Clinical Practice Guideline for Diagnosis and Treatment of Hyperplasia of the Mammary Glands: Chinese Society of Breast Surgery (CSBrS) Practice Guideline 2021
Hyperplasia of the mammary glands (HMG) is a non-inflammatory and non-tumorous lesion characterized by structural disorders of the mammary glands due to varying degrees of hyperplasia and subinvolution of the mammary parenchyma and stroma. In the literature, HMG is also referred to as mastopathy, fibroadenosis, fibrocystic breast disease, mastalgia, fibrocystic change, benign mammary dysplasia, or sclerosing adenosis. Despite its prevalence, there are no standardized, scientifically validated diagnostic and treatment approaches for HMG. To address this gap, the Chinese Society of Breast Surgery (CSBrS) has developed clinical practice guidelines based on a review of domestic literature and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) handbook. These guidelines aim to provide a reference for Chinese breast specialists in their clinical practice.
The guidelines were formulated by an expert panel consisting of 85 voting committee members, including 71 breast surgeons, four oncologists, four radiologists, two pathologists, two radiation therapists, and two epidemiologists. The target audience for these guidelines is clinicians specializing in breast diseases in China.
Definition and Clinical Manifestations
HMG is defined as a non-inflammatory and non-tumorous lesion of the mammary glands, resulting from structural disorders associated with hyperplasia and subinvolution of the mammary parenchyma and stroma. The major clinical manifestations of HMG include cyclical or non-cyclical breast pain, nodular breast or diffuse distribution of thickened glands, and nipple discharge in some patients. The nodular breast may present as granular nodules, striped nodules, solitary masses, or locally or diffusely thickened breast tissue. Palpation often reveals solitary or multiple firm nodules with unclear boundaries, which may exhibit cyclic changes in size and nature over the menstrual cycle.
Diagnostic Methods
The diagnosis of HMG is based on the exclusion of other conditions, a detailed patient history, systematic breast examination, clinical manifestations, auxiliary examinations, and histopathological examination of biopsy specimens. Key diagnostic methods include:
- Patient History: This includes information on breast symptoms, concomitant symptoms, duration of symptoms, factors associated with symptom aggravation or relief, past history of breast or ovarian diseases, family history of breast cancer, and history of reproductive hormone or oral contraceptive use. For patients with breast pain, the type, duration, location, severity, and relationship to menstruation should be documented.
- Systematic Breast Examination: This involves inspection and palpation of the breasts in both upright and supine positions.
- Ultrasonography: This imaging modality is superior to breast radiography for resolving nodes, cysts, and solid tumors in dense breasts.
- Breast Radiography: This is effective for detecting early carcinoma and microcarcinoma, particularly microcalcifications.
- Breast Magnetic Resonance Imaging (MRI): MRI is more sensitive but has a higher false-positive rate than ultrasonography and radiography. It is recommended as a supplementary examination for high-risk patients.
- Histopathological Examinations: Techniques include core needle biopsy (CNB), vacuum-assisted breast biopsy (VABB), and excisional biopsy.
Imaging Findings
On ultrasonography, HMG typically manifests as thickened and enhanced echoes, internal hypoechoic nodes with irregular and unclear margins, or no attenuation or slight enhancement of posterior echoes. Color Doppler ultrasonography may reveal a few punctiform or short rod-like blood-flow signals. Radiography may show massive high-density shadows or nodular shadows without visible borders, sometimes accompanied by calcifications. However, dense breast tissue can reduce the sensitivity of radiography for detecting lesions, particularly malignant ones. Breast MRI is recommended for women unsuitable for ultrasonography or radiography or those at high risk of breast cancer with negative findings on other imaging modalities.
Histopathological Classification
HMG exhibits diverse and complicated histopathological findings, leading to controversy in its classification. It is generally classified into two categories:
- Mastopathy: This includes lobular hyperplasia, fibro-adenosis, and sclerosing adenosis.
- Fibrocystic Mastopathy: This includes cysts, ductal epithelial hyperplasia, blunt duct adenosis, and adenosis with apocrine metaplasia. These subtypes may occur singly or multiply in the mammary lobules of the same patient, with varying degrees of hyperplastic development.
The risk of malignant transformation varies among the subtypes. Fibrocystic mastopathy with atypical ductal hyperplasia (ADH) carries a significantly increased risk of breast cancer, with a transformation rate ranging from 1% to 5%.
Treatment Principles
The treatment of HMG focuses on regular monitoring, non-medical treatments, and symptomatic management.
- Regular Monitoring: Regular follow-up examinations are recommended for patients with HMG.
- Non-Medical Treatments: These include psychological counseling and lifestyle interventions, such as dietary changes.
- Symptomatic Treatments: Medications such as bromocriptine, danazol, and tamoxifen are effective for severe breast pain. However, there is limited evidence supporting the use of drugs to reverse histopathological changes in HMG. The side effects of medications should be carefully considered when weighing their risks and benefits.
- Surgical Interventions: HMG is not an indication for surgical treatment. Any surgical intervention, including puncture biopsy or resection, is aimed at avoiding misdiagnosis or missed diagnosis of breast cancer.
High-Risk Patients
Patients at high risk of breast cancer include those with ADH or a family history of breast cancer in first-degree relatives. For these patients, preventive strategies such as careful follow-up examinations, medications, and surgical interventions should be implemented.
Conclusion
The concept of HMG continues to evolve with the discovery of new evidence-based information, impacting clinical practice. The establishment of standardized diagnostic and treatment guidelines for HMG can prevent the misdiagnosis of benign disease as malignant, thereby avoiding improper treatment, waste of medical resources, and unnecessary physical and mental harm to patients. The CSBrS guidelines provide a comprehensive framework for the diagnosis and management of HMG, emphasizing the importance of regular monitoring, non-medical interventions, and careful consideration of symptomatic treatments.
doi.org/10.1097/CM9.0000000000001521
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