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

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

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

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 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

Management implication! 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/ simple The 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 Sclerosing adenosis Cysts > 3mm Papillary apocrine metaplasia Epithelial calcification

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

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!

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 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

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%

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: 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 Indications Grows over time >2cm at diagnosis Doubt on diagnosis 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 features Proliferative change Slightly increased 1.5-2 ADH ALH Moderately increased 4-5 LCIS Markedly increased 9

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

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

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!

Fibroadenoma What do we need to know? Thank You