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BENIGN BREAST DISEASES FIBROADENOMA FOR GENERAL PRACTITIONERS What is a Fibroadenoma?
A Fibroadenoma is a benign breast lump. It is made up of fibrous tissue and
glandular tissue. ”Oma” refers to
tumour or lump, “fibro” refers to fibrous and “adeno” refers to glands.
They are often mobile, hence called a “breast mouse”.
What is the
incidence of Fibroadenoma? Fibroadenoma accounts for approximately 13% of all
symptomatic breast lumps.
When does it occur? Although it can develop at any age it usually occurs in the late teens and early twenties when the breast lobular development is the greatest. What causes Fibroadenoma?
The cause of Fibroadenoma is unknown.
Hormonal
factors are thought to play a part as Fibroadenoma is known to fluctuate during
the menstrual cycle and during pregnancy. Fibroadenoma may present in women on
hormone replacement therapy and
tend to regress after the menopause.
What
is a juvenile Fibroadenoma or a giant Fibroadenoma? Although rare some Fibroadenoma grow rapidly within a short time and cause marked asymmetry of the breast. Tumours greater than 5 cm are termed as giant Fibroadenoma and are common in the African countries. Juvenile Fibroadenoma are characteristically seen in teenagers or in the early twenties. What
is a complex Fibroadenoma?
Approximately 50% of Fibroadenomas contain other
proliferative changes of breast, such as sclerosing adenosis, adenosis, and duct
epithelial hyperplasia. Fibroadenomas that contain these elements are called
complex Fibroadenomas.
How do patients present? In young women they may present as a
lump.
Fibroadenoma is usually painless, but in some, may
feel tender or even painful. It may also be seen as
an incidental finding during breast imaging (ultrasound, mammogram or MRI scan)
for other problems in the breast.
Which patients with breast
lumps should be referred to the hospital? URGENT REFERRALS Who are female, aged 30
years and older With a discrete lump that persists
after their next period, or presents after menopause
Who are female, aged younger
than 30 years With a lump that enlarges
With a lump that is fixed and hard
In whom there are other reasons for concern such as family
history NON URGENT REFERRALS Women aged younger than 30 years with a lump.
Which patients with breast
lumps can be managed at the GP practice? All patients with lumps should be referred to the breast clinic.
What is the relationship between
Fibroadenoma and breast cancer?
Simple Fibroadenoma is not associated with any increased risk for subsequent
breast cancer.
However, women with complex Fibroadenoma may have a slightly higher risk for
subsequent cancer [1]. Fibroadenoma
in older women or in women with a family history of breast cancer have a higher
incidence of associated carcinoma [2, 3].
Complex
and multiple Fibroadenoma is associated with a two-fold increase in the risk of
breast cancer.
What is the natural history of Fibroadenoma?
In most women, only one Fibroadenoma is found. Occasionally, there is more than one and sometimes they occur in both breasts. Fibroadenoma varies in size. Fibroadenoma can be palpable or impalpable. In women less than 40 years of age majority of Fibroadenoma does not change size (80%), some get smaller or completely disappear (15%) and some increase in size (5-10%).How is a Fibroadenoma diagnosed?
Patients below 25 years of age will have
a clinical and an ultrasound examination of the breast.
Patients may not usually undergo a needle test or a biopsy unless the
ultrasound image is atypical or patients have risk factors such as a family
history of breast cancer. The reason being it is extremely rare to have breast
cancer in this age group and ultrasound confirmation is enough evidence.
Patients over 25 years of age
will have a clinical and an ultrasound
examination of the breast.
Ultrasound is preferred in younger women with dense breasts as mammograms are
difficult to interpret and Fibroadenoma may not be visible. However in less
fatty breasts mammogram may also be done.
In majority of patients over 25 years of age, ultrasound of the breast or
mammogram alone may not be enough to confirm the diagnosis of Fibroadenoma.
The patient may have a fine needle aspiration. Cells are studied by the
pathologist to confirm a diagnosis of Fibroadenoma.
Because of the high proportion of fibrous tissue relative to epithelial tissue
in Fibroadenoma, fine needle aspiration may be insufficient for diagnosis. Hence
most breast specialists will recommend a core biopsy
to obtain a sample of tissue rather than cells to confirm
the diagnosis
of Fibroadenoma. The sample is processed by the pathologist and may take up to
48 hours for the results.
How is Fibroadenoma managed? The management again depends on patients age, patient
preference and the results of the tests.
Age less than 25
Once confirmed that
a lump is a Fibroadenoma, patients will be reassured and discharged. There is no
need to remove it. It can be safely left alone unless patient wishes that the
lump is removed.
Age
more than 25
If a diagnosis of
Fibroadenoma is confirmed with core biopsy patients will be reassured and
discharged. It can be safely left alone unless patient wishes that the lump is
removed.
In
all patient
Excision of the lump is recommended if
The lump
significantly increases in size,
Or where the lump
is larger than 4 cms in size
Or if the presence
of the tumour causes asymmetry in the breast
Or if there is a
concern about increased activity in the lump
Surgical excision
The operation is
simple and usually done as a day case. It can be done under a local anaesthetic
or under a general anaesthetic and patients can go home the same day.
Removing a Fibroadenoma doesn’t usually affect the shape of the breast, as
normal breast tissue will fill the space where it used to be.
Mammotome excision
Lumps can also be
removed using a vacuum assisted needle under the guidance of ultrasound
without having
surgery. It will be done
as a day case with
local anaesthetic and patients can go home the same day.
The lump is
sucked up through a
needle until it is seen to disappear.
Will surgical removal of the lump affect the ability to breast feed?
Removing a
Fibroadenoma causes no harm to the breast and won't affect the ability to
breastfeed.
Follow up of Fibroadenoma
After triple assessment and confirmation of diagnosis of
symptomatic lump patients are reassured and information leaflets about
Fibroadenoma is given. They are
advised to contact GP s if lump increases in size or if new lump occurs.
If it appears to be growing in size a breast specialist may perform
further investigations or recommend that the lump is removed.
References 1.
Carter BA, Page DL, Schuyler P et al. No elevation in long-term breast carcinoma
risk for women with Fibroadenomas that contain atypical hyperplasia. Cancer
2001;92:30–36. 2. Shabtai M,
Saavedra-Malinger P, Shabtai EL et al. Fibroadenoma of the breast: analysis of
associated pathological entities--a different risk marker in different age
groups for concurrent breast cancer. Isr Med Assoc J 2001;3:813–817
3. El-Wakeel
H, Umpleby HC. Systematic review of Fibroadenoma as a risk factor for breast
cancer. Breast 2003;12:302–307.
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