Fibroadenoma Of female breast

• Define fibroadenoma: Short case in surgery? A fibroadenoma is a very common benign breast condition. The most common symptom is a lump in the breast which during a clinical breast exam, you or doctor will check both breasts for lumps and other problems. Some fibroadenomas are too small to feel, so they can only be discovered in imaging tests. The overall diagnostic efficacy of these three modalities—namely, A) manual breast examination, B) imaging and C) cytology is approximately 70% to 80%, but they provide a 95% (±2% SD) accurate differentiation between a benign and a malignant lesion. A follow-up period of 1 to 3 years after fibroadenoma is diagnosed and breast cancer is excluded using the three modalities can enhance the accuracy of the diagnosis. If you have a lump that can be felt (palpable), it will be wise to go ahead with some tests and those tets depends /or procedures, will depend on her age and the characteristics of the lump. 
  What is etiology ? Fibroadenomas are common benign lesions of the breast that usually present as a single breast mass in young women. They are assumed to be aberrations of normal breast development or the product of hyperplasic processes, rather than true neoplasms. 
  How to examine Breasts at Exam Hall / or your private clinic?? If male candidate ask ward Nurse to be present and be polite,& courteous to woman concerned, Show & practice as U practice how best to palpate thyroid, Axillary glands!! 
  Dilemma & Dilemma; To do or not to do: After a clinical diag of Fibroadenoma you now have two options like Breast sonography & FNAC,I leave it to members,-The clinician often faces the dilemma whether to remove the mass or to monitor it by means of periodic follow-up examinations. 
  Adv of surgical removal:-Although removal of these lesions is a definitive solution, But disadvantages of surgery: surgery may involve 1) unnecessary excisions of benign lesions and2) unbecoming cosmesis. Moreover, a policy of conducting surgery on all patients with fibroadenomas would place an 3) enormous burden on health care systems.
  
  Then whom to vote for ?? What is in your back of mind?? Thinking:1:- Cancer probality in near future. Or no cancer?? That lurks in one’s mind,. A balanced and rational approach to the management of a fibroadenoma of the breast needs to address the crucial questions about its association with breast cancer, especially whether or not it is a marker of increased risk of breast malignancy. Another consideration to be weighed is that a Thinking: 2 :-A substantial percentage of these lesions undergo spontaneous regression. Herein, based on our review of the current data on fibroadenomas of the breast and our experience, we propose practical algorithms for their management.
  What is the prevalence. More common in young women. Fibroadenomas usually form during menarche (15 –25 years of age), a time at which lobular structures are added to the ductal system of the breast There are no clear-cut data on the incidence of fibroadenomas in the general population. In one study, the rate of occurrence of fibroadenomas in women who were examined in breast clinics was 7% to 13% while it was 9% in another study of autopsies. Fibroadenomas comprise about A) 50% of all breast biopsies, and this rate rises to B) 75% for biopsies in women under the age of 20 years. Fibroadenomas are more frequent among women in C) higher socioeconomic classes and in dark-skinned populations.
  
  Can I take OCP:_Yes, no restrictions in presence Fibroadenoma. The age of menarche, the age of menopause, and hormonal therapy, including oral contraceptives, were shown not to alter the risk of these lesions., 
  
  Which factors discourages development of fibroadenoma?? body mass index and the number of full-term pregnancies were found to have a negative correlation with the risk of fibroadenomas., Moreover, consumption of large quantities of vitamin C and surprisingly cigarette smoking were found to be associated with reduced risk of a fibroadenoma. 
  No genetics factors are known to alter the risk of fibroadenoma. However, a family history of breast cancer in first-degree relatives was reported by some investigators to be related with increased risk of developing these tumors. 
  At What age this initiates?? Fibroadenomas usually form during menarche (a time at which lobular structures are added to the ductal system of the breast . Hyperplasic lobules are common at that time, and may be regarded as a normal phase of breast development. Hyperplasic lobules were shown to be Histologically identical with fibroadenomas. .Analyses of the cellular components of fibroadenomas by means of polymerase chain reaction demonstrated that both the stromal and the epithelial cells are polyclonal supporting the theory that fibroadenomas are hyperplasic lesions associated with aberration of the normal maturation of the breast, rather than true neoplasms.

