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