Fibroadenomas

1. Fibroadenomas:
   • Are benign tumors composed of stromal and epithelial elements:
     • That are commonly seen in young women
   • Multiple or complex fibroadenomas:
     • May indicate a slightly increased risk for breast cancer:
       • The relative risk of breast cancer in patients with such fibroadenomas:
         • Is approximately twice that of patients of similar age without fibroadenomas
   • A patient’s age determines the preferred imaging method:
     • In general, ultrasonography (US) is preferred:
       • If a palpable mass is found
       • If a patient is younger than 30 years
       • If the patient is pregnant
     • Mammography and US are both useful if the patient has:
       • A palpable mass
       • Is older than 30 years
       • Is not pregnant
     • In patients younger than 30 years:
       • The most appropriate modality is ultrasound:
         • Because the patient is spared radiation exposure and because the likelihood for fibroadenoma is high
     • Mammography is not indicated as the primary imaging study in women younger than 30 years:
       • Unless high-risk factors are present
     • Computed tomography (CT) scanning:
       • Is not initially indicated for assessing a palpable lump in a woman in women younger than 30 years:
         • Because of radiation exposure
         • The inability of CT to demonstrate micro-calcifications
         • The lack of specificity in the findings
     • Magnetic resonance imaging (MRI):
       • Is not initially indicated for assessing a palpable lump in women younger than 30 year:
         • Mainly because of its high cost and the high likelihood of false-positive findings
     • Positron emission tomography:
       • Is expensive and is not universally available
     • On mammograms:
       • Fibroadenomas typically appear as:
         • Circumscribed oval or round masses:
           • Which occasionally have coarse calcifications
     • On ultrasonograms:
       • Fibroadenomas appear as:
         • Circumscribed, homogeneous, oval, hypoechoic masses:
           • That may have gentle lobulations
           • A smooth, thin, echogenic capsule
           • Variable acoustic enhancement; and homogeneity
     • On MRI:
       • Fibroadenomas typically appear as smooth masses with high signal intensity on T2-weighted images and enhancement with the administration of gadolinium-based contrast agent
     • Fibroadenoma:
       • Is a common benign breast lesion:
         • Results from the excess proliferation of connective tissue o
       • Fibroadenomas characteristically contain both:
         • Stromal and epithelial cells
     • Epidemiology:
       • They usually occur in women:
         • Between the ages of 10 and 40 years
         • It is the most common breast mass:
           • In the adolescent and young adult population :
         • Their peak incidence is between:
           • 25 and 40 years
           • The incidence decreases after 40 years
       • Clinical presentation:
         • The typical presentation is in a woman of reproductive age:
           • With a mobile palpable breast lump:
         • Due to their hormonal sensitivity:
           • Fibroadenomas commonly enlarge during pregnancy and involute at menopause:
             • Hence, they rarely present after the age of 40 years
         • The lesions are well defined and well-circumscribed clinically and the overlying skin is normal
         • The lesions are not fixed to the surrounding parenchyma and slip around under the palpating fingers:
           • Hence the colloquial term a breast “mouse”
     • Pathology:
       • A fibroadenoma is a type of adenomatous breast lesion:
         • It contains epithelium:
           • Has minimal malignant potential
       • Multiple fibroadenomas occur in:
         • 10% to 15% of patients:
           • Patients with multiple fibroadenomas:
             • Tend to have a strong family history of these tumors
             • They are assumed to be:
               • Aberrations of normal breast development (ANDI) or the product of hyperplastic processes:
                 • Rather than true neoplasms
       • Fibroadenomas can be stimulated by estrogen and progesterone:
         • Some fibroadenomas also have receptors and respond to:
           • Growth hormone and epidermal growth factor
       • When found in an adolescent girl:
         • The term juvenile fibroadenoma is more appropriate
     • Location:
       • Although they can be located anywhere in the breast:
         • There may be a predilection for the upper outer quadrant
     • Associations:
       • Cyclosporin use o Cowden syndrome
     • Radiographic features:
       • Mammography:
         • Fibroadenomas have a spectrum of features:
           • Well-circumscribed discrete oval mass hypodense or isodense to the breast glandular tissue
           • Mass with macro-lobulation or partially obscured margin
           • Involuting fibroadenomas in older, typically postmenopausal patients may contain:
             • Calcification:
               • Often producing the classic, coarse popcorn calcification appearance
               • In some cases the whole lesion is calcified
               • Calcification may also present as crushed stone-like micro-calcification:
                 • Which makes differentiation from malignancy difficult
       • Breast ultrasound:
         • Typically seen as a well-circumscribed, round to ovoid, or macro-lobulated mass with generally uniform hypoechogenicity
         • Intralesional sonographically detectable calcification:
           • May be seen in approximately 10% of cases
         • Sometimes a thin echogenic rim (pseudo capsule) may be seen sonographically
       • Breast MRI:
         • T1: typically hypo intense or isointense compared with adjacent breast tissue
         • T2: can be hypo- or hyper intense
         • T1 C+ (Gd): can be variable but a majority will show slow initial contrast enhancement followed by a persistent delayed phase (type I enhancement curve); non-enhancing internal septations may be seen
     • Diagnosis:
       • These lesions are easily biopsied under ultrasound guidance
       • When a lesion has the typical features of a fibroadenoma on ultrasound and there are no clinical red flags:
         • They can be safely followed clinically
       • When lesions enlarge or have atypical imaging findings:
         • Ultrasound-guided core biopsy is a minimally invasive outpatient procedure that will give a diagnosis with virtually no complications o
         • There may be a maximum diameter above which a biopsy should be done if no previous imaging is available:
           • The reason for intervention based on size is that a phyllodes tumor may be indistinguishable from a fibroadenoma on ultrasound:
             • A maximum diameter of 2.5 cm may be a useful benchmark for biopsy if you have no previous imaging
         • Interval enlargement is an indication for biopsy
       • Treatment and prognosis:
         • They are benign lesions with minimal or no malignant potential
         • The risk of malignant transformation is extremely low:
           • Has been reported to range around 0.0125% to 0.3%
         • Indications for biopsy include:
           • Enlarging lesion
           • Atypical findings on ultrasound
           • A lesion above 2.5 cm and there are no previous studies for comparison
           • Patient peace of mind:
             • Some patients are simply not happy with a palpable mass in the breast without a histological diagnosis:
               • This is a valid and reasonable indication for biopsy

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