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  Srimanta Pal Histologic section of a fibroadenoma (hematoxylin-eosin staining, × 40). The cellular fibroblastic stroma, which resembles interlobular stroma, encloses glandular and cystic spaces lined by epithelium. Round and oval gland spaces, lined by either single or multiple cell layers, are present in other areas. The stroma in the connective tissue appears to have undergone a more active proliferation with compression on the gland spaces. The pattern of stromal growth in a fibroadenoma depends on its epithelial component: stromal mitotic activity was found to be higher near this component.1 Fibroadenomas are stimulated by estrogen and progesterone, and by lactation during pregnancy, and they undergo atrophic changes in menopause. Some fibroadenomas have receptors and respond to growth hormone and epidermal growth factor. 
  How a woman present with Fibroadenoma?? A fibroadenoma is most often detected incidentally during a medical examination or during self examination, usually as a discrete solitary breast mass of 1 to 2 cm Although they can be located anywhere in the breast, the majority are situated in the upper outer quadrant A fibroadenoma is usually smooth, mobile, contender, and rubbery in consistency . Several other breast lesions have similar characteristics, and physical examinations provided an accurate diagnosis in only one half to two thirds of cases studied. However, most of the masses that are erroneously diagnosed by palpation as fibroadenomas are found on histologic examination to be another benign form of breast disease, such as cystic fibrosis.
  
  How useful Breast sonography?? Breast sonography is often used for the diagnosis of fibroadenomas. The sonographic criteria that support the diagnosis of a fibroadenoma are a round or oval solid mass with a smooth contour and weak internal echoes in a uniform distribution and intermediate acoustic attenuation ,This imaging technique is very useful for differentiating between solid and cystic lesions. However, attempts to correlate between the sonographic features of solid masses compatible with fibroadenomas and pathologic findings were disappointing. There is some overlap in the sonographic criteria for fibroadenomas and for breast cancer and approximately 25% of fibroadenomas appear with irregular margins, which may imply that the lesions are malignant. Also, only 82% of biopsy-proven fibroadenomas were visualized by sonography in one study.. 
  Treatment: A) Follow up:-In many cases, fibroadenomas require no treatment. However, some women choose surgical removal for their peace of mind. If physician is reasonable certain that breast lump is a fibroadenoma — based on the results of the A) clinical breast exam & Axillary gland palpitation, B) imaging test and C) FNAC:-biopsy — then follow up may be advised without lumpectomy..

  

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  Srimanta Pal Fibriadenoma Breasts:-Points against surgery?? Because:
  • Surgery can distort the shape and texture of the breast
  • Fibroadenomas sometimes shrink or disappear on their own
  • The breast has multiple fibroadenomas that appear to be stable — no changes in size on an ultrasound compared to an earlier ultrasound
  If one is advised not to have surgery, it's important to monitor the fibroadenoma under regular follow-up visits preferably under the supervision of a dedicated breast clinic if available nearby .
  Rpt breast ultrasounds to detect changes in the appearance or size of the lump may be necessary . 
  Surgery: What kind??
  It may be necessary to remove the fibroadenoma if lump is big; the fibroadenoma is extremely large, gets bigger or causes symptoms.
  & consultant after reviewing all the three reports, taken together —1) the clinical breast exam, 2) an imaging test or 3) FNAC is abnormal or if Procedures to remove a fibroadenoma include:
  
  Can left out Fibroadenoma turn out to be cancer??
  This is an imp topic that every woman & surgeon would like to know about it?? The associations of fibroadenomas with breast cancer must address two main questions: whether or not a fibroadenoma is a marker for increased risk of breast cancer, and whether or not breast cancer can evolve from the epithelial component of a fibroadenoma. The first issue was originally assessed in several retrospective studies, which demonstrated a 1.3 to 2.1 increased risk of breast cancer in women with fibroadenomas compared with the general population. The elevated risk was persistent, and did not decrease with time. A more recent study designed to delineate the possible correlation between the histologic features of the fibroadenomas and the risk for subsequent breast cancer used the term “complex fibroadenoma.”
  
  Malignant transformations in the epithelial components of fibroadenomas are generally considered rare. The incidence of a carcinoma evolving within a fibroadenoma was reported to be 0.002% to 0.0125%.,, About 50% of these tumors were lobular carcinoma in situ (LCIS), 20% were infiltrating lobular carcinoma, 20% were ductal carcinoma in situ (DCIS), and the remaining 10% were infiltrating ductal carcinoma. The clinical, sonographic and mammographic findings are usually similar to those of benign fibroadenomas, and the malignant changes are often noted only when the fibroadenoma is excised.
  Who are more prone to Ca ?? Fibroadenomas having the histologic characteristic of being A) more than 3 mm in diameter, or B) with elements of sclerosing adenosis, epithelial calcifications, or C) papillary apocrine metaplasia, which were associated with a 3.1 elevated risk of breast cancer. D) Proliferative changes in the parenchyma adjacent to the fibroadenoma were related to a further increase of the risk to 3.88. E) The relative risk for women with a familial history of breast cancer and complex fibroadenoma was 3.72, compared with control women with a family history of breast cancer without fibroadenoma. In these studies, women with non complex fibroadenomas and no family history of breast cancer were not at a greater risk of breast cancer.
  
