Fibroadenoma

Fibroadenomas are the most common benign tumor of the female breast and the most common breast tumor in adolescent and young women. The tumors are well-circumscribed, mobile, and unencapsulated, with a rubbery or firm consistency. Fibroadenomas are hormonally responsive, so they may increase in size during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care and usually regress after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause. Histologically, fibroadenomas are composed of a biphasic proliferation of both glandular and stromal elements. Fibroadenomas are associated with a slightly increased risk of carcinoma, with a somewhat higher risk if so-called “complex” features are present. Diagnosis is based on physical findings and ultrasonography. Management is based on regular checkups to monitor growth.

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Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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Definition, Epidemiology, and Etiology

Definition

  • Benign breast masses
  • Composed of fibrous and glandular tissue

Epidemiology

  • Most common in women < 35 years of age (peak incidence: 15–35 years)
  • Most common benign tumor of the breast, and the most common tumor in young women
  • Accounts for half of all breast biopsies
  • Only a slightly increased risk of developing malignant breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer, with a somewhat higher risk if “complex” features are present:
    • Cysts > 0.3 cm
    • Sclerosing adenosis
    • Epithelial calcifications
    • Papillary apocrine change

Etiology

  • Unknown
  • Unlikely to be hereditary
  • Negative correlation with tobacco smoking
  • A relationship has been established with estrogen:
    • Increases in size during pregnancy Pregnancy Pregnancy is the time period between fertilization of an oocyte and delivery of a fetus approximately 9 months later. The 1st sign of pregnancy is typically a missed menstrual period, after which, pregnancy should be confirmed clinically based on a positive β-hCG test (typically a qualitative urine test) and pelvic ultrasound. Pregnancy: Diagnosis, Maternal Physiology, and Routine Care, lactation, cyclically with menstruation, and with the use of oral contraceptives
    • Regresses after menopause Menopause Menopause is a physiologic process in women characterized by the permanent cessation of menstruation that occurs after the loss of ovarian activity. Menopause can only be diagnosed retrospectively, after 12 months without menstrual bleeding. Menopause

Clinical Presentation

  • Generally asymptomatic
  • Solitary lesion in 80% of cases
  • 20% of cases consist of multiple fibroadenomas occurring in the same breast or bilaterally.
  • Small, spherical, well-defined, mobile mass with a rubbery or firm consistency
  • Diameter of 3–10 cm that causes breast asymmetry (usually < 3 cm)
  • Usually found in the upper outer quadrant of the breast
  • Cyclic changes in size related to the menstrual cycle Menstrual cycle The menstrual cycle is the cyclic pattern of hormonal and tissular activity that prepares a suitable uterine environment for the fertilization and implantation of an ovum. The menstrual cycle involves both an endometrial and ovarian cycle that are dependent on one another for proper functioning. There are 2 phases of the ovarian cycle and 3 phases of the endometrial cycle. Menstrual Cycle due to sensitivity to estrogen 
  • Other types of fibroadenomas:
    • Juvenile fibroadenomas
      • Usually occur in African American patients aged 10–18 years
      • Rapid increase in size 
      • May cause skin Skin The skin, also referred to as the integumentary system, is the largest organ of the body. The skin is primarily composed of the epidermis (outer layer) and dermis (deep layer). The epidermis is primarily composed of keratinocytes that undergo rapid turnover, while the dermis contains dense layers of connective tissue. Structure and Function of the Skin ulceration
    • Giant fibroadenomas
      • Histologically typical fibroadenomas > 10 cm in size
      • Excision is recommended
    • Complex fibroadenomas
      • Proliferative pathologic changes
      • Associated with a slightly increased risk of cancer
      • Management is controversial

Diagnosis and Management

Diagnosis

  • Ultrasonography:
    • Well-defined mass with smooth and regular boundaries and a weak echo signal
    • 25% of cases have irregular borders → biopsy to confirm benignancy
  • Mammogram or magnetic resonance imaging (MRI): regular boundaries and popcorn-like calcifications
  • Fine needle aspiration (method of choice for biopsy):
    • Fibrous and glandular tissue with clusters of spindle cells
    • Antler horn clusters
    • Honeycomb sheets

