What's the next step for a 25-year-old woman with a 3 cm fibroadenoma confirmed by ultrasound (US), who is anxious about the lump and requests excision?

From the Guidelines

The next step for this 25-year-old woman with a 3 cm fibroadenoma would be to proceed with surgical excision of the mass, as the patient is anxious about the lump and has specifically requested removal, and the fibroadenoma has already been confirmed by ultrasound 1.

Key Considerations

• The patient's anxiety and request for removal are important factors in the decision-making process.
• The size of the fibroadenoma (3 cm) and the patient's age (25 years) are also relevant considerations.
• According to the NCCN guidelines, surgical excision is recommended for benign masses that are not concordant with imaging findings or for lesions that increase in size 1.

Procedure and Recovery

• The procedure would typically be performed as an outpatient surgery under local anesthesia with sedation or general anesthesia depending on patient preference and surgeon recommendation.
• The surgeon would make a small incision (often along natural skin lines for better cosmetic results), remove the fibroadenoma completely, and close the wound with absorbable sutures.
• Recovery is usually quick, with most patients returning to normal activities within a few days, though strenuous exercise should be avoided for 1-2 weeks.

Follow-up and Counseling

• After excision, the specimen would be sent for pathological examination to confirm the diagnosis, though no further treatment would typically be needed once the benign nature is confirmed.
• The patient should be counseled that while fibroadenomas are not cancerous and don't increase breast cancer risk significantly, new lumps should always be evaluated promptly 1.

Alternative Options

• Observation with regular follow-up would also be a reasonable option for fibroadenomas, but patient preference is an important consideration in management decisions 1.
• However, given the patient's anxiety and request for removal, surgical excision is the most appropriate course of action.

From the Research

Next Steps for a 25-Year-Old Woman with a 3 cm Fibroadenoma

• The patient has a confirmed fibroadenoma of 3 cm, which is larger than the typical size threshold for consideration of excision in some guidelines 2.
• However, studies suggest that excision based solely on size is not warranted in clinically and radiologically concordant cases with a diagnosis of fibroadenoma on core needle biopsy (CNB) 3.
• The patient's anxiety and request for excision should be considered, but it's essential to weigh the risks and benefits of surgical excision.
• According to some studies, excision is typically recommended for cellular fibroepithelial lesions or those lesions with clinical, radiologic, or pathologic features concerning for phyllodes tumor (PT) 3, 4.
• In this case, since the patient is 25 years old and the lesion is 3 cm, with no other concerning features mentioned, the next step could be:
  • Core needle biopsy (CNB) if not already performed, to confirm the diagnosis and rule out any atypical features or phyllodes tumor 5.
  • If the CNB confirms a fibroadenoma with no atypical features, and the patient still requests excision, surgical excision could be considered, taking into account the patient's anxiety and preferences 6.
  • Alternatively, regular follow-up with clinical examination and imaging could be recommended to monitor the lesion's size and characteristics, with excision considered if there are any changes or concerns 4.

Considerations for Excision

• Excision is generally recommended for lesions with suspicious features, rapid growth, or patient request 2, 4.
• However, studies have shown that enlarging biopsy-proven fibroadenomas are not associated with malignancy, and surgical excision may not be necessary in these cases 6.
• The decision to excise should be based on a combination of radiological, clinical, and pathological features, as well as patient preferences and anxiety levels 4.