1. Fibroadenoma What do we need to know?
C C Lee
Department of Surgery
Tuen Mun Hospital

2. A common patient… DDx? - Fibrocystic change - Inflammatory masses
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

3. A common patient… 20/F Right breast mass for 3 months P/E: 3cm R10H E2
FNAC: C2
USG: R2
Mx: Local excision
Path: Fibroadenoma

4. What is a fibroadenoma
Arise from the lobule of the terminal duct-lobular unit
Proliferation of both glandular and stromal elements

5. 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 ( )
Cyclical hormonal effects on glandular and stromal tissues
Exaggerated effects:
cyclical mastalgia/ nodularity
Severe mastalgia/ nodularity
Involution (35-55)
Lobular involution
Macrocysts
Sclerosing lesions
Extensive/recurrent cysts
Ductal involution
Duct ectasia
Periductal mastitis with bacterial infection and abscess formation
Epithelial turnover
Simple epithelial hyperplasia
With atypia

6. Management implication!
What is a fibroadenoma
Management implication!

7. Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma

8. Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
Conventional/ typical/ simple
The most common form

9. Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
≥ 5 separate lesions in an individual breast

10. Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
Sclerosing adenosis
Cysts > 3mm
Papillary apocrine metaplasia
Epithelial calcification

11. Classification of fibroadenoma
Common fibroadenoma
Multiple fibroadenoma
Complex fibroadenoma
Giant fibroadenoma
≥ 5cm
≥ 500g
replacing ≥ 4/5 of the breast

12. Management implication!
Natural history
Variable
Over 2 years   
Dent DM & Cant PJ
1989
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!

13. Diagnostic approach Triple assessment 1. Clinical Examination
2. Imaging
3. Biopsy
Doctor, is this a cancer?

14. Management of fibroadenoma
Options:
1. Conservative
2. Operative
3. Other alternatives
Doctor, do I need an operation?

15. 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 ( )
Cyclical hormonal effects on glandular and stromal tissues
Exaggerated effects:
cyclical mastalgia/ nodularity
Severe mastalgia/ nodularity
Involution (35-55)
Lobular involution
Macrocysts
Sclerosing lesions
Extensive/recurrent cysts
Ductal involution
Duct ectasia
Periductal mastitis with bacterial infection and abscess formation
Epithelial turnover
Simple epithelial hyperplasia
With atypia

16. Conservative
Majority remains static or gets smaller or even disappears
Over 2 years   
Dent DM & Cant PJ
1989
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%

17. Doctor, will the lump ‘change’?
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: )
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: )
Doctor, will the lump ‘change’?

18. 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)

19. Management options Conservative Operative Other alternatives
Indications
Grows over time
>2cm at diagnosis
Doubt on diagnosis
Patient anxiety

20. 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)

21. 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 features
Proliferative change
Slightly increased
1.5-2
ADH
ALH
Moderately increased
4-5
LCIS
Markedly increased 9

22. Management options Conservative Operative Other alternatives
Indications
Grows over time
≥ 3cm at diagnosis
Doubt on diagnosis
Patient anxiety
Vacuum assisted excision
?Laser ablation
?Radiofrequency ablation
?Cryosurgery

23. 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
What is your management plan?
Mx: local excision
Mx: local excision

24. Remember this graph…

25. 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

26. 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

27. 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!

28. Fibroadenoma What do we need to know?
Thank You