Fibroadenoma

Classification according to ICD-10
D24	Fibroadenoma
ICD-10 online (WHO version 2019)

Classification according to ICD-O-3
9010/0	Fibroadenoma nas
9011/0	Intra-canalicular fibroadenoma
9012/0	Pericanalicular fibroadenoma
9016/0	Juvenile fibroadenoma
9030/0	Giant fibroadenoma
ICD-O-3 first revision online

The fibroadenoma is a relatively common benign neoplasm in the breast that may occur singly or in majority in one or both breasts and usually affects girls and women of reproductive age. Fibroadenomas are usually 1–2 cm in size, painless, movable nodules of a rubbery or firm consistency, which are often detected during palpation examinations or in mammography . The lesion shows limited growth and often a spontaneous regression tendency with advancing age. The transition of the fibroadenoma into a malignant tumor is considered extremely rare, the relative risk of developing a malignant one laterDisease tumors of the mammary gland are only slightly increased in affected women. A surgical therapy is not necessary in asymptomatic patients and confirmed diagnosis. After adequate surgical removal of the lesion, there are usually no recurrences . A variant of the clinical picture is the juvenile fibroadenoma , which is a fibroadenoma that occurs in adolescence, sometimes with rapid growth, which can reach a size of 15 to 20 cm ( giant fibroadenoma ) and is therefore more often associated with deformity of the breast. Otherwise, the biological behavior of this lesion does not differ from the usual fibroadenoma, so that a good prognosis can be made here as well.

Epidemiology

Fibroadenomas can occur at any age after puberty , but they tend to manifest themselves in the third decade of life. The lesion is seen in about 8-10 percent of women over the age of 40, and is the most commonly diagnosed breast mass in women up to 30 years of age . A new occurrence of fibroadenoma in older women is rare. When all age groups are included, the fibroadenoma is the most common benign neoplasm and, after breast cancer, the second most common solid tumorous or tumor-like lesion in the female breast.

The occurrence of fibroadenomas in men is described in individual case reports, but is a rarity. There may be a causal relationship to an antiandrogenic therapy.

Ethnic differences in the incidence of fibroadenomas have not yet been reported.

causes

Although the underlying causes of the development of fibroadenomas have not been conclusively clarified, the findings available so far suggest an at least partially hormonally- related process in which hyperplasia of normal glandular lobules of the mammary gland occurs. Apparently there is an imbalance between the hormones estradiol and progesterone, with a relative predominance of the former. The hormone dependency is also shown by the fact that the size of fibroadenomas varies in part during the menstrual cycle and increases during pregnancy and there are often signs of regression (reduction in size, calcification, etc.) in the postmenopause . While the lesion was previously classified as a benign tumor and is sometimes still listed as such in the specialist literature, more recent findings, including clonality studies , speak against the hypothesis that it is a real neoplasm .

About half of the women who receive the immunosuppressive drug cyclosporine after a kidney transplant develop fibroadenomas, often multiple and bilateral. The Epstein-Barr virus (EBV) can frequently be detected in rapidly growing fibroadenomas in immunocompromised patients .

Multiple fibroadenomas with myxoid stroma can occur within the Carney complex together with myxomas of the heart , hyperpigmentation , endocrine disorders and other abnormalities.

Clinical symptoms

Fibroadenomas show up clinically, especially in younger women, as palpable, painless and movable, firm or rubber-like nodes. In older women, they are increasingly being discovered in the course of mammographic examinations and are only palpable in some of the cases. The juvenile fibroadenoma that occurs in adolescence can reach a considerable size of up to 20 cm ( giant fibroadenoma ) and can therefore already be outwardly noticeable due to a deformity of the affected breast.

diagnosis

smoothly demarcated solid fibroadenoma on ultrasound

The palpation examination and imaging procedures allow a suspected diagnosis to be made, which can be confirmed by aspiration cytology or fine needle biopsy to such an extent that a conservative, wait-and-see approach may be justifiable.

Mammographically, fibroadenomas usually appear as circumscribed masses which, depending on the age of the lesion, can show visible, coarse calcifications. On ultrasound examinations , the lesion is also circumscribed, homogeneous and hypoechogenic, and with posterior amplification. Under certain circumstances the lobed structure and a thin capsular border may be visible. The magnetic resonance imaging demonstrated a smooth limited lesion with high signal intensity on T2-weighted images and use gadolinium -containing contrast agents .

If the benign nature of the lesion cannot be clearly confirmed or if the patient so requests, the definitive diagnosis can also be made on the surgical specimen after complete removal or biopsy of the mass and histological processing by the pathologist .

therapy

As a benign lesion with no tendency to degenerate, surgical treatment of a fibroadenoma is not absolutely necessary. However, surgical removal may be indicated in the event of a diagnosis that cannot be confirmed otherwise, cosmetically disturbing or psychologically stressful manifestations of the disease. This is usually done in the form of an excision under sonographic control. Procedures in which the fibroadenoma tissue is exposed to low temperatures using a probe and thereby destroyed ( cryoablation ) are also used with good results. Other surgical procedures use the effects of great heat (ablation by means of laser , radio frequency waves , high-intensity focused ultrasound and microwaves ). The disadvantage of thermal methods is that the histological assessment of the tissue is difficult or impossible.

pathology

Histological image of a tissue sample obtained by needle biopsy from a fibroadenoma of the breast ( hematoxylin-eosin stain ).

