Fibroadenoma of the Breast Case File

Fibroadenoma of the Breast Case File

Eugene C. Toy, MD, Patti Jayne Ross, MD, Benton Baker III, MD, John C. Jennings, MD

CASE 46

A 22-year-old woman is seen by her physician for a routine physical examination. She seems to be up to date regarding her immunizations and has received the human papilloma virus (HPV) vaccine. She has no family history of breast cancer. She denies breast leakage or prior medical problems. On examination, her blood pressure (BP) is 100/60 mm Hg. Her physical examination is unremarkable except for 1-cm, right, nontender breast mass. Her neck is supple, and the heart and lung examinations are normal. Palpation of her right breast reveals a firm, mobile, nontender, rubbery 1-cm mass in the upper outer quadrant. There are no skin abnormalities noted. No adenopathy is noted. The left breast is normal to palpation.

» What is your next step?

» What is the most likely diagnosis?

ANSWER TO CASE 46:

Fibroadenoma of the Breast                                           

Summary: A 22-year-old woman is noted to have a 1-cm breast mass on routine physical examination. Palpation of her right breast reveals a firm, mobile, nontender, rubbery 1-cm mass in the upper outer quadrant. No adenopathy is noted.

• Next step: Biopsy of the mass (fine-needle biopsy or core needle biopsy).
• Most likely diagnosis: Fibroadenoma of the breast.

ANALYSIS

Objectives

1. Understand that any three-dimensional (3D) dominant mass needs a biopsy.
2. Know the characteristic presentation of fibroadenomas of the breast.
3. Understand that the greater the risk of breast cancer, the more tissue that is needed for biopsy.

Considerations

This woman comes in for a health maintenance examination; the approach is generally immunizations, cancer screening, and assessment and prevention for common diseases. On the physical examination, she is found to have a dominant breast mass. The firm, nontender, rubbery description is classic for a fibroadenoma. Fibroadenomas, as opposed to fibrocystic changes, do not change with the menstrual cycle. Although the most likely etiology is a fibroadenoma, this diagnosis needs to be confirmed by biopsy. Ultrasound of the breast is probably the best imaging modality in a young patient, since mammography is hampered by the dense breast tissue. The three methods of biopsy are fine-needle aspiration (FNA), core needle stereotactic biopsy, and excisional biopsy. Both core needle and excisional biopsy remove more tissue but are more prone to bruising and pain; an excisional biopsy is a more extensive surgical procedure involving removal of the entire mass. In this case, FNA is acceptable since the patient is at low risk for breast cancer. She has no family history of breast cancer, is of a young age, and her examination does not contain any worrisome features of breast cancer. If the mass were fixed, or if there were nipple retraction or bloody nipple discharge, the better method of biopsy would be a core needle or excisional biopsy to remove more tissue for histologic analysis.

APPROACH TO:

Breast Masses                                              

DEFINITIONS

CORE NEEDLE BIOPSY: A 14- to 16-gauge needle used to extract tissue from a breast mass, which preserves cellular architecture.

FINE-NEEDLE ASPIRATION: The use of a small-gauge needle with associated vacuum via a syringe to aspirate fluid or some cells from a breast mass and/ or cyst. The histology from the FNA would be loose cells (cytology).

FIBROADENOMA: Benign, smooth muscle tumor of the breast, usually occurring in young women.

EXCISIONAL BIOPSY: Surgical procedure to remove the entire lesion.

CLINICAL APPROACH

Background

Breast masses can involve tissue that comprise the breast including ducts, lobules, connective tissue, and the overlying skin. Fibrocystic changes are the most common breast mass, and is found in up to 90% of females at autopsy. Fibroadenomas are the most common benign tumor, whereas infiltrating ductal carcinoma is the most common malignancy. Although fibroadenomas are the most common cause of a breast mass in a woman less than age 25, the atypical breast cancer must always be considered.

Evaluation

One of the key skills of any primary care physician is differentiating normal breast changes from abnormal ones, that is, identification of the dominant breast mass. Fibrocystic changes, the most common of the benign breast conditions, are described as multiple, irregular, “lumpiness of the breast.” It is not a disease per se, but rather an exaggerated response to ovarian hormones. Fibrocystic changes are very common in premenopausal women, but rare following menopause. The clinical presentation is cyclic, painful, engorged breasts, more pronounced just before menstruation, and occasionally associated with serous or green breast discharge. Through careful physical examination, fibrocystic changes can usually be differentiated from the 3D-dominant mass suggestive of cancer, but occasionally, a fineneedle or core biopsy must be performed to establish the diagnosis. Treatment includes decreasing caffeine ingestion, and adding NSAIDs, a tight-fitting bra, oral contraceptives, or oral progestin therapy. With severe cases, danazol (a weak antiestrogen and androgenic compound) or even mastectomy are considered.