  In a clinicopathologic study of 105 women with carcinoma developing within fibroadenomas, the mean age was higher than in patients with benign fibroadenomas (44 vs 23 years).33, 34, 46 However, in that study, DCIS and LCIS in equal frequencies comprised 95% of the cases, and carcinoma in situ was also present in the adjacent breast tissue in about 20% of these women. No axillary metastases were found in any of the study patients.

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  Srimanta Pal Role of mammography in a clinically suspected Fibroadenoma?? 
  The yield of mammography in young women is low, and its role in the diagnosis of fibroadenomas is limited. However, it may disclose features of infiltrative lesions in older women. In the mammographic image, fibroadenomas appear as soft, homogenous, and well-circumscribed nodules, and inner coarse calcifications are often observed.
  Usefulness of FNAC?? ASPIRATION CYTOLOGY
  Fine needle aspiration (FNA) has become a popular method in the evaluation of breast masses. The characteristic Cytologic features of fibroadenomas are: clusters of spindle cells without inflammatory or fat cells, found in 96% of all fibroadenomas; aggregates of cells with a papillary configuration resembling elk antler (antler horn clusters), found in 93% of all cases; and uniform cells with well-defined cytoplasm lying in rows and columns (honeycomb sheets), found in 95% of all fibroadenomas. Taken together with the clinical diagnosis of fibroadenoma, FNA can improve the sensitivity of the diagnosis to 86% with a specificity of 76%, while for breast cancer FNA is 96% sensitive and 98% specific. Thus, while aspiration cytology may confuse fibroadenomas with other benign breast lesions, incorrect diagnosis of a malignant process is rare.
  The overall diagnostic efficacy of these three modalities—namely, A) manual breast examination, B) imaging and C) cytology is approximately 70% to 80%, but they provide a 95% (±2% SD) accurate differentiation between a benign and a malignant lesion. A follow-up period of 1 to 3 years after fibroadenoma is diagnosed and breast cancer is excluded using the three modalities can enhance the accuracy of the diagnosis.

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  Srimanta Pal As fibroadenomas are benign breast lesions, it could be argued that they should not be excised and can be expected to regress spontaneously. Moreover, 30% of breast tumors that are diagnosed as fibroadenomas are found post surgically to be other types of benign lesions. In Cant et al.'s follow-up studies on clinically diagnosed fibroadenomas, persistent lesions were excised after 3 years: fibroadenomas were found in the histologic examinations of 97% of these cases. These findings suggest that the other benign lesions had resolved spontaneously during 1 to 3 years, that the remaining masses were true fibroadenomas, and that conservative management is warranted. Not all women can be candidates for conservative treatment: the patient's age, a family history of malignancy, and any data on proliferative changes in the breasts from previous biopsies must be taken into consideration.
  The risk of missing breast cancer in women under 25 years of age who have fibroadenomas as diagnosed by physical examination, sonography, and FNA is 1 in 229 to 1 in 700. This risk remains very low in women under the age of 35 years. Therefore, it has been recommended that young patients should be observed with frequent clinical evaluations, and the lesions excised in women over the age of 35 years Other investigators suggested that the cutoff age should be 25 years. 
  The preferred management of multiple fibroadenomas is complete excision. However, this approach can lead to undesirable scarring or to extensive ductal damage if all the fibroadenomas are excised through one incision. Giant fibroadenomas tend to shrink after cessation of lactation, so their removal should be delayed until the patient's hormonal status returns to normal, and a smaller excision can be performed. .It may be very disfiguring to excise juvenile fibroadenomas because of their large sizes; nevertheless, no recurrences were reported after complete excision, and normal and symmetrical development of the breasts can be anticipated.

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  Srimanta Pal

  

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  Srimanta Pal

  

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  Srimanta Pal FNAC of Breast

  

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• ne-needle aspiration. Through a thin needle inserted into your breast, your doctor attempts to withdraw the contents of the breast lump. If fluid comes out, the lump is likely a cyst.

