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FibroadenomaWhat do we need to know?
C C Lee
Department of Surgery
Tuen Mun Hospital
A common patient…
20/F Right breast mass for 3
months P/E: 3cm R10H E2
DDx?
- Fibrocystic change
- Inflammatory masses
- Mammary harmatoma
- Phylloides tumour
- Tubular adenoma
- Malignancies
FNAC: C2 USG: U2
A common patient…
Mx: Local excision
Path: Fibroadenoma
20/F Right breast mass for 3
months P/E: 3cm R10H E2 FNAC: C2 USG: R2
What is a fibroadenoma Arise from the lobule of
the terminal duct-lobular unit
Proliferation of both glandular and stromal elements
What is a fibroadenoma Concept of ANDI – Aberration of Normal
Development and Involution (LE Hughes,1987)
Stage (Years) Normal Process Aberration Disease
Early reproductive period (< 25)
Breast development
Lobular development
Fibroadenoma
Giant fibroadenoma/ multiple fibroadenomas
Stromal development
Juvenile hypertrophy
Excessive hypertrophy
Mature reproductive period (25 - 40)
Cyclical hormonal effects on glandular and stromal tissues
Exaggerated effects:cyclical mastalgia/ nodularity
Severe mastalgia/ nodularity
Involution (35-55)
Lobular involution MacrocystsSclerosing lesions
Extensive/recurrent cysts
Ductal involution Duct ectasia Periductal mastitis with bacterial infection and abscess formation
Epithelial turnover Simple epithelial hyperplasia
With atypia
0
10
20
30
40
50
60
70
80
90
20 21-30 31-40 41-50 51-60 >60 Age (years)
% o
f Tot
al
Fibroadenoma
Cancer
Cyst
What is a fibroadenoma
Management implication!
Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
Conventional/ typical/ simpleThe most common form
Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
≥ 5 separate lesions in an individual breast
Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
1. Sclerosing adenosis2. Cysts > 3mm3. Papillary apocrine metaplasia4. Epithelial calcification
Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma• ≥ 5cm• ≥ 500g• replacing ≥ 4/5 of the breast
Natural history
Variable
Over 2 years Dent DM & Cant PJ1989 43% 25% 32%
Dobie V, Walsh J, Lamb J et al
1994
13% 85% 2%
Dixon JM, Dobie V, Lamb J et al
1996
37% 55% 8%
Management implication!
Diagnostic approach
Triple assessment
1. Clinical Examination
2. Imaging
3. Biopsy Doctor, is this a
cancer?
Management of fibroadenoma
Options:
1. Conservative
2. Operative
3. Other alternatives
Doctor, do I need an
operation?
Conservative We are treating a disease, not a normal process
Stage (Years) Normal Process Aberration Disease
Early reproductive period (< 25)
Breast development
Lobular development
Fibroadenoma
Giant fibroadenoma/ multiple fibroadenomas
Stromal development
Juvenile hypertrophy
Excessive hypertrophy
Mature reproductive period (25 - 40)
Cyclical hormonal effects on glandular and stromal tissues
Exaggerated effects:cyclical mastalgia/ nodularity
Severe mastalgia/ nodularity
Involution (35-55)
Lobular involution MacrocystsSclerosing lesions
Extensive/recurrent cysts
Ductal involution Duct ectasia Periductal mastitis with bacterial infection and abscess formation
Epithelial turnover Simple epithelial hyperplasia
With atypia
Conservative
Majority remains static or gets smaller or even disappears
Over 2 years Dent DM & Cant PJ1989 43% 25% 32%
Dobie V, Walsh J, Lamb J et al
1994
13% 85% 2%
Dixon JM, Dobie V, Lamb J et al
1996
37% 55% 8%
Conservative
Conservative approach is safe for patient < 25 yo (Cant PJ, Madden MV, Close PM et al. Case for conservative management of selected
fibroadenomas of the breast. British Journal of Surgery 1987; 74: 857-859)
Conservation is safe in < 40 yo, with diagnosis confirmed by cytology and USG (+ MMG if >35 yo)
(Dixon JM, Dobie V, Lamb L et al. Assessment of the acceptability of conservative management
of fibroadenoma of the breast. British Journal of Surgery 1996; 83: 264-265)
Doctor, will the lump ‘change’?
Cancer in a fibroadenoma
Incidence 0.3% (Osello 1985)
Prevalance of CA within FA ~0.02% (Deschenes 1985) 2 cases of LCIS over 45 years (Haagensen 1986)
5 out of 4000 FA over 43 years (Buzanowski-Konarky 1975)
By chance!!
(Diaz NM 1991, Fondo EY 1979)
Management options
Conservative Operative Other alternatives
Indications1. Grows over time2. >2cm at diagnosis3. Doubt on diagnosis
4. Patient anxiety
Fibroadenoma and subsequent cancer risk
Genetic changes
- Genetic alterations most frequently involved in
malignant breast carcinomas were not identified in FA (Noreli Franco et al 2003)
Fibroadenoma and subsequent cancer risk
Epidemiological studies- Complex features + family history: 3-4x (Dupont 1994)
- No increase in risk in women with fibroadenoma (Maria J Worsham 2008)
Level of increased risk for invasive breast cancer
Relative risk
Fibroadenoma without complex features
No increase 1
Fibroadenoma with complex featuresProliferative change
Slightly increased 1.5-2
ADHALH
Moderately increased 4-5
LCIS Markedly increased 9
Management options
Conservative Operative Other alternatives
Indications1. Grows over time2. ≥ 3cm at diagnosis3. Doubt on diagnosis
4. Patient anxietyVacuum assisted excision?Laser ablation?Radiofrequency ablation?Cryosurgery
How about these patients…?
45/F Right breast mass x 6 months P/E 2cm R9H E2 MMG/ USG: R2 FNAC: C2
60/F Left breast mass x 2 years P/E 1.5cm L2H E2 MMG/ USG: R2 FNAC: C2
Mx: local excision Mx: local excision
What is your management plan?
0
10
20
30
40
50
60
70
80
90
20 21-30 31-40 41-50 51-60 >60 Age (years)
% o
f Tot
al
Fibroadenoma
Cancer
Cyst
Remember this graph…
How about these patients…?
45/F Right breast mass x 6 months P/E 2cm R9H E2 MMG/ USG: R2 FNAC: C2
60/F Left breast mass x 2 years P/E 1.5cm L2H E2 MMG/ USG: R2 FNAC: C2
Mx: local excision Path: phylloides tumour
Mx: local excision Path: mucinous carcinoma
Take home message - 1 Majority of FA in the young could be managed
conservatively with the concept of ANDI and its natural history
Excision is indicated if it grows, or is > 2cm or if there is any suspicion on diagnosis
Patient anxiety is a concern
Take home message - 2
Occurrence of CA in FA is purely by chance
Subsequent risk of CA breast does not increase in pure FA unless there are presence of complex features
‘FA’ may not be FA!
FibroadenomaWhat do we need to know?
Thank You
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