Management

  • Regular check-ups in cases confirmed to be benign (“wait-and-see” approach)
  • Cryoablation for small but symptomatic fibroadenomas 
  • Surgical resection for cases of juvenile and giant fibroadenomas, irregular boundaries, and patients with personal or family history of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer

Differential Diagnosis

The following conditions are differential diagnoses of fibroadenomas:

  • Galactocele: retention cyst within the mammary gland containing milk, which presents as a palpable, firm mass in the subareolar region.
  • Breast abscess: accumulation of pus within the mammary gland. Usually associated with lactational mastitis Mastitis Mastitis is inflammation of the breast tissue with or without infection. The most common form of mastitis is associated with lactation in the first few weeks after birth. Non-lactational mastitis includes periductal mastitis and idiopathic granulomatous mastitis (IGM). Mastitis. Presents as a unilateral and fluctuant mass within a painful, erythematous, and edematous breast.
  • Intraductal papilloma: benign mass with a papillary configuration of breast stroma and epithelium Epithelium The epithelium is a complex of specialized cellular organizations arranged into sheets and lining cavities and covering the surfaces of the body. The cells exhibit polarity, having an apical and a basal pole. Structures important for the epithelial integrity and function involve the basement membrane, the semipermeable sheet on which the cells rest, and interdigitations, as well as cellular junctions. Surface Epithelium within a breast duct, which presents as a solitary mass found close to or behind the nipple, with bloody nipple discharge.
  • Phyllodes tumor: uncommon fibroepithelial tumor similar to a fibroadenoma but requiring complete surgical excision with clean borders because of its malignant potential. The tumors are categorized into benign, borderline, and malignant types. Histologically, these tumors have stromal overgrowth with increased mitotic activity, with the borderline and malignant tumors showing infiltrative borders. 
  • Fibrocystic changes of the breast: refers to the common changes that happen to breast tissue as a woman ages, causing a “lumpy-bumpy” breast in the more pronounced expressions of the condition. These changes can be non-proliferative (cysts, fibrosis, adenosis) or proliferative (epithelial proliferation, sclerosing adenosis, papilloma), with or without atypia. Atypical hyperplasia has a moderately increased risk of carcinoma.
  • Mastitis: inflammation Inflammation Inflammation is a complex set of responses to infection and injury involving leukocytes as the principal cellular mediators in the body's defense against pathogenic organisms. Inflammation is also seen as a response to tissue injury in the process of wound healing. The 5 cardinal signs of inflammation are pain, heat, redness, swelling, and loss of function. Inflammation of the mammary gland tissue; can be lactational or non-lactational. Mastitis is most common in women of childbearing age.
  • Fat necrosis of the breast Fat necrosis of the breast Fat necrosis of the breast is an inflammatory, benign condition resulting from injury to the breast tissue. Forms of injury include blunt traumatic injury as well as trauma from surgical procedures, biopsies, and radiation therapy. Fat Necrosis of the Breast: usually due to breast injury, which often goes unnoticed. As the damaged breast tissue is repaired, it is replaced by scar tissue. However, some fat cells may have a different response and form what are known as oily cysts.
  • Breast cancer: malignant tumor of the mammary gland. The 2 most common histological types of breast cancer Breast cancer Breast cancer is a disease characterized by malignant transformation of the epithelial cells of the breast. Breast cancer is the most common form of cancer and 2nd most common cause of cancer-related death among women. Breast Cancer are ductal carcinoma and lobular carcinoma.

References

  1. Vinay K, Abbas A, Aster J. Robbins & Cotran Pathologic Basis of Disease. 2020, 10th Edition, Elsevier.
  2. Sabel MS. Overview of benign breast disease. UpToDate. Retrieved on August 28, 2020, from https://www.uptodate.com/contents/overview-of-benign-breast-disease#H14
  3. Rohan, T. E., & Miller, A. B. (1999). A cohort study of cigarette smoking and risk of fibroadenoma. Journal of Epidemiology and Biostatistics, 4(4), 297–302.

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