From the Guidelines
The next step for a 25-year-old woman with a 3 cm fibroadenoma who desires excision would be surgical removal through an excisional biopsy. This recommendation is based on the most recent and highest quality study available, which suggests that excisional biopsy is the appropriate management for fibroadenomas, especially for larger ones (>2-3 cm) that may cause discomfort or cosmetic concerns 1.
Preoperative Assessment
Prior to surgery, the patient should have a preoperative assessment including a review of medical history, medications, and allergies. She should avoid blood-thinning medications like aspirin for 7-10 days before surgery.
Surgical Procedure
The procedure is typically performed as an outpatient surgery under local anesthesia with sedation. The surgeon will make a small incision (often along natural skin lines for better cosmetic results), remove the entire fibroadenoma, and close the incision with sutures.
Postoperative Care
The procedure typically takes 30-60 minutes, and recovery involves limited activity for 24-48 hours with a return to normal activities within a week. Pain management usually consists of over-the-counter medications like acetaminophen or NSAIDs.
Pathological Examination
The excised tissue will be sent for pathological examination to confirm the diagnosis and rule out any unexpected findings. This is crucial because, although fibroadenomas are benign breast tumors, there is a small risk of an unexpected malignancy, and pathological examination can provide a definitive diagnosis 1.
Alternative Management
While observation would be medically acceptable for smaller fibroadenomas, surgical excision is appropriate when the patient prefers removal, especially for larger fibroadenomas (>2-3 cm) that may cause discomfort or cosmetic concerns. The NCCN guidelines recommend surgical excision for indeterminate lesions, benign lesions that are not concordant with imaging findings, or atypical ductal hyperplasia (ADH) 1.
Key Considerations
It is essential to note that core needle biopsy (CNB) may not distinguish fibroadenoma from phyllodes tumor in most cases, and excisional biopsy is necessary for a definitive diagnosis 1. Additionally, the patient's preferences and concerns should be taken into account when deciding on the management plan.
In summary, excisional biopsy is the recommended management for a 25-year-old woman with a 3 cm fibroadenoma who desires excision, based on the most recent and highest quality evidence available 1.
From the Research
Next Steps for a 25-year-old Lady with a 3 cm Fibroadenoma
- The patient has a confirmed fibroadenoma by ultrasound (US) and is requesting excision 2.
- According to a study published in 2008, modern ultrasound is a reliable technique to diagnose fibroadenoma in the hands of experienced breast radiologists, and a palpable lump that has the ultrasound characteristics entirely consistent with a fibroadenoma need not be biopsied unless there is overriding clinical concern 2.
- However, since the patient is requesting excision, the next step would be to consider core needle biopsy (CNB) to confirm the diagnosis and rule out any associated atypia or phyllodes tumor 3, 4.
- A study published in 2019 found that enlarging biopsy-proven fibroadenomas are not associated with malignancy, and surgical excision does not seem warranted unless there is associated atypia or suspected phyllodes tumor 3.
- Another study published in 2017 found that fibroepithelial lesions diagnosed by core needle biopsy demonstrate a moderate rate of upstaging to phyllodes tumors, and surgical excision is indicated for lesions with associated atypia or suspected phyllodes tumor 4.
- Vacuum-assisted core-needle biopsy can be used as a diagnostic and therapeutic method in lesions radiologically suspicious of breast fibroadenoma, and it combines features of a lesion resection and histopathologic material collection providing an access with minimum invasiveness 5.
- A recent study published in 2022 recommends excision only for cellular fibroepithelial lesions and rapidly growing lesions with a core biopsy diagnosis of fibroadenoma, and persistent pain is a relative indication for excision 6.
Possible Courses of Action
- Perform CNB to confirm the diagnosis and rule out any associated atypia or phyllodes tumor before excision 3, 4.
- Consider vacuum-assisted core-needle biopsy as a diagnostic and therapeutic method 5.
- Excise the lesion if the patient is experiencing persistent pain or if the lesion is rapidly growing 6.