Fibroadenomas account for 60% of all palpable lumps in the female population under 20 years of age. They can sometimes go unnoticed by the patient until the breast softens with involution, or they may represent an incidental finding on the first screening mammogram.
Treatment of fibroadenomas ranges from conservative to invasive, depending on the certainty of diagnosis on imaging. Many women decide to get the fibroadenoma surgically removed; nevertheless, as fibroadenomas are clinically linked to estrogen levels, the lesions tend to shrink in the post-menopausal years.
Conservative Management
Initial approach to a mass considered to be a fibroadenoma should be an observation during at least one whole menstrual cycle, assuming normality of menstrual patterns. The physician should strive to reassure the patient about the safety of this approach, as up to 40% of fibroadenomas show spontaneous regression.
However, not all women are default candidates for such “watch and wait” approach; the patient's age, information on proliferative changes from previous biopsies, and a family history must definitely be taken into consideration.
Furthermore, if the patient feels uncomfortable with just observing the lump, and there is an underlying anxiety and fear of malignancy despite the fact that the actual risk of malignant transformation is less than 1%, it is recommended to remove asymptomatic fibroadenoma. The literature data shows that, when confronted with the option of conservative management, a majority of women actually prefer excisional biopsy.
Minimally Invasive Techniques
Vacuum-assisted percutaneous biopsy is used to remove fibroadenomas that are smaller than 3 cm in size. This procedure is conducted percutaneously by multiple passes of a hollow bore needle, usually under ultrasound guidance. Subsequently, the breast tissue is aspirated by employing vacuum suction, and patients report significant satisfaction with the procedure.
Ablative procedures (most notably cryotherapy) under local anesthesia are also used to remove fibroadenomas in the breast. In this procedure, a probe is placed percutaneously along the axis of the fibroadenoma and then cooled by argon gas to –160 degrees Celsius. This leads to cell membrane disruption, hypoxia, and destruction of the fibroadenoma.
Conversely, fibroadenomas can be treated with heat, most often by placing a guided laser needle in the fibroadenoma and using a laser to generate heat in order to ablate the mass. High-intensity focused ultrasound represents another heat-based ablative method with a mean volume reduction of 72.5%.
Surgical Excision
Despite these attractive, minimally invasive techniques, open excision of fibroadenomas under local or general anesthesia is still the most common procedure for fibroadenoma removal. It is usually utilized if the lump is symptomatic or shows rapidly growing nature.
Ideally, the incision is positioned around the areola or in the inframammary crease in order to minimize visible scarring, although the location and size of the mass may eventually guide the incision characteristics. After surgery, patients should attend regular follow-ups to assess potential complications and evaluate the necessity for reconstructive surgery.
In that regard, giant fibroadenomas are typically treated surgically due to their size, whereas juvenile fibroadenomas are excised due to their rapid growth. Surgical excision of smaller lesions are considered when masses are hard, non-mobile, tender, fixed to overlying skin or associated with supraclavicular or axillary enlargement of the lymph nodes.
Further Reading