General Surgery Rotation

General Surgery: Benign breast disease: fibroadenomas and fibrocystic breast disease

Patient will present as → a 27-year-old female with a painless mass in the left breast. She discovered this mass three months ago while showering and reports it has been unchanged since that time. Her last menstrual period was 10 days ago. There is no family history of breast cancer. On physical exam, you palpate a 3 cm, firm, non-tender mass in the upper lateral quadrant of the left breast. The mass is smooth, well-circumscribed, and mobile. There are no skin changes, nipple discharge, or axillary lymphadenopathy. Ultrasound of the breast was performed with results seen here.

Fibroadenomas are the most common benign breast tumor affecting 10-20% of women and account for 1/2 of all breast biopsies

  • They are composed of glandular and fibrous tissue and most commonly found in women between the ages of 15 and 35 years
  • Painless, firm solitary (rubbery feeling) well defined mobile mass
  • Fibroadenomas gradually grow over time and size does not usually wax and wane with menstruation although they may cause discomfort for a few days before the onset of menses. There is no axillary involvement or nipple discharge
  • Fibroadenomas are rubbery, well-circumscribed, mobile masses with an average size of 2 to 3 cm
  • They are most frequently found in the upper, outer quadrants but may occur in any quadrant
  • The etiology of fibroadenomas is not known, but a hormonal relationship is likely since they persist during the reproductive years, can increase in size during pregnancy or with estrogen therapy, and usually regress after menopause

Fibroadenomas can be diagnosed clinically ⇒ in equivocal cases, mammogram with ultrasound and/or needle aspiration is helpful

  • Present as a well-defined solid mass on ultrasound
  • Mammography is not indicated in adolescents, because a large amount of glandular tissue present in adolescents makes mammography difficult to interpret
  • A well-defined solid mass with benign imaging features can be managed with a core needle biopsy or short-term (three to six months) follow-up with a repeat ultrasound and breast examination
  • Definitive diagnosis can only be confirmed with a core biopsy or excision

Management of fibroadenomas entails careful follow-up and reassurance, as most fibroadenomas decrease in size, and some completely disappear with time

  • Fibroadenomas less than 5 cm without concerning features can be observed at one to two-month intervals for growth or regression
  • When the mass regresses, observation at three to four-month intervals (with increasingly longer intervals each time) is appropriate for up to two years while the mass is regressing
  • If there is persistence of the lesion, an ultrasound can be obtained. If the ultrasound characteristics are entirely consistent with a fibroadenoma, the mass need not be biopsied or excised unless there is an overriding clinical concern
  • If there is a growth of the lesion, the lesion is greater than 5 cm, or (in adolescents) if the lesion persists to adulthood, excisional biopsy is warranted
  • If a biopsy-proven fibroadenoma is asymptomatic, then it can be left in place, although some women wish to have the mass excised so that they will not worry further
    • Disadvantages of excisional surgery include scarring at the incision site, dimpling of the breast from the removal of the tumor, damage to the breast's duct system, and mammographic changes (eg, architectural distortion, skin thickening, increased focal density)
  • Cryoablation is an alternative to surgical excision of fibroadenomas but should only be considered after a core biopsy diagnosis of fibroadenoma has been made

Adapted from surgical recall, by Lorne Blackbourne

Picmonic
Fibroadenomas

IM_MED_Fibroadenoma_v1.4_

Fibroadenomas are benign lumps of fibrous and glandular tissue, which must be biopsied to rule out cancer. These are small, mobile masses which often have well-defined edges. They are not a precursor to cancer and an increase in size and tenderness with estrogen exposure (or in the menstrual cycle).

Play Video + Quiz

Question 1
A 23-year-old woman consults her physician because of a breast mass; the mass is mobile, firm, and approximately 1 cm in diameter. It is located in the upper outer quadrant of the right breast. No axillary lymph nodes are present. What is the most likely diagnosis in this patient?
A
Carcinoma of the breast
B
Fibrocystic disease
C
fibroadenoma
D
Pagets disease
Question 1 Explanation: 
This patient has a fibroadenoma, or breast mouse. Fibroadenomas are the most common type of solid benign breast tumors. They are most prevalent in women younger than 25 years. They are usually painless, well circumscribed, completely round, and freely mobile. The classic description with respect to consistency is “rubbery.”
Question 2
What is the treatment of choice for the condition described here?
A
modified radical mastectomy
B
lumpectomy
C
biopsy
D
radical mastectomy
Question 2 Explanation: 
The treatment of choice for a suspected fibroadenoma is either a fine-needle biopsy or an excision biopsy. Although rare, malignant neoplasms have occasionally been found in fibroadenoma. Radical mastectomy and radiation therapy are not treatment modalities for a fibroadenoma.
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