Mastopathia Cystica and Mammary Carcinoma

The relationship of cystic disease of the breast, mastopathia cystica, to carcinoma is, and has always been, a subject of controversy. In 19o6, when Bloodgood (2) considered senile parenchylnatous hypertrophy, he and many other authors thought that this condition was a precancerous lesion and that the probability of cancer being associated with it was as high as 5o per cent. However, in 1921 (3) he described a group of 35o patients with chronic cystic mastitis, in 222 of whom he had had the opportunity to study the entire breast. In not a single instance (lid he find gross or microscopic cancer. In I932 (4) , a check-up examination on these patients showed that none had developed evidence of malignancy. At this time he added 3o new operative cases and almost 2oo examples of unoperated "shotty" breast which had been followed by yearly examination. He reaffirmcd the opinion formulated IO years previously that the development of cancer of the breast after removal of a zone of the breast, which is the seat of chronic cystic mastitis, is apparently not more frequent than in the same number of women at the same age upon wholn operation has not been performed (3)Deaver and McFarland (lO), after examining 335 cancerous breasts, found 23 in which abnormal involution and carcinoma coexisted, but stated that they "cannot see the necessity for supposing that two conditions that happen to coexist must be connected to one another in the relation of cause and effect." Kilgore (17) found carcinoma in only I of x9 instances of hyperplastic cystic disease showing clinically as a lump in the breast. Klingenstein (18) presented the follow-up data on 54 of an original group of 74 patients who had had partial excision of a breast for chronic cystic mastitis. Only 2 patients (3.7 per cent) were known to have developed carcinoma. Campbell (5) reported 43 examples of hyperplastic cystic disease among 233 cases of cystic disease of the breast of all types, which had been treated by local excision. In only one did carcinoma of the breast subsequently develop and then in an area far removed from the site of the previous operation. Of 57 patients treated by amputation of one breast, carcinoma developed in the remaining breast of but one. Thus, of 29o patients followed, only 2 or o.7 per cent developed carcinoma. Johnson (15) followed 6I of IOI patients with cyst of the breast for periods of i to 20 years and found no evidence of carcinoma. In 4 instances in which both a cyst and carcinoma were dealt with, the carcinoma was on the same side as the cyst in 2 and on the opposite side in 2. Lewis and Oeschickter ( I9 ) also emphasized Bloodgood's views. They reported 3 deaths from carcinoma among 27i patients with adenosis of the breast who had been followed for more than 5 years, and I death from carcinoma among 252 patients with cystic disease followed for the same period. In a study of 2,675 carcinomas of the breast, only 0. 5 per cent of the usual types were found to show changes characteristic of Schimmelbusch's disease, yet 3 ~ per cent having carcinoma of the ductal (comedo) type were associated with breast tissue showing these changes. Greenough and Simmons (14) traced 83 women with partial resection of the breast for cystic disease over periods of i to 17 years (average 7 years). In 4 (4.8 per cent) carcinoma developed in the remaining breast tissue. Fischcr (13) found cystic disease in I4 per cent of 151 patients. Rodman (22) found that chronic cystic mastitis was associated with carcinoma in I5.5 per cent of more than a hundred cases studied by him. Cheatle and Cutler (7, 8) stated that at least 2o per cent of all carcinomas of the breast can be traced directly to mastopathia cystica. This figure is in close agreement with that of Sernb (23) , who found the incidence of carcinoma in Ioo cases of "fibro-adenomatosis cystica" to be 24 per cent, and of Morpurgo (21), who found cystic changes in 24 per cent of 196 patients with carcinoma of the breast. Dietrich and Frangenheim ( I I ) studied 5o0 mammary gland preparations of which 233 (46.6 per cent) showed mastopathia cystica. Sixty-eight of the 233 (29.2 per cent) showed coexistent carcinoma. Ewing (12) found minimal carcinomas in 50 per cent of the breasts excised for cystic disease. Dahl-Iverson and Starup (9) found coincidence of carcinoma and mastopathia cystica in 44 per cent of 34 cases studied by thcm. Keynes (16) reported on 116 specimens of breast tissue removed post-mortem, of which 57 were normal and 59 showed "inflammatory lesions." He also reported that in 25 examples of carcinoma of the breast, 2o (8o per cent) showed some evidence of "chronic mastitis." Upon histologic study, Charteris (6) found that 41 (85 per cent) of 48 breasts removed for carcinoma were also the seat of chronic cystic mastitis in some degree. The malignant growth was believed to have arisen from the ducts in 31 of the 48 (64 per cent). MacCarty and Mensing (2o) examined 967 breast~ removed for carcinoma and found evidence of mastopathia cystica in IOO per cent of them. Thus, it can be seen that a historical review of the literature from either a clinical or pathologic viewpoint will reveal considerable evidence to support either the casual or the causal relationship of mastopathia cystica and carcinoma. The most recent report is that of Warren (24) , who followed clinically for at least 5 years a group of women who had portions of the breast removed. He compared the incidence of carcinoma in this group with that of the general female population and found that 35 cancers occurred in 1,o44 individuals with chronic mastitis and chronic cystic mastitis. On contrasting specific cancer rates with those of the female population of Massachusetts, evidence was found that the cancer rate for women with pre-cxisting breast lesions is 4.5 times as great as for all women, and that this predominance is especially marked in the decades below 5o years of age. The definition of mastopathia cystica depends, to a large degree, upon each author's opinion as to the nature of the disease. Cheatle and Cutler (7) considered that mastopathia cystica includes two distinct diseases. The first, named "mazoplasia," is a physiologic rather than a pathologic process, and there are no other lesions in the breast such as fibroadenomas, cysts, or papillomas. It is characterized by desquamation of the epithelial cells in the terminal ducts and acini, accompanied by hyperplasia of the pericanalicular and periacinous connective tissue. The second type of epithelial hyperplasia results in the formation of cysts, minute to large, and is designated "cystipherous desquamative epithelial hyperplasia." It was the opinion