    In a woman in the adolescent years or in her 20s, the most common cause of a dominant breast mass is a fibroadenoma. These tumors are firm, rubbery, mobile, and solid in consistency. They typically do not respond to ovarian hormones and do not vary during the menstrual cycle. Since any 3D-dominant mass necessitates histologic confirmation, a biopsy should be performed. In a woman less than age 35 years, an FNA or core needle biopsy is often chosen. The advantages of FNA are less expense, less pain, but higher nondiagnostic rate; advantages of core needle biopsy include higher sensitivity but higher cost.

    The concept of the triple assessment, that is, clinical examination, imaging (ultrasound or mammography), and histology being concordant (all in agreement) has high reliability with either FNA or core needle biopsy. Nonconcordance usually indicates obtaining more tissue. If the histologic examination supports fibroadenoma (mature smooth muscle cells) and the mass is small and not growing, careful follow-up is possible. A rare tumor seen in adolescents and younger women, cystosarcoma phylloides, is diagnosed by biopsy. Nevertheless, many women choose to have excision of the mass. Most clinicians will excise any dominant 3D mass occurring in a woman over the age of 35 years, or in those with an increased likelihood of mammary cancer (family history).

BRCA Testing

Hereditary breast and ovarian cancer syndrome is most commonly related to mutations in BRCA 1 and BRCA 2 genes. Together, BRCA 1 and 2 account for 10% of ovarian cancer cases, and 3% to 5% of breast cancers. Women with BRCA-1 mutation have a 65% lifetime risk of breast cancer and 39% lifetime risk of ovarian cancer; those with BRCA-2 mutation have a 45% risk of breast and a 15% risk of ovarian cancer. These mutations are associated with an increased risk of fallopian tube, peritoneal, and pancreatic cancer. See Case 47 for more details.

COMPREHENSION QUESTIONS

Match the breast lesion (A-E) to the clinical presentation (46.1-46.4).

A. Fibroadenoma

B. Fibrocystic changes

C. Intraductal papilloma

D. Breast cancer

E. Galactocele

46.1 A 34-year-old woman complains of unilateral serosanguineous nipple discharge from the breast, expressed from one duct. No mass is palpated.

46.2 A 27-year-old woman complains of breast pain, which increases with menses. The breast has a lumpy-bumpy sensation.

46.3 A 47-year-old woman has a 1.5-cm right breast mass with nipple retraction and skin dimpling over the mass.

46.4 An 18-year-old adolescent female has an asymptomatic, 1-cm, nontender, mobile right breast mass.

46.5 A 32-year-old G0P0 woman complains of a 1-week history of a red and tender breast. She denies trauma, insect bites, pustules, or other lesions. Her family history is negative for breast disease. She denies oral contraceptive use. On examination, her temperature is 98°F (36.6°C), heart rate (HR) is 80 beats per minute (bpm), and BP is 100/ 60 mm Hg. Her heart and lung examination is normal. The right breast reveals a 5 × 4 cm area of redness, induration, and tenderness. There is no breast discharge. Her right axillary lymph nodes are mildly tender and enlarged. Which of the following is the next best step for this patient?

A. Oral antibiotic therapy

B. Biopsy of the breast

C. Intravenous antibiotic therapy

D. Advise the use of a tight-fitting bra and avoid caffeine

46.6. A 25-year-old G0P0 woman states that her mother, who lives in another city, was diagnosed with breast cancer at age 45. There is also a history of ovarian cancer in a maternal aunt. Which of the following is the best next step?

A. Offer BRCA testing to the patient

B. Request that the patient’s mother have BRCA testing

C. Offer the patient tamoxifen chemoprophylaxis

D. Offer the patient magnetic resonance imaging of bilateral breasts

ANSWERS

46.1 C. The most common cause of bloody (serosanguineous) nipple discharge when only one duct is involved and in the absence of a breast mass is intraductal papilloma. These are typically small, benign tumors that grow in the milk ducts. The highest incidence of this condition is in the 35 to 55 age group; causes and risk factors are unknown. The discharge is typically serosanguineous like the woman in this scenario. Because malignancy is also a common cause of bloody nipple discharge (second most common cause!), ductal exploration is required to rule out cancer.

