Breast cyst is a volumetric formation of a non–tumor nature, represented by an expanded duct filled with liquid contents, one of the forms of mastopathy. The disease is manifested by the presence of a dense elastic node in the depth of the organ, detected by palpation, cyclic swelling of the breast, accompanied by pain, sometimes – discharge from the nipple. To diagnose a cyst, echography, pneumocystography, morphological examination of the contents of the cystic formation is used. Treatment in most cases is conservative, constant dynamic monitoring is shown. Surgical operation is required when signs of possible malignancy are detected.
ICD 10
N60.0 N60.1 N60.3
Meaning
Breast cyst is a formation up to 6-8 cm in size and is one of the manifestations of benign dysplastic disease (fibrocystic mastopathy). The prevalence of mastopathy is 50-60%, the formation of cysts is accompanied by most cases of the disease. Macrocysts with a diameter of more than 1-2 cm are detected in the nodular form of dysplastic disease, found in a quarter of patients. Local nodular mastopathy with the formation of a single large node (solitary cyst) develops in 75% of cases. Diffuse nodular mastopathy, characterized by the appearance of multiple macrocysts, is noted in 25% of cases and often affects both breasts. Large cystic formations are more often detected in women over 35 years old, new cysts do not form in postmenopause.
Causes
The mammary gland is a target organ for female sex hormones, therefore, the development of cystic formations is usually caused by hyperestrogenism – both absolute and relative (against the background of a decrease in progesterone production), as well as increased sensitivity of organ tissues to estrogens. Such conditions arise due to the violation of complex feedback loops between the ovaries, pituitary gland, hypothalamus, adrenal glands and have a multifactorial nature. The main reasons for the formation of breast cyst include:
- Features of reproductive anamnesis. Factors that increase the likelihood of hyperestrogenism are early (up to 14 years) menarche, late (after 50 years) menopause, unrealized reproductive function or late (after 30 years) first pregnancy, absence or shortening of the breastfeeding period, abortions, in vitro fertilization.
- Endocrine disorders. Mammogenesis processes are directly or indirectly regulated by the ovaries, hypothalamic-pituitary system, adrenal glands and thyroid gland. The consequence of functional disorders and organic lesions of these glands can be cystic mastopathy. In a quarter of women, pathology occurs against the background of inflammatory diseases of the internal genital organs – chronic oophoritis and endometritis lead to ovarian insufficiency and progesterone deficiency.
- Neurogenic factors. Disorders of the nervous system entail failures of neuroendocrine regulation processes and, as a result, provoke hormonal imbalance. Risk factors include prolonged psychoemotional stress, sexual dissatisfaction, vegetoneurosis, intracranial hypertension as a result of head and neck injuries, osteochondrosis of the cervical spine and infections (encephalitis, meningitis).
- Diseases of the digestive system. As a result of damage to the hepatobiliary system and pancreas, the synthesis of steroid hormones, the ability of the liver to inactivate estrogens, and the binding of estradiol is disrupted.
- Exchange disorders. Metabolic syndrome, manifested by abdominal obesity, arterial hypertension, atherosclerosis, and its extreme form – type II diabetes mellitus – are accompanied by an increase in the blood level of insulin, which stimulates an increase in the sensitivity of the mammary glands to sex hormones.
The consequence of hyperestrogenism is not only pathological processes in the mammary glands, but also hyperplastic diseases of the uterus, with which mastopathy is often combined. Most cases of cystic mastopathy are noted in patients with uterine fibroids, whereas against the background of glandular endometrial hyperplasia and adenomyosis, other forms of benign breast dysplasia are more likely to develop. In addition to hormonal disorders, risk factors for the occurrence of cystic formations are considered to be a violation of the patency of the ducts due to injuries of the organ, mastitis and constant compression of clothing.
Pathogenesis
The female breast consists of one and a half or two dozen lobes located radially relative to the nipple and surrounded by fatty and fibrous tissue. Each lobe is represented by glandular lobules secreting milk. The lobules and their structural units (alveoli) are connected by small ducts merging into a common milky duct directed to the nipple. The ducts consist of connective tissue lined with epithelium. The physiological restructuring of the gland (an increase in the number of lobules and their tissues), aimed at preparing the organ for future possible lactation, is regulated by sex hormones through a relatively small number of receptors located in the cells of the lobes of the organ.
Estrogens are responsible for the growth of the alveolar and ductal epithelium and stroma, and progestogens are responsible for the development of glandular tissue and a decrease in the activity of estrogens. Under the influence of adverse factors, the balance of estradiol and progesterone is disrupted (the level of the first increases, the second decreases), the number of receptors increases, which leads to lobule atrophy, duct dilation, fibrosis. The progression of the process is accompanied by periductal inflammation, obstruction of the ducts, their filling with secretions or serous exudate – the formation of cysts. Proliferative forms are characterized by the proliferation of epithelium inside the formations.
Classification
Macrocysts can transform into a malignant tumor. Depending on the morphological properties of the cyst, the risk of its malignancy can range from 1% to 30%, therefore, the most significant in clinical mammology is the classification of these formations by microscopic signs of their possible malignancy – the activity of epithelial tissue growth. There are three degrees of histological severity of proliferation:
- I degree. There is no proliferation, the probability of malignancy is minimal.
- II degree. Mastopathy with epithelial proliferation without signs of cell atypia, there is a moderate risk of developing a malignant tumor.
- III degree. The proliferative process is accompanied by atypia of cells, there is a high probability of malignant transformation.
The risk of malignancy of breast cysts without proliferative growth is 0.9-1%. Proliferating forms are quite rare (0.3-1.4% of all cystic formations) and belong to precancerous conditions. The probability of malignancy in the case of moderate proliferation is 2-3%, pronounced epithelial overgrowth increases the risk to 25-30%.
