What is the next step for a 25-year-old woman with a 3 cm breast lump confirmed by ultrasound (US) to be a fibroadenoma, who is requesting excision?

Management of Fibroadenoma in a 25-Year-Old Woman Requesting Excision

For a 25-year-old woman with a 3 cm breast fibroadenoma confirmed by ultrasound who is requesting excision, core needle biopsy (CNB) followed by excision is the appropriate management approach given her preference and the size of the lesion.

Decision Algorithm for Fibroadenoma Management

Initial Assessment

• The patient has a 3 cm palpable breast lump confirmed as fibroadenoma by ultrasound
• Patient is young (25 years old)
• Patient has expressed anxiety and requested excision

Recommended Approach

Step 1: Core Needle Biopsy (CNB)

• CNB is recommended before excision to confirm the diagnosis and rule out phyllodes tumor 1
• While ultrasound suggests fibroadenoma, core biopsy provides histological confirmation before surgical intervention

Step 2: Excision

• After CNB confirmation, proceed with excisional biopsy as requested by the patient 1
• Excision is appropriate in this case due to:
  • Size of the mass (3 cm) - larger fibroadenomas (>2.5 cm) have higher risk of being phyllodes tumors 2
  • Patient preference and anxiety - a valid indication for excision 1, 3

Evidence-Based Rationale

Size Considerations

• Fibroadenomas >2.5 cm have increased risk of being phyllodes tumors 2
• The National Comprehensive Cancer Network guidelines note that phyllodes tumors often present with:
  • Palpable mass
  • Large size (>2 cm)
  • Ultrasound findings similar to fibroadenoma 1

Patient Preference

• The ACR Appropriateness Criteria specifically states that "situations in which biopsy may alleviate extreme patient anxiety may prompt tissue sampling" 1
• Patient anxiety is a recognized indication for surgical excision of fibroadenomas 3

Diagnostic Accuracy

• Core needle biopsy is superior to FNA for accurate diagnosis 1
• However, CNB may not always distinguish between fibroadenoma and phyllodes tumor 1
• In a study of excised fibroadenomas, 1.72% had atypical features including benign phyllodes tumors 4

Important Considerations

Why Not Just Observation?

While observation would be appropriate for smaller, asymptomatic fibroadenomas, this case warrants excision because:

• The 3 cm size exceeds the threshold where risk of phyllodes tumor increases
• The patient has specifically requested removal due to anxiety
• The NCCN guidelines support excision for fibroadenomas when patients are concerned 1

Why Not Mammogram?

• Mammography is not routinely indicated in women under 30 years with a palpable mass already characterized by ultrasound 1
• The ACR guidelines state: "If a correlate for a palpable mass has been identified on US and is probably benign, there is no indication for either diagnostic mammography or DBT in this age group" 1

Why Not Just Monthly Self-Examination?

• While self-examination is important for general breast health, it is not an adequate substitute for addressing a confirmed 3 cm fibroadenoma in a patient requesting removal

Surgical Approach

• Excision can be performed through an inframammary or periareolar approach 5
• No reconstructive surgery is typically needed for fibroadenomas of this size 5
• Good cosmetic outcomes can be expected with proper surgical technique 5

Remember that while most fibroadenomas can be managed conservatively, the combination of the 3 cm size and patient preference makes excision after CNB the most appropriate management in this specific case.