Management of 3 cm Fibroadenoma in a 25-Year-Old Woman
For this 25-year-old woman with a 3 cm ultrasound-confirmed fibroadenoma requesting excision, the next step is core needle biopsy (CNB) followed by surgical excision (Answer A). Patient anxiety and request for removal is a valid indication for excision, particularly when the lesion exceeds 2 cm 1.
Rationale for Core Needle Biopsy Before Excision
CNB must be performed before proceeding to excision, even when ultrasound suggests fibroadenoma, because:
Imaging alone cannot reliably distinguish fibroadenoma from phyllodes tumor or other pathology 1, 2. Phyllodes tumors can appear identical to fibroadenomas on ultrasound and require different surgical margins 1.
CNB provides superior diagnostic accuracy compared to fine needle aspiration, with better sensitivity, specificity, and histological grading 1.
Tissue diagnosis establishes concordance between clinical, radiologic, and pathologic findings (the "triple test"), which is essential before any surgical intervention 3.
CNB can identify unexpected findings such as atypical hyperplasia, lobular neoplasia, or rarely malignancy, which would alter surgical planning 4, 5.
Why Excision is Indicated in This Case
This patient meets multiple criteria for surgical excision:
Size >2 cm: The American College of Radiology recommends excision for fibroadenomas larger than 2 cm 1, 2.
Patient anxiety and request for removal: This is explicitly recognized as a valid indication for excision by multiple guidelines 4, 1, 2.
Young age with 3 cm mass: At 25 years old, a 3 cm mass may cause breast asymmetry or deformity, which is another indication for removal 6.
Why Other Options Are Incorrect
Mammogram (Option B) is not indicated as the next step because:
- Women under 30 years should proceed directly to ultrasound for palpable masses 4.
- Mammography has limited utility in young women due to dense breast tissue 4.
- The diagnosis is already established by ultrasound; mammography would not change management 4.
CNB alone (Option C) is incomplete because:
- While CNB is necessary, it must be followed by excision given the patient's request and the >2 cm size 1.
- The question asks "what's next" in the context of a patient requesting excision—the complete answer is CNB followed by excision.
Self-examination (Option D) is inappropriate because:
- The patient has already expressed concern and requested excision 1.
- Observation alone would only be appropriate for smaller lesions (<2 cm) in patients comfortable with surveillance 2, 3.
- This 3 cm lesion exceeds the size threshold for conservative management 1, 2.
Clinical Pearls and Pitfalls
Critical distinction: Distinguishing fibroadenoma from phyllodes tumor can be difficult even on CNB 1. If CNB shows cellular fibroepithelial lesion or suggests phyllodes tumor, excision with wider margins is mandatory 4, 1.
Surgical approach: Use inframammary or periareolar incisions for optimal cosmetic results, particularly important in young women 6.
Post-excision management: If final pathology confirms simple fibroadenoma without atypia, the patient returns to routine age-appropriate screening 4, 1. If atypical features are found, follow risk-reduction guidelines 4.