Macroscopically , fibroadenomas usually manifest themselves as 1–2 cm, sometimes up to 4 cm, sharply demarcated, spherical or ovoid nodules of gray-white color and a firm or rubbery consistency, which can be displaced in relation to the surrounding tissue. The cut surface shows a lobed structure and an often shiny, myxoid appearance.

Histologically , there is a proliferate of loose cellular connective tissue in which duct-like epithelial structures are embedded to a variable extent (biphasic structure). The stroma consists of cells with spindle-shaped nuclei that show no significant pleomorphism and hardly any mitotic figures . The duct structures appear either as slit-shaped, compressed, elongated epithelial formations ( intra-canalicular pattern ) or smaller gland-like structures that are concentrically surrounded by stroma ( pericanalicular pattern ). Both patterns also occur in combination and possibly only represent different cutting planes of one and the same lesion in the histological image. The growth pattern has no prognostic significance. A myxoid transformation of the stroma or calcifications can be present to varying degrees (regressive changes).

Cytology of a fine needle aspirate from a fibroadenoma (Diff-Quik stain).

Cell- rich smears with a characteristic biphasic picture of epithelial and stromal cells are often found cytologically. The epithelia usually present themselves as cohesive cell plates made of even ductal epithelium, which shows folds, branches and a papilla-like architecture. Bipolar myoepithelial bare nuclei can be seen. Furthermore, fibrous or chondromyxoid stromal fragments with different levels of cells can be detected.

Differential diagnosis

A sufficiently reliable delineation from malignant tumors of the breast, especially the common breast cancer , is clinically imperative . Histologically, the fibroadenoma has to be differentiated from the morphologically very similar, mostly benign, but prognostically uncertain phyllodes tumor , which often shows a more cell-rich stroma with nuclear polymorphism and increased mitoses. A rare histological differential diagnosis is the manifestation of fibromatosis within the breast. Here, an infiltrative growth behavior, a cell-rich stroma and a sparse epithelial component speak in favor of fibromatosis and against a fibroadenoma.

forecast

As a benign lesion, the fibroadenoma has an excellent prognosis. Transitions from a fibroadenoma to a malignant tumor have only been described in individual cases, and the risk of breast cancer (localized outside the fibroadenoma) is only marginally increased in the women affected. Fibroadenomas do not recur with adequate surgical therapy and show a tendency to spontaneous regression even without any therapy (about 10 percent of fibroadenomas disappear on their own every year).

Individual evidence

1. ↑ ^{a b c d e f} C. DM Fletcher: Histopathology of Tumors. 3. Edition. Churchill Livingston Elsevier, 2007, ISBN 978-0-443-07434-9 .
2. ↑ ^{a b c d e f} M. A. Roubidoux: Breast, Fibroadenoma. July 29, 2009; [1]
3. ^ Y. Ansah-Boateng, FA Tavassoli: Fibroadenoma and cystosarcoma phyllodes of the male breast. In: Mod Pathol . 1992 Mar; 5 (2), pp. 114-116. PMID 1315437
4. ↑ SJ Shin, PP Rosen: Bilateral presentation of fibroadenoma with digital fibroma-like inclusions in the male breast. In: Arch Pathol Lab Med . 2007 Jul; 131 (7), pp. 1126-1129. PMID 17617003
5. ↑ PathConsult: fibroadenomas. (March 18, 2006), Elsevier; Archived copy ( memento of the original from June 26, 2011 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. 
6. ↑ CS Kaufman, PJ Littrup, LA Freeman-Gibb, JS Smith, D. Francescatti, R. Simmons, LH Stocks, L. Bailey, JK Harness, BA Bachman, CA Henry: Office-based cryoablation of breast fibroadenomas with long-term follow-up. In: Breast J. 2005 Sep-Oct; 11 (5), pp. 344-350. PMID 16174156
7. ↑ K. Dowlatshahi, S. Wadhwani, R. Alvarado, C. Valadez, J. Dieschbourg: Interstitial laser therapy of breast fibroadenomas with 6 and 8 year follow-up . In: Breast J. 2010 Jan; 16 (1), pp. 73-76. Epub 2009 Oct 12. PMID 19825000
8. ↑ B. Cavallo Marincola, F. Pediconi, M. Anzidei, E.Miglio, L. Di Mare, M. Telesca, M. Mancini, G. D'Amati, M. Monti, C. Catalano and A. Napoli: High -intensity focused ultrasound in breast pathology: non-invasive treatment of benign and malignant lesions . In: Expert Review of Medical Devices, 1-9 (2014). doi : 10.1586 / 17434440.2015.986096 .
9. ↑ R. Kovatcheva, J. Vlahov, J. Stoinov, K. Zaletel: Efficacy and Safety of US-guided High-intensity Focused Ultrasound for Treatment of Breast Fibroadenoma . Abstract 4th Focused Ultrasound Symposium 2014 .
10. ↑ R. Kovatcheva, JN Guglielmina, M. Abehsera, L. Boulanger, N. Laurent, E. Poncelet: Ultrasound-guided High-Intensity-Focused-Ultrasound treatment of breast fibroadenoma - a multicenter experience . In: Journal of Therapeutic Ultrasound. Jan. 22, 2015; 3 (1). doi : 10.1186 / s40349-014-0022-3 . PMC 4310188 (free full text).
11. ↑ F. Moinfar: Essentials of Breast Pathology. Springer, 2007, ISBN 978-3-540-45117-4 .
12. ↑ SZ Ali, AV Parwani: Breast Cytopathology . Springer, 2007, ISBN 978-0-387-71594-0 .

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