Breast cyst symptoms
A large cyst can be detected during self–examination of the breast in an upright position in the form of a painful or painless smooth dense elastic node with clear contours, more often rounded or oval, less often irregular in shape. Unlike true neoplasias, when palpating an organ in the supine position, the cyst is practically not determined. Small cystic formations can be detected only with the help of hardware diagnostic methods. Sometimes the macrocyst in the breast thickness is determined randomly, without any previous signs, but more often the formation of cystic formations is accompanied by appropriate symptoms.
The symptoms of a cyst include diffuse changes (granular, heavy, lobular seals in the thickness of the organ), swelling, an increase in the volume of the breast on one or both sides, a feeling of heaviness, tingling, bursting, pain of varying intensity, which can radiate into the armpit, shoulder, shoulder blade and neck. Most often, external manifestations are observed from the second half of the menstrual cycle and disappear by the beginning or end of menstruation, less often they are constantly observed. Subjective sensations are more pronounced in the initial phase and are significantly smoothed out later, during the formation of the palpable node, whereas diffuse changes in the later stages are constantly determined.
With the development of dysplasia, manifestations of premenstrual syndrome often occur or worsen – depression, irritability, headache, nausea, vomiting, dizziness, flatulence, tachycardia, swelling of the face and limbs. 5-6% of women have minor discharge from the nipple of various types (serous, colostrum, bloody), which may indicate the presence of papillary growths inside the cyst, increasing the risk of malignancy.
Complications
Symptoms of cystic formations in a “cancer-prone” organ can provoke anxiety, uncertainty, carcinophobia, often accompanied by severe emotional disorders. Large cysts lead to visible asymmetry of the mammary glands, which aggravates the experiences of patients. The stagnant contents of cysts are a favorable environment for the development of infectious processes, the suppuration of the cyst is manifested by an increase in body temperature, intense throbbing pain and malaise, often requires surgical intervention. The most dangerous complication of a cyst is a malignant degeneration of its epithelium, and the development of a cancerous tumor in the early stages is not accompanied by the appearance of external signs that the patient could detect on her own.
Diagnostics
Despite the availability of the female breast for examination, the diagnosis of cysts presents certain difficulties due to the clinical similarity with other pathologies. Differential diagnosis is carried out with inflammatory diseases (mastitis, abscess, lipogranuloma), other non-tumor formations (atheromas, seromas, galactocele), benign (lipoma, fibroadenoma) and malignant (adenocarcinoma, sarcoma) tumors. Cystic changes can be suspected during the examination of the organ by a mammologist or gynecologist on the fifth or tenth day of the menstrual cycle. To clarify the diagnosis, the following diagnostic procedures are required:
- Instrumental techniques. Ultrasound of the gland is the most accurate method of determining cysts (including microscopic ones). To study the walls of the cyst, pneumocystography is performed, which allows to identify wall formations, thickening of the walls, indicating proliferation. With thin-walled single-chamber cysts, manipulation is not only diagnostic, but also therapeutic.
- Cytological examination. The contents of the cyst obtained by puncture are subjected to laboratory examination. The result of the analysis is data on cell atypia, which makes it possible to detect a precancerous condition or carcinoma.
For differential diagnosis with adenocarcinoma, consultations with an oncologist, mammography, tomographic examination of the gland, trepanobiopsy with subsequent histological examination of the sample can additionally be prescribed, with pathological discharge from the nipple – ductography. To determine the tactics of treatment, it is necessary to find out the cause of cystic mastopathy by involving narrow specialists: an endocrinologist, gynecologist, gastroenterologist, etc.
Breast cyst treatment
The management of patients is carried out by a mammologist. Conservative therapy is used for cysts with a low risk of malignancy. Surgical operation is indicated in case of ineffectiveness of conservative treatment, multiple macrocysts, epithelial proliferation, intracystic formations, the presence of hemorrhagic contents. To prevent the formation of new cysts, pathogenetic treatment is necessarily prescribed, which depends on the causes that caused mastopathy:
- Drug therapy. For small cysts, depending on the etiology, sedatives, iodine preparations, progestogens, dopamine agonists are recommended. With severe pain syndrome, swelling of the gland, nonsteroidal anti-inflammatory drugs, diuretics are used.
- Physical therapy. It is used in the same cases as medications, is carried out under the supervision of an oncologist, has an anti-inflammatory, resorbing and analgesic effect. A good result is observed after laser and magnetic therapy, electrophoresis of local anesthetics and organic iodine compounds.
- Sclerotherapy. An invasive method of treatment of solitary cysts, consisting in emptying the cystic cavity followed by the introduction of obliterating agents (ethanol, ozone-oxygen mixture).
- Surgical intervention. In the case of a solitary cyst, a sectoral resection is performed, with multiple formations, a simple mastectomy is prescribed.
Prognosis and prevention
With conservative treatment of breast cyst, the prognosis is doubtful due to a sufficiently high probability of recurrence. The efficiency of ethanol sclerosing is 50%, ozone therapy gives a slightly better result. Relapses are more often observed in multi-chamber, thick-walled, thick-filled cavities. The probability of new cysts after excision of existing formations in women of reproductive age depends on the effectiveness of pathogenetic treatment.
Primary prevention includes early detection and treatment of diseases of the genital organs, nervous and digestive system, metabolic and endocrine pathologies, prevention of metabolic syndrome (increased physical activity, restriction of sweet and fatty foods), exclusion of abortions, breastfeeding for at least six months, avoidance of stressful situations, selection of a comfortable bra. Secondary prevention involves an examination by a mammologist at least twice a year.
Literature
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