  • Core needle biopsy. A radiologist with guidance from an ultrasound usually performs this procedure. The doctor uses a needle to collect tissue samples from the lump, which go to a lab for analysis.
  Treatment
  In many cases, fibroadenomas require no treatment. However, some women choose surgical removal for their peace of mind.
  Nonsurgical management
  If reasonably certain that your breast lump is a fibroadenoma — based on the results of the clinical breast exam, imaging test and biopsy — one might not need surgery.
  One may decide against surgery because:
  • Surgery can distort the shape and texture of the breast
  • Fibroadenomas sometimes shrink or disappear on their own
  • The breast has multiple fibroadenomas that appear to be stable — no changes in size on an ultrasound compared to an earlier ultrasound
  If you choose not to have surgery, it's important to monitor the fibroadenoma with follow-up visits to your doctor for breast ultrasounds to detect changes in the appearance or size of the lump. If you later become worried about the fibroadenoma, you can reconsider surgery to remove it.
  Surgery
  Some commend surgery to remove the fibroadenoma if one of your tests — the clinical breast exam, an imaging test or a biopsy — is abnormal or if the fibroadenoma is extremely large, gets bigger or causes symptoms.
  Procedures to remove a fibroadenoma include:
  • Lumpectomy or excisional biopsy. In this procedure, a surgeon removes breast tissue and sends it to a lab to check for cancer.
  • Cry ablation. Pathologist, along with sono & surgeon r inserts a thin, wand-like device (cry probe) through your skin to the fibroadenoma. A gas is used to freeze and destroy the tissue.
  After a fibroadenoma is removed, it's possible for one or more new fibroadenomas to develop. New breast lumps need to be assessed with a mammogram, ultrasound and possibly biopsy — to determine if the lump is a fibroadenoma or might become cancerous.
  usually moves when you touch it. Fibroadenomas often develop during puberty so are mostly found in young women, but they can occur in women of any age

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• al A fibroadenoma is a very common benign (not cancer) breast condition. The most common symptom is a lump in the breast which usually moves when you touch it.Fibroadenomas often develop during puberty so are mostly found in young women, but they can occur in women of any age. Men can also get fibroadenomas, but this is very rare. Symptoms of fibroadenoma:-A fibroadenoma is usually felt as a lump in the breast which has a rubbery texture, is smooth to the touch and moves easily under the skin. Fibroadenomas are usually painless, but sometimes they may feel tender or even painful, particularly just before a period.
  Types of fibroadenoma
  A) Simple fibroadenoma
  Most fibroadenomas are about 1–3cm in size and are called simple fibroadenomas. When looked at under a microscope, simple fibroadenomas will look the same all over.
  Simple fibroadenomas don’t increase the risk of developing breast cancer in the future 2) Complex fibroadenoma:: Some fibroadenomas are called complex fibroadenomas. When these are looked at under a microscope, some of the cells have different features.Having a complex fibroadenoma can vary slightly increase the risk of developing breast cancer in the future.
  B) Giant or juvenile fibroadenoma
  Occasionally, a fibroadenoma can grow to more than 5cm and may be called a giant fibroadenoma. Those found in teenage girls may be called juvenile fibroadenomas.
  Causes
  It’s not known what causes a fibroadenoma. It’s thought that it probably occurs because of increased sensitivity to the hormone oestrogen. 
  Breasts are made up of lobules (milk-producing glands) and ducts (tubes that carry milk to the nipple). These are surrounded by glandular, fibrous and fatty tissue.
  Fibroadenomas develop from a lobule. The glandular tissue and ducts grow over the lobule and form a solid lump.
  
  Diagnosis. We should remember that “Younger women’s breast tissue can be dense which can make the x-ray image less clear so normal changes or benign breast conditions can be harder to identify easily detected though occasionally mammography may be warranted. 
  Best Tr will be at a dedicated breast clinic where concerned woman seen by specialist doctors or nurses. At the breast clinic facilities for various investigations, known as ‘triple assessment’, to help make a definite diagnosis. This assessment consists of:
  • a breast examination
  • ultrasound scan (uses high frequency sound waves to produce an image) and/or a mammogram (breast x-ray)
  • a core biopsy and/or a fine needle aspiration (FNA).
  Fibroadenomas are often easier to identify in younger women. If the woman is in her early 20s or younger fibroadenoma may be diagnosed with a breast examination and ultrasound only. However, if there’s any uncertainty about the diagnosis, a core biopsy or FNA will be done.
  But for elderly women but under 40, one will be likely to have an ultrasound than a mammogram. Younger women’s breast tissue can be dense which can make the x-ray image less clear so normal changes or benign breast conditions can be harder to identify. However, for some women under 40, mammograms may still be needed to complete the assessment.

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• l Breast asymmetry : A small degree of asymmetry between the breasts is quite normal when differences in volume or shape lead to problems of physical comfort or difficulty in dress surgical intervention may be warranted. This may also be true in circumstances where asymmetry makes the woman self conscious and ill at ease in intimate situations. Not surprisingly the surgical techniques employed will vary considerably depending upon the nature of the problem.

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