History

Fact Explanation
Breast lump Often noticed incidentally by the patient on self examination of the breast. Presents as a discrete and mobile lump.Most often found in the upper outer quadrant. [1] Is a benign neoplasm of the breast with epithelial and stromal components [2] where the fibromatous element is the most dominant feature.[3] Fibroadenomas grow slowly and become extremely large (>5cm), whence they are referred to as 'giant' fibroadenomas.
Age of presentation <30 years Most commonly seen in younger women below the age of 30. The histological variant seen in younger women is of the pericanalicular type and is a hard-firm lump. May occasionally present in older women where the intracanalicular variant is more common, the consistency of the lump is relatively softer when compared to the former. [3]
Increases in size during pregnancy [4] The stromal and epithelial cells of the breast contain estrogen and progesterone receptors. [4] The increase in these hormones during pregnancy cause proliferation of the lesion.
Regresses following menopause [1] Fibroadenoma is a hormone dependent tumor, due the reduction in the secretion of estrogen and progesterone there is a predictable reduction in size following menopause. [4]
Almost exclusively seen in females [5] Is the most common benign breast tumor in adolescent women that arises from a terminal duct lobular unit. Fibroadenoma in the male breast is extremely rare. [5]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Arnold. 2000.
  2. Fibroadenoma of breast. Pathology Outlines. PathologyOutlines.com, Inc. [viewed 23 March 2014]. Available from: http://www.pathologyoutlines.com/topic/breastfibroadenoma.html
  3. BROWSE Normal L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. London. Hodder and Arnold. 2005.
  4. BEWTRA Chhanda. Fibroadenoma in women in Ghana. The Pan African Medical Journal. 2009 vol- 2:1. [viewed 23 March 2014}. Available from: http://www.panafrican-med-journal.com/content/article/2/11/full/
  5. ASHUTHOSH N, VIRENDRA K, ATTRI PC, ARATI S. Giant male fibroadenoma: a rare benign lesion. Indian J Surg. 2013 Jun;75(Suppl 1):353-5. [viewed 23 March 2014] Available from: doi: 10.1007/s12262-012-0566-9.

Examination

Fact Explanation
Breast lump Most common benign breast lump seen in adolescent women. [1] Typical presentation is a discrete, painless lump that is firm in consistency and is freely mobile that merits its description as 'breast mouse'. [2,3] Usually of a spherical or ovoid shape, with a smooth surface though it may occasionally be lobulated. [3] Note that that the intracanalicular variety found in the older age group may be of a softer consistency.
Multiple lumps Most fibroadenomas are discrete solitary lesions but rarely they can be multiple and/or bilateral. [1,4]
References
  1. RUSSELL RCG, WILLIAMS Norman S, BULSTRODE Christopher JK. Bailey and Love's Short Practice of Surgery. 23rd edition. London. Arnold. 2000.
  2. ASHUTHOSH N, VIRENDRA K, ATTRI PC, ARATI S. Giant male fibroadenoma: a rare benign lesion. Indian J Surg. 2013 Jun;75(Suppl 1):353-5. [viewed 23 March 2014] Available from: doi: 10.1007/s12262-012-0566-9.
  3. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. London. Hodder and Arnold. 2005.
  4. CAMARA O, EGBE A, KOCH I, HERRMANN J, GAJDA M, BALTZER P,RUNNEBAUM IB. Surgical Management of Multiple Bilateral Fibroadenoma of the Breast: The Ribeiro Technique Modified by Rezai. Anticancer Research July 2009 vol. 29 no. 7 2823-2826 [ viewed 23 March 2014] Available from: http://ar.iiarjournals.org/content/29/7/2823.full

Differential Diagnoses

Fact Explanation
Benign or Low grade Phylloides tumor[1] This is a relatively rare lesion. Commonly presents as a slow growing, smooth swelling of the middle aged breast.[2] If large may cause skin necrosis. Often distinguished on histological analysis. Histology will show a hypercellular stroma with stromal overgrowth and a prominent leaf-like architecture. There is stromal condensation around ducts which may infiltrate surrounding breast tissue. [1]
High grade Phylloides tumor[1] Similar clinical presentation to benign or low grade Phylloides tumor.[3] Histological characteristics are different: presence of pleomorphic stromal cells, stromal mitotic rate < 4-5/hpf ,abnormal forms may be found with infiltration of the surrounding breast.[1]
Tubular adenoma[1] Is a rare epithelial tumor of the breast found in young women of reproductive age. [4] Histology will demonstrate scant stroma and uniform tubules. [1]
Fibrocystic disease[1] Breast lumps, swelling and tenderness usually worsens before menstruation. Common in women of childbearing age and are commonly multiple and bilateral.
Mammary hamartoma[1] A rare benign breast lump. Painless, well circumscribed and mobile. [5] Can be differentiated with histology; lobules typically present (may be atrophic), morphologically normal ducts and lobules and fat is integral to the lesion. [1]
Breast cysts[2] A spherical, immobile lump that maybe tender on palpation. Often seen in middle aged women in their forties and late fifties. [2] Needle aspiration once a presumptive diagnosis of a breast cyst is made will yield a fluid that may vary in color from yellow, dark green to black.
References
  1. Fibroadenoma of the breast. Surgical Pathology Criteria. Stanford School of Medicine. 2014 [viewed 23 March 2014]. Available from: http://surgpathcriteria.stanford.edu/breast/fibroadenoma/differentialdiagnosis.html
  2. BROWSE Norman L, BLACK John, BURNAND Kevin G, THOMAS William EG. Browse's Introduction to the Symptoms and Signs of Surgical Disease. 4th edition. London. Hodder and Arnold. 2005.
  3. ALTAF Fadwa Jameel, DAFFA Noura. Phyllodes Tumor. Bahrain Medical Bulletin, Vol. 26, No. 3, September 2004. [viewed 23 March 2014]. Available from: http://www.bahrainmedicalbulletin.com/September_2004/phyllodes.pdf
  4. SALEMIS Nikolaos S et al. Tubular Adenoma of the Breast: A Rare Presentation and Review of the Literature. J Clin Med Res. Feb 2012; 4(1): 64–67. [viewed 23 March 2014] Available from: doi: 10.4021/jocmr746w
  5. RUIZ Tovar J et al. Mammary hamartoma. Clin Transl Oncol. 2006 Apr;8(4):290-3. [viewed 23 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pubmed/16648106

