From the Guidelines
Management of fibroadenomas typically involves observation with regular follow-up for small, asymptomatic lesions that have been confirmed by imaging and possibly biopsy. For most fibroadenomas under 2-3 cm that are not causing symptoms, a conservative approach is recommended with clinical breast exams every 6-12 months and imaging surveillance as appropriate for the patient's age 1. Surgical excision is considered for fibroadenomas that are large (>2-3 cm), rapidly growing, causing symptoms such as pain or discomfort, or when there is diagnostic uncertainty. Some key points to consider in the management of fibroadenomas include:
- Alternative minimally invasive options include vacuum-assisted excision, cryoablation, or high-intensity focused ultrasound, though these may not be widely available 1.
- The decision for intervention should be individualized based on the patient's age, symptoms, anxiety level, and preferences.
- Reassurance is important as fibroadenomas are benign breast lesions with minimal risk of malignant transformation (less than 0.1%) 1.
- Young women (under 25) with typical fibroadenomas may not require biopsy if ultrasound features are characteristic, while older women generally need tissue diagnosis to exclude malignancy.
- Hormonal therapies are not typically used for management as evidence for their effectiveness is limited. It's also important to note that the likelihood of a mass with probably benign features representing a cancer is low in all series and particularly low in young women, with one study finding that only 1 of 357 patients (0.3%) younger than age 25 years with such features was subsequently diagnosed with malignancy 1.
From the Research
Management of Fibroadenomas
The management of fibroadenomas can be approached in several ways, including:
- Surgical excision: Traditionally, symptomatic fibroadenomas were treated by surgical excision, and this option should always be offered 2.
- Conservative management: There is increasing evidence that a conservative approach is safe and acceptable, provided the result of an adequate triple test is both negative for cancer and consistent with a fibroadenoma 2.
- Imaging and biopsy: The choice of imaging is mammography, combined with ultrasound in older women, and ultrasound alone in younger women. Tissue biopsy, by either fine-needle aspiration or core biopsy, is the most accurate means of establishing the diagnosis 2.
Size-Based Management
Some studies have suggested surgical excision in all fibroadenomas >30 mm to reduce core needle biopsy sampling errors 3. However, a study found that excision based solely on size is not warranted in clinical and radiologically concordant cases with a diagnosis of fibroadenoma on core needle biopsy 3.
Enlarging Fibroadenomas
Enlarging biopsy-proven fibroadenomas are not associated with malignancy, and therefore, surgical excision does not seem warranted 4. For presumed enlarging fibroadenomas on imaging, core biopsy should be performed to exclude associated atypia or phyllodes tumor 4.
Complex Fibroadenomas
Complex fibroadenomas are a subtype of fibroadenoma harboring one or more complex features. Women with complex fibroadenomas may be managed with a conservative approach, similar to the approach now recommended for women with simple fibroadenomas, due to the low incidence of malignancy in complex fibroadenomas 5.
Feasibility of Conservative Management
A study found that conservative management of fibroadenomas over 5 years is not practical in their local setting due to the high patient attrition rate 6. However, in those who completed the 5-year observation period, only 1 in 10 patients had complete resolution of their fibroadenoma 6.
Key Considerations
Key considerations in the management of fibroadenomas include: