What is the next step in management for a 25-year-old female with a 3 cm breast lump confirmed by ultrasound to be a fibroadenoma (Fibroadenoma), who is requesting excision due to concerns about the lump?

Management of a 3 cm Fibroadenoma in a 25-Year-Old Woman Requesting Excision

Core needle biopsy (CNB) is the recommended next step for this 25-year-old woman with a 3 cm fibroadenoma who is requesting excision due to anxiety. 1

Rationale for Core Needle Biopsy

• The National Comprehensive Cancer Network (NCCN) guidelines specifically recommend tissue sampling via core needle biopsy for:

  • Solid breast masses larger than 2-2.5 cm 1
  • Cases where patient anxiety is a factor 1
  • To exclude phyllodes tumor, which can mimic fibroadenoma on imaging 1

• Core needle biopsy offers superior diagnostic accuracy with:

  • Sensitivity of 95-100%
  • Specificity of 90-100% 1

Why CNB Before Excision?

1. Surgical Planning: CNB helps ensure appropriate surgical planning, especially if the lesion turns out to be a phyllodes tumor requiring wider margins 1

2. Definitive Diagnosis: While ultrasound is highly accurate for diagnosing fibroadenomas, histological confirmation is necessary for lesions >2 cm 1, 2

3. Patient Anxiety: The patient's request for excision should be considered in management decisions, but proper diagnosis must precede surgical intervention 1

Why Not Other Options?

• Mammogram (Option B): Not indicated as the primary next step in women under 30 years with a palpable mass already evaluated by ultrasound 3

• Self-examination monthly (Option D): Not appropriate for a 3 cm fibroadenoma in a patient requesting excision. Observation alone is only appropriate for lesions <2 cm with low clinical suspicion 1

• Excision after CNB (Option A): While this may ultimately be the treatment path, CNB must be performed first to confirm diagnosis and guide surgical approach 1

Important Considerations

• Although the risk of malignancy in fibroadenomas is very low (0.3% in women under 25 years) 2, the large size (3 cm) warrants tissue sampling before excision 1

• Surgical intervention is indicated when one or more of the following features are present:

  • Diameter greater than 2 cm
  • Patient anxiety
  • Complex features 4

• Be aware that in rare cases, breast cancers can mimic fibroadenomas on imaging, particularly in older patients 5

• For fibroadenomas <1.5 cm, ultrasound-guided vacuum-assisted biopsy may provide both diagnosis and complete excision in a single procedure, but this is less effective for larger lesions like the 3 cm mass in this case 6

By following the evidence-based approach of performing CNB before surgical excision, you ensure proper diagnosis and appropriate surgical planning while addressing the patient's concerns.