Breast Fibroadenoma


Article Author:
Maleeha Ajmal


Article Editor:
Kelly Van Fossen


Editors In Chief:
Susan Johnson
Alexandra Caley


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Frank Smeeks
Kristina Soman-Faulkner
Trevor Nezwek
Radia Jamil
Patrick Le
Sobhan Daneshfar
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Nazia Sadiq
Hajira Basit
Phillip Hynes
Tehmina Warsi


Updated:
12/13/2018 10:57:57 AM

Introduction

A fibroadenoma is a painless, unilateral, benign (non-cancerous) breast tumor that is a solid, not fluid-filled, lump. It occurs most commonly in women between the age of 14 to 35 years but can be found at any age. Fibroadenomas shrink after menopause, and therefore, are less common in post-menopausal women. Fibroadenomas are often referred to as a breast mouse due to their high mobility. Fibroadenomas are a marble-like mass comprising both epithelial and stromal tissues located under the skin of the breast. These firm, rubbery masses with regular borders are often variable in size.

Types

Complex Fibroadenoma

Rapidly growing hyperplastic cells; the pathologist can establish diagnosis after carefully reviewing the biopsy of breast tissue

Juvenile Fibroadenoma[1][2]

This fibroadenoma is commonly found in patients age 10 to 18 years. These fibroadenomas have a faster growth rate and eventually shrink or disappear.

Giant Fibroadenoma

This non-cancerous lesion is slightly larger than other types. It commonly needs excision because it compresses or replaces normal breast tissue.

Phyllodes Tumor

A stromal tumor of the breast that can be either benign or malignant. It is not a fibroadenoma, therefore; it needs to be watched closely. Most doctors recommend removing it.

Etiology

Causes of fibroadenoma are debatable, but professionals believe that the lesion has a hormonal etiology related to the increased sensitivity of breast tissue to the female reproductive hormone estrogen. Fibroadenoma usually grows during pregnancy and tends to shrink during menopause. This supports the hormonal etiologic theory. Females who take oral contraceptives before 20 years of age tend to suffer from fibroadenoma at higher rates than the general population.

Epidemiology

Fibroadenoma tends to occur in early age. It is most commonly found in adolescents and less commonly found in postmenopausal women. The incidence of fibroadenoma decreases with increasing age and generally found before 30 years of age in females in the general population. It is estimated that 10% of the world's female population suffers from fibroadenoma once in a lifetime.

Pathophysiology

Hormonal

Fibroadenoma arises from stromal and epithelial connective tissue cells that are functionally and mechanically important in the breast. These tissues contain receptors for both estrogen and progesterone. For this reason, fibroadenomas tend to proliferate during pregnancy because of excessive production of female reproductive hormones. Hormone sensitivity causes excessive proliferation of breast connective tissues.

Genetics

Mediator complex subunit 12 (MED12) gene is also important in the pathophysiology of fibroadenomas.

Histopathology

The histological diagnostic features of fibroadenoma can be described as sheets of uniformly distributed epithelial cells that are typically arranged in a honeycomb pattern. There is a presence of foam cells and apocrine cells and an absence of excessive mitotic activity or anaplasia. Calcification may also be present. Juvenile fibroadenoma has increased in stromal cellularity. The stroma is hypovascular as compared to the malignant neoplasms. The basement membrane also remains intact in fibroadenoma which reflects its benign feature.Microscopic Features

Contains both stromal and epithelial tissues that are arranged in 2 patterns:

  1. Pericanalicular: Includes the proliferation of stromal cells around epithelial structures
  2. Intracanaliccular: Includes the proliferation of stromal cells compressing epithelial cells into clefts

Unique Histological Features of Various Fibroadenomas

  1. Complex fibroadenoma: Sclerosing adenosis, calcification, apocrine metaplasia.
  2. Juvenile fibroadenoma: Epithelial and stromal hyperplasia, absence of mitoses, thin micropapillae
  3. Myxoid fibroadenoma: Stroma has myxoid features

History and Physical

Age is the most important factor in the incidence of fibroadenoma. Therefore, when obtaining a medical history, age is the most important factor which should be considered.

A family history of breast cancer is also significant. Female patients who have first-degree relatives with breast cancer should be monitored and observed more carefully for malignant features than patients without this family history.

Fibroadenoma most commonly occurs in the upper outer quadrant of the breast. On physical examination, it has the following features:

  • Non-tender or painless
  • Mobile
  • Solitary
  • Rapidly growing solid lump with rubbery consistency and regular borders.

Evaluation

After a thorough history and physical examination, the following imaging modalities are used for the diagnosis of fibroadenomas.

Diagnostic Mammogram

A mammogram uses x-rays to evaluate the suspicious masses in women above 35 years of age. Fibroadenoma on a mammogram appears as a distinct area from other breast tissue, with smooth round edges. See figure 1.

Mammographic features of fibroadenomas are variable from a well-circumscribed discrete oval mass hypodense or isodense of breast glandular tissue to a mass with macro lobulation or partially obscured margins. Involuting fibroadenomas in older, typically postmenopausal patients may contain calcification, often producing the classic, coarse popcorn calcification appearance.

Breast Ultrasound[3][4]

Ultrasound (US) uses sound waves to detect the features of fibroadenomas in women younger than 35 years of age. US easily differentiates solid from the cystic masses. On US, a fibroadenoma is typically seen as a well-circumscribed, round to ovoid, or macrolobulated mass with generally uniform hypoechogenicity.

If necessary, a minimally invasive biopsy may be performed via a core needle biopsy[5]

Treatment / Management

In the majority of cases, fibroadenomas need no treatment. They shrink and disappear over time, but if their size is large and they are compressing other breast tissues, they should be removed.

Many females decide against the surgery because the lesions are harmless and involve no long-term risk of malignancy. Surgery also distorts the shape of a breast.

Surgery

Doctors might decide to remove fibroadenoma if it is massive and continues to increase in size.

Indications for surgical intervention include rapid growth, size greater than 2 cm, and patient request.

There are 2 surgical procedures used to remove a fibroadenoma:

  1. Lumpectomy or excisional biopsy: In this procedure, the surgeon removes the fibroadenoma and sends it to the laboratory for further evaluation.
  2. Cryoablation: Surgeons use a cryoprobe to freeze and destroy the cellular structure of fibroadenoma. A core needle biopsy must be performed before cryoablation to confirm the fibroadenoma.

Differential Diagnosis

A fibroadenoma can be confused with:

  • Breast cyst
  • Breast carcinoma
  • Phyllodes tumor
  • Breast lymphoma
  • Metastasis to the breast from another primary site

Prognosis

Prognosis of fibroadenoma is good because it is a benign mass which shrinks in size over time in the majority of cases.

Complications

Breast cancer risk may slightly increase in patients with a complex fibroadenoma. This type of lesion may contain calcified breast tissue.

Enhancing Healthcare Team Outcomes

An interprofessional approach to fibroadenoma is recommended.

The majority of breast lesions in young women are identified on an incidental breast exam either by the patient or the healthcare provider. Even though fibroadenomas are benign lesions, sometimes there may be a need to confirm the histology. Healthcare workers including nurse practitioners should never assume that all firm, rubbery lesions are benign. If ever in doubt, get a radiologist or surgeon to perform a biopsy. Missing a malignant breast lesion in a young female can lead to litigation.


  • Image 7181 Not availableImage 7181 Not available
    Image courtesy S Bhimji MD
Attributed To: Image courtesy S Bhimji MD

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Breast Fibroadenoma - Questions

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Which is true of breast fibroadenomas?



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A 17-year-old female detects a round mass in her right breast while showering. She reports no symptoms and was previously unaware of the mass. On examination, the mass appears semi-soft, globular, and unattached to underlying tissues. What is the best course of treatment for this patient?



