation have been attributed to a more prominent estrogen than progesterone effect on breast tissue. Increased tissue sensitivity to estrogen is also related to fluid retention. Exogenous estrogen, such as oral contraceptives or estrogen replacement therapy during menopause, is known to cause similar symptoms. (http://www.mayoclinic.org/diseases-conditions/fibrocystic-breasts/symptoms-causes/dxc-20194996).

Some reflections there….

• In my case more than a decade ago, the fibroadenoma removed from my right breast was never categorized as simple or complex. I was just told, “You are safe, it was benign!!” I went home feeling happy with my boobs.

• In recent years based on my bilateral cysts confirmed using ultrasound, there was never a suggestion to do a biopsy by the good surgeon. I knew that a biopsy would be ideal but I chose to trust the doctor instead. I ought to go for another mammogram and probably a MRI which I also chose to forego. A great lesson there for early detection. Anyway, nobody will understand the feelings of having to go through these screenings, unless you are in their shoes. Easier said than done!

• Only a biopsy on any benign breast disease (BBD) can determine the characteristics of such disease as mentioned above, thus, I strongly feel that surgeons should offer a choice (or insist) of biopsy to those poor ignorant women (me included) who have BBD?

• I have definitely overlooked the importance of diet, estrogenic foods and my lumpy breasts.

• In my humble opinion as a patient, benign cysts or fibroadenomas should be core-biopsied for early characterization simply because some of them can be cancerous later! 

References:

Boyd NF, Guo H, Martin LJ, Sun L, Stone J, Fishell E, et al. (2007). Mammographic density and the risk and detection of breast cancer. The New England journal of medicine, 356(3), 227-236.

Carter CL, Corle DK, Micozzi MS, Schatzkin A and Taylor PR (1988). A prospective study of the development of breast cancer in 16,692 women with benign breast disease. American journal of epidemiology, 128(3), 467-477.

Chen Y, Bekhash A, Kovatich AJ, Hooke JA, Liu J, Kvecher L, et al. (2015). Positive Association of Fibroadenomatoid Change with HER2-Negative Invasive Breast Cancer: A Co-Occurrence Study. PloS one, 10(6), e0129500.

Cote ML, Ruterbusch JJ, Alosh B, Bandyopadhyay S, Kim E, Albashiti B, et al. (2012). Benign breast disease and the risk of subsequent breast cancer in African American women. Cancer prevention research (Philadelphia, Pa.), 5(12), 1375-1380.

Cummings SR, Tice JA, Bauer S, Browner WS, Cuzick J, Ziv E, et al. (2009). Prevention of breast cancer in postmenopausal women: approaches to estimating and reducing risk. Journal of the National Cancer Institute, 101(6), 384-398.

Hartmann LC, Sellers TA, Frost MH, Lingle WL, Degnim AC, Ghosh K, et al. (2005). Benign breast disease and the risk of breast cancer. The New England journal of medicine, 353(3), 229-237.

London SJ, Connolly JL, Schnitt SJ and Colditz GA (1992). A prospective study of benign breast disease and the risk of breast cancer. Jama, 267(7), 941-944.

Nassar A, Visscher DW, Degnim AC, Frank RD, Vierkant RA, Frost M, et al. (2015). Complex fibroadenoma and breast cancer risk: a Mayo Clinic Benign Breast Disease Cohort Study. Breast cancer research and treatment, 153(2), 397-405.

Santen RJ (2000) Benign Breast Disease in Women. in De Groot, LJ, Beck-Peccoz, P, Chrousos, G, Dungan, K, Grossman, A, Hershman, JM, et al., eds., Endotext, South Dartmouth (MA): MDText.com, Inc.

Tice JA, O'Meara ES, Weaver DL, Vachon C, Ballard-Barbash R and Kerlikowske K (2013). Benign breast disease, mammographic breast density, and the risk of breast cancer. Journal of the National Cancer Institute, 105(14), 1043-1049.

Ziv E, Shepherd J, Smith-Bindman R and Kerlikowske K (2003). Mammographic breast density and family history of breast cancer. Journal of the National Cancer Institute, 95(7), 556-558.