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

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

Excision after core needle biopsy (CNB) is appropriate for this patient due to the size of the fibroadenoma (>2 cm) and the patient's request for removal due to anxiety. 1, 2, 3

Indications for Surgical Excision of Fibroadenomas

• Fibroadenomas larger than 2 cm in size warrant consideration for surgical excision 2, 3
• Patient request or anxiety about the mass is a valid indication for excision 1, 3
• Other indications include rapid growth, suspicious features, or complex characteristics 3, 4

Management Algorithm for This Case

1. Core needle biopsy (CNB) confirmation before excision

   • CNB is preferred over fine needle aspiration biopsy (FNAB) for better sensitivity, specificity, and histological grading 1
   • CNB allows for definitive diagnosis and helps distinguish fibroadenoma from phyllodes tumor 2

2. Surgical excision following CNB

   • Excision is indicated in this case due to:
     • Size >2 cm 2, 3
     • Patient anxiety and request for removal 1, 3

3. Post-excision management

   • If pathology confirms benign fibroadenoma, routine breast screening is recommended 1
   • If pathology reveals atypical features, follow appropriate guidelines for risk reduction 1

Evidence Supporting This Approach

• ACR Appropriateness Criteria states that image-guided core biopsy may be performed to establish a definitive diagnosis when patient anxiety is a factor 1
• According to clinical guidelines, surgical intervention is indicated when fibroadenomas are >2 cm in diameter 2, 3
• NCCN guidelines support surgical excision for solid lesions that are large or causing patient concern 1

Important Considerations and Pitfalls

• Distinguishing fibroadenoma from phyllodes tumor: Core biopsy is essential as distinguishing between these entities can be difficult on imaging alone 2
• Sampling error: While rare (1.72% in one study), CNB may occasionally miss atypical features or phyllodes tumors 5
• Growth doesn't necessarily indicate malignancy: Studies show that enlarging fibroadenomas rarely harbor malignancy (0% in one series), but excision is still warranted for those >2 cm 6, 7
• Conservative management option: If the patient changes her mind about excision, conservative management with follow-up is a safe alternative provided triple assessment (clinical, imaging, and pathology) is negative for cancer 4

Follow-up After Excision

• If pathology confirms benign fibroadenoma, no specific follow-up is needed beyond routine breast screening 1
• If any atypical features are found, follow appropriate risk-reduction guidelines 1