46.2 B. A diffuse “lumpy-bumpy” examination suggests fibrocystic changes. They are very common in premenopausal women but rare following menopause. The classic clinical picture includes cyclic, painful, engorged breasts, more pronounced just before menstruation, and occasionally associated with breast discharge. Treatment includes decreasing caffeine intake and adding NSAIDs, a tight-fitting bra, oral contraceptives, or oral progestin therapy. With severe cases, danazol (a weak antiestrogen and androgenic compound) or even mastectomy is considered. A patient who presents with painful, engorged breasts may also have a galactocele; however, a galactocele does not have a “lumpy-bumpy” breast examination, nor is it associated with hormonal changes or the menstrual cycle. Galactoceles are mammary gland tumors that are cystic in nature and contain milk or milky fluid. They typically occur when there is any sort of obstruction of milk flow in the lactating breast.

46.3 D. Nipple retraction or skin dimpling over a mass is very suggestive of malignancy. In the physical examination, maneuvers to accentuate the skin changes such as “hands on hips” or “arms raised over the head” assist in evaluating for these findings. Most clinicians excise any dominant 3D mass occurring in a woman older than 35 years or in those with an increased likelihood of mammary cancer (family history). Histologic analysis from the excisional biopsy will most likely confirm the diagnosis of cancer.

46.4 A. In females in the adolescent years or in their twenties, the most common cause of a dominant breast mass is a fibroadenoma. These tumors are firm, rubbery, mobile, and solid in consistency. The best way to image the breast of a woman less than age 30 is usually ultrasound due to the dense fibrocystic changes that interfere with mammographic interpretation. Ultrasound can differentiate a solid versus a cystic mass, and sometimes can suggest a fibroadenoma; nevertheless, tissue should be obtained to confirm the diagnosis.

46.5 B. In a woman who has a “red tender indurated breast” who is nonlactating, inflammatory breast cancer must be ruled out. Biopsy of the breast is critical. Inflammatory breast cancer is aggressive in nature, and the skin changes occur due to the cancer cells within the subdermal lymph channels. Immediate diagnosis and therapy are crucial, whereas delay with various antibiotics would be detrimental. Interestingly, inflammatory breast cancer occurs more in younger patients, although women of any age can be affected.

46.6 B. In a patient who develops bilateral or premenopausal breast cancer, BRCA testing should be offered to the patient. If BRCA testing is positive, then first degree relatives should be notified, so that these individuals can consider whether BRCA testing is desired. If BRCA testing is negative in this index patient, then no further testing is needed to other relatives.This is the most efficient approach. Chemoprophylaxis with tamoxifen or bilateral mastectomy is not needed unless BRCA mutation is present.

    CLINICAL PEARLS    

» A firm, nontender, smooth mobile breast mass in a young woman (less than age 25 years) is most likely a fibroadenoma. » Ultrasound is the best initial imaging modality in a younger patient. » Although the biggest risk factor for breast cancer in general is age, breast malignancy does occur in younger patients. » A red inflamed breast in a nonlactating woman should be evaluated for possible inflammatory breast cancer. » BRCA testing is indicated for conditions of high risk for genetic breast and/or ovarian cancer.

REFERENCES

American College of Obstetricians and Gynecologists. Breast cancer screening. ACOG Practice Bulletin 122. Washington, DC; 2011. (Reaffirmed 2014.) 

American College of Obstetricians and Gynecologists. Breast concerns in children and adolescents with cancer. ACOG Committee Opinion 607. Washington, DC; 2014. 

Hacker NF, Friedlander ML. Breast disease: a gynecologic perspective. In: H acker NF, Gambone JC, Hobel CJ, eds. Essentials of Obstetrics and Gynecology. 5th ed. Philadelphia, PA: Saunders; 2009: 332-344. 

Valea FA, Katz VL. Breast diseases. In: Lentz GM, Lobo RA, Gershenson DM, Katz VL, eds. Comprehensive Gynecology. 6th ed. St. Louis, MO: Mosby-Year Book; 2012:301-335.

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