Investigations - for Diagnosis

Fact Explanation
Ultrasound scan of the breast Sonographic data that support the diagnosis of fibroadenoma are: a round or oval mass with a smooth contour and weak internal echoes in a uniform distribution and intermediate acoustic attenuation. [1]
Mammography The mammography yield in young women is low and the role it plays in the diagnosis of fibroadenoma is limited.[1] If present fibroadenomas appear as soft, homogenous, well circumscribed nodules with inner coarse calcifications.
Fine needle aspiration cytology (FNAC) The characteristic cytologic features of fibroadenomas are: clusters of spindle cells without inflammatory or fat cells; aggregates of cells with a papillary configuration resembling elk antler (antler horn clusters); and uniform cells with well-defined cytoplasm lying in rows and columns (honeycomb sheets). When combined with the clinical diagnosis of fibroadenoma the sensitivity of the diagnosis is 86% with a specificity of 76%. [1] Though FNAC may confuse the diagnosis of fibroadenoma with another benign breast lesion, confusion with a malignant lesion is extremely rare. [1,2]
References
  1. GREENBERG Ron, SKORNICK Yehuda, KAPLAN Ofer. Management of breast fibroadenomas. Journal of General Internal Medicine September 1998, Volume 13, Issue 9, pp 640-645 [viewed 23 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497021/
  2. DENT DM, CANT PJ. Fibroadenoma. World Journal of Surgery . 1989 vol- 13:706–10.

Investigations - Screening/Staging

Fact Explanation
Mammogram [1] Several studies have shown that there is a 1.3 to 2.1 increased risk of breast cancer in women with fibroadenomas compared with the general population. [1,2] This is important for women with a family history of breast cancer or a complex fibroadenoma as it adds to their risk of breast malignancy. This should give additional incentive to a patient to participate in regular mammogram screening.[2]
References
  1. GREENBERG Ron, SKORNICK Yehuda, KAPLAN Ofer. Management of breast fibroadenomas. Journal of General Internal Medicine September 1998, Volume 13, Issue 9, pp 640-645 [viewed 23 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497021/
  2. Dupont WD, Page DL, Park FF. Long-term risk for breast cancer in women with fibroadenoma. N England Journal of Medicine. 1994;331:10–15 [viewed 23 March 2014]. Available from: http://www.nejm.org/doi/pdf/10.1056/NEJM199407073310103

Management - General Measures

Fact Explanation
Reassurance If conservative management is embarked upon, the clinical, imaging and cytological findings should all be compatible with a fibroadenoma.In women younger than 35 years a conservative approach is recommended. With follow up every 12 months until the lesion has completely disappeared. If the lesion has not disappeared at 35 years, excision is warranted. In a woman above 35 years imaging should be repeated every 6 months to ascertain whether the features of the fibroadenoma are changing. If the lesion has not disappeared at 12 months excision is warranted. [1]
References
  1. GREENBERG Ron, SKORNICK Yehuda, KAPLAN Ofer. Management of breast fibroadenomas. Journal of General Internal Medicine September 1998, Volume 13, Issue 9, pp 640-645 [viewed 23 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497021/

Management - Specific Treatments

Fact Explanation
Cryoablation of fibroadenoma [1] This is an office based procedure that uses a cryoprobe to treat biopsy proven fibroadenomas. Studies show that there is little or no pain,that target lesions are reduced in size or eliminated, scarring was minimal, cosmesis is outstanding and patient satisfaction is excellent. [1]
Excision [2] Recommended in patients who have a large fibroadenoma that is not cosmetically unacceptable or prefer excision rather than conservative management. Surgical excision requires an incision that is 1-2 inches long. There will be a external scar after healing and the internal scar may interfere with future mammogram readings.
Mammotome [3] A breast biopsy technique that is done with local anesthesia and under ultra sound guidance. Is an outpatient procedure with minimal scarring and post procedural pain. [3]
References
  1. KAUFMAN Cary S. Office-based ultrasound-guided cryoablation of breast fibroadenomas. The American Journal of Surgery 184 (2002) 394–400 [viewed 23 March 2014]. Available from: http://endocare.mx/docs/mama/cancer%20mama%201.pdf
  2. GREENBERG Ron, SKORNICK Yehuda, KAPLAN Ofer. Management of breast fibroadenomas. Journal of General Internal Medicine September 1998, Volume 13, Issue 9, pp 640-645 [viewed 23 March 2014]. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497021/
  3. How a breast biopsy using the Mammotome breast biopsy system works. Mammotome 2013 [viewed 23 March 2014] Available from: http://www.mammotome.com/BSBiopsySystemWorks.aspx