Background 1. Definition Fibroadenoma: Group of hyperplastic breast lobules composed of stromal and epithelial elements

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1 Fibradenma Backgrund 1. Definitin Fibradenma: Grup f hyperplastic breast lbules cmpsed f strmal and epithelial elements Simple benign slid tumrs with glandular and fibrus tissue Cmplex Scleringadensis Ductal epithelial hyperplasia Epithelial Calcificatin Papillary apcrine changes Pathphysilgy 1. Pathlgy f disease Etilgy unknwn Hrmnal relatinship likely Increases in size Pregnancy Estrgen use Immunsuppressin May regress after menpause 2. Incidence, prevalence Mst cmmn benign breast tumr in wmen Mst cmmn breast lesin in adlescents % with multiple fibradenmas Mst cmmn between y/ 8 N racial predilectin 2 3. Risk factrs fr breast cancer Hrmne use Alchl intake Adjacent prliferative disease Family histry f breast cancer 7 Diagnsis 1. Histry Nature and pattern f symptms Relatinship t menstrual cycles Timing f nset and subsequent curse Presence f and characteristics f nipple discharge r breast pain Hrmne use All prir treatments Past histry f similar prblem Fibradenma Page 1 f

2 2. Mrbidity/Mrtality Increased Risk f Breast Cancer 7 Cmplex Fibradenmas Relative Risk 3.10 Cmplex and family histry f breast cancer Relative Risk 3.72 Cmplex with benign prliferative disease in adjacent parenchyma Relative Risk 3.88 Simple Fibradenmas w/ family histry f Breast cancer N increased risk 3. Physical exam Inspect breast fr evidence f ulceratin r cntur changes Examine nipple Palpate in bth upright and supine psitins May appear as: Palpable val, freely mbile, rubbery masses, smth brders Size vary frm 1-15 cm Inspect chest wall, axilla, and neck 4. Diagnstic evaluatin N labratry testing necessary Diagnstic imaging Ultrasund - Preferred if distinct palpable mass present, age <30 y/ r pt pregnant Findings c/w fibradenma circumscribed hypechic val r rund mass with gentle lbulatins smth thin, echgenic pseudcapsule variable acustic enhancement hmgeneity Mammgram Use if palpable mass, >30 y/, r nn-pregnant Fibradenmas typically circumscribed val r rund masses which ccasinally have carse calcificatins In yung wmen with dense breast tissue, ultrasngraphy shuld be used vice mammgraphy t detect breast lesins (SOR C) 9 The USPSTF recmmends biennial screening mammgraphy fr wmen aged 50 t 74 years. Grade B recmmendatin (USPSTF) 6 MRI Fibradenmas typically smth masses with high signal intensity n T2 weighted images and enhancement with gadlinium Diagnstic criteria: Definitive diagnsis requires image guided bipsy Fibradenma Page 2 f

3 Differential Diagnsis 1. Simple r cmplex cysts 2. Hamartmas 3. Lipmas 4. Cystsarcmaphylldes 5. Lactatinal adenmas 6. Papillmas 7. Mucinus carcinmas 8. Medullary carcinmas 9. See als Breast masses Treatment 1. Management Simple fibradenmas diagnsed n clinical and radilgical exam, ptins include: Cre bipsy Cnfirm diagnsis with n further fllw up required, r Serial ultrasunds Lk fr changes in appearances every 6 mnths fr 2 years with excisin if changes ccurs, r Office-based cryablatin Further clinical experience and data n lng term fllw up are needed Interstitial laser therapy Current data inadequate fr safety and efficacy f this prcedure Rutine excisinal bipsy N supprting evidence (simple fibradenmas) Excisinal bipsy shuld be perfrmed in wmen with clinically suspicius lesins, r lesins that are equivcal n imaging, FNA, r CNB.(SOR C) 9 If increases in size r symptmatic, excisin is needed t rule-ut malignancy 9 Risk f scarring that hampers future mammgraphic and sngraphic interpretatin Cmplex fibradenmas diagnsed n clinical and radilgical exam Excisinal bipsy N further therapy after cmplete remval If dx f fibradenma uncertain: Aspiratin w/cytlgical evaluatin f aspirate, r Steretactic cre bipsy r ultrasund guided bipsy A histry f benign breast disease r a psitive family histry f breast cancer shuld nt be regarded as cntraindicatins t ral cntraceptive use (SOR A) 10 Fibradenma Page 3 f

4 Fllw-Up 1. Return t ffice Serial ultrasund Every 6 mnths fr 2 years in patients with simple fibradenmas Fllwed by regular screening thereafter Rutine screening Patients with simple fibradenmas and family Hx f breast cancer in first degree relatives Patients with cmplex fibradenmas after cmplete excisin Yearly mammgram and clinical exam by a physician Thse with a histlgical finding f atypical ductal r lbular hyperplasia in the fibradenma Fllw up breast exam in 4-6 weeks preferably pst menstrually Thse with nn palpable mass and negative imaging, r Nn dminant mass and negative imaging, r Dminant mass that reslved n aspiratin with pst aspiratin imaging remaining negative 2. Refer t specialist Pts requiring cre bipsy r aspiratin f breast mass Persisting dminant mass after aspiratin, all recurring cystic masses r bldy tap Pts with abnrmal imaging Pts with cmplex fibradenma requiring excisinal bipsy Pts with lbular r ductal hyperplasia with atypia n image guided bipsy Evidence-Based Inquiry 1. Fr a nn-lactating wman with breast inflammatin, is a trial f antibitics apprpriate befre imaging and/r bipsy? References 1. Diagnsis f breast disease. Institute fr Clinical Systems Imprvement Guidelines, 2005 Nv. Available at 2. Schnitt, SJ, Cllins, L.C. Pathlgy f benign breast disrders. In: Breast diseases, 4 th ed, Harris, JR, et al, Lippinctt, Philadelphia Page Interstitial laser therapy fr fibradenmas f the breast. Natinal Institute fr Clinical Excellence June,. Available at 4. Greydanus,DE,Matytsina,LGains,M. Breast disrders in children and adlescents. Primary Care 2006; 33: El-Wakeel H, et al. Systematic review f fibradenma as a risk factr fr breast cancer. Breast Oct; 12(5): USPSTF, Nv Dupnt, WD, Page, DL, Parl, FF, et al. Lng-term risk f breast cancer in wmen with fibradenma. N Engl J Med 1994; 331:10 8. Carty, NJ, Carter, C, Rubin, C, et al. Management f fibradenma f the breast. Ann R CllSurgEngl 1995; 77:127. Fibradenma Page 4 f

5 9. Klein, Susan. Evaluatin f Palpable Breast Masses. American Family Physician/ 2005 May 1;71(0); Use f Hrmnal Cntraceptin in Wmen with C-Existing Medical Cnditins. Natinal Guideline Clearinghuse. June Authr: Whitney Curtney, DO, United Hspital Center Prgram, WV Editr: Rbert Marshall, MD, MPH, MISM, CMIO, Madigan Army Medical Center, Tacma, WA Fibradenma Page 5 f