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Which is true about fibroadenomas?



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A 17-year-old patient is seen in the clinic with a breast mass. Examination reveals a 2 cm by 2 cm hard, mobile lump that is non-tender and appears semi-solid. The woman denies any trauma and does not take any medications. Which of the following is false about the breast mass?



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Which one of the following lesions is most likely going to present a discrete mobile mass in a 28-year-old female?



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A female undergoes a breast biopsy that reveals intracanalicular and pericanalicular glands. She may have which of the following conditions?



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What is the most likely lesion to present as a discrete mobile breast mass in a 28-year-old female?



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A 22-year-old female presents with a 2 cm mass in her left breast. She had no symptoms, and this was discovered incidentally while showering. The mass is round, firm, and mobile. There are no other visible features. Which of the following does this patient most likely have?



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Which of the following lesion most likely presents as a discrete mobile breast mass in a 28-year-old female?



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A 25-year-old asymptomatic female undergoes a breast biopsy that reveals intracanalicular and pericanalicular glands. Which condition does this patient likely have?



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What is the most common benign breast mass in females under the age of 35?



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A solitary, discrete, freely mobile 2.0 cm breast mass in a 22-year-old nulliparous woman is most likely going to be diagnosed as which of the following?



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What of the following is not true of a fibroadenoma?



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What is the most likely cause of a solitary, discrete, freely movable 2.5 cm breast mass in an adolescent or young adult nulliparous female?



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What is the second most common benign breast disorder?



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What is the most probable diagnosis in a teen who presents with a tender breast and two palpable, 1 cm, round, noncompressible rubbery masses in the right lower quadrant of one breast?



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A 24-year-old female has a biopsy of a 2 cm breast mass that is freely movable and rubbery. What histologic changes are most probable?



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A 23-year-old female is found to have a nontender, mobile, firm, round mass of the breast. What is the most likely diagnosis?



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What is the most common benign breast neoplasm?



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A 30-year-old woman notes a non-tender, well-defined breast lump. What is the most likely diagnosis?



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Based on multiple prior screening mammograms, a 57-year-old woman has a known fibroadenoma in the 10 o'clock position of the right breast. A change is noted on the latest mammogram, and it reassures the provider as benign. What finding would indicate this judgment?



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Ultrasound typically shows fibroadenomas associated with which of the following?



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An adolescent female presents with a breast mass. Which of the following statements is correct?



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How are fibroadenomas most commonly discovered in women under 30 years of age?



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A middle-aged female undergoes a screening mammogram shown. What is the most common comorbid condition associated with this lesion?

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A 22-year-old African American female presents with a new mass in the upper outer quadrant of her left breast. It is mildly tender and mobile. What is the next step in management?



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Breast Fibroadenoma - References

References

Neville G,Neill CO,Murphy R,Corrigan M,Redmond PH,Feeley L,Bennett MW,O'Connell F,Browne TJ, Is excision biopsy of fibroadenomas based solely on size criteria warranted? The breast journal. 2018 May 25     [PubMed]
Woodard S,Schetter S,Millington K, Diagnosis and imaging characteristics of a juvenile fibroadenoma in a 2-year-old patient: a case report. Radiology case reports. 2018 Feb     [PubMed]
Namazi A,Adibi A,Haghighi M,Hashemi M, An Evaluation of Ultrasound Features of Breast Fibroadenoma. Advanced biomedical research. 2017     [PubMed]
Huang IC,Li PC,Ding DC, Recurrent juvenile fibroadenoma of the breast in an adolescent: A case report. Medicine. 2018 May     [PubMed]
Giannos A,Stavrou S,Gkali C,Chra E,Marinopoulos S,Chalazonitis A,Dimitrakakis C,Drakakis P, A prepubertal giant juvenile fibroadenoma in a 12-year-old girl: Case report and brief literature review. International journal of surgery case reports. 2017     [PubMed]

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