Fibroadenomas

Question 1

What are fibroadenomas?

Answer 1

Fibroadenomas are the most common benign tumour of the breast.

Question 2

Traditionally referred to as ‘breast mice’, these discrete, mobile lumps often occur in younger women. It is important to distinguish and exclude breast cancer, as such patients should be referred for a triple assessment in line with NICE guidance. - what is this referring to?

Answer 2

Fibroadenomas - Traditionally referred to as ‘breast mice’, these discrete, mobile lumps often occur in younger women. It is important to distinguish and exclude breast cancer, as such patients should be referred for a triple assessment in line with NICE guidance.

Question 3

As a general rule, in fibroadenomas - …% regress spontaneously, …% will remain unchanged and 25% will get bigger.

Answer 3

As a general rule, 50% regress spontaneously, 25% will remain unchanged and 25% will get bigger.

Question 4

Fibroadenomas most commonly occur in women aged … to …

Answer 4

Fibroadenomas most commonly occur in women aged 14 to 35.

Question 5

Fibroadenomas are typically seen in … patients and often regress after ….

Answer 5

Fibroadenomas are typically seen in younger patients and often regress after menopause. There is up to a 10% lifetime incidence of fibroadenomas in women.

Question 6

There is up to a …% lifetime incidence of fibroadenomas in women.

Answer 6

There is up to a 10% lifetime incidence of fibroadenomas in women.

Question 7

Fibroadenoma may be split into a number of sub-types. These include: (3)

Answer 7

These include:

Simple fibroadenomas: These are small (1-3cm) lumps with classical features of a firm, mobile and painless lump.
Complex fibroadenomas: Complex appearance on histopathology. These have been associated with a slight increase in the risk of breast cancer.
Giant fibroadenomas: Large fibroadenomas growing to a size of greater than 5cm. Difficult to distinguish from a phyllodes tumour.

Question 8

Simple fibroadenomas: These are small (…-…cm) lumps with classical features of a firm, mobile and … lump.

Answer 8

Simple fibroadenomas: These are small (1-3cm) lumps with classical features of a firm, mobile and painless lump.

Question 9

Complex fibroadenomas: Complex appearance on histopathology. These have been associated with a slight increase in the risk of ….

Answer 9

Complex fibroadenomas: Complex appearance on histopathology. These have been associated with a slight increase in the risk of breast cancer.

Question 10

Giant fibroadenomas: Large fibroadenomas growing to a size of greater than …cm. Difficult to distinguish from a phyllodes tumour.

Answer 10

Giant fibroadenomas: Large fibroadenomas growing to a size of greater than 5cm. Difficult to distinguish from a phyllodes tumour.

Question 11

Fibroadenomas are fibroepithelial tumours arising from … and epithelial tissue.

Answer 11

Fibroadenomas are fibroepithelial tumours arising from stromal and epithelial tissue.

Question 12

Fibroadenomas - There is clear evidence of a hormonal link. They tend to develop after menarche and regress after menopause. They may be triggered or increase in size during … or when taking ….

Answer 12

Fibroadenomas - There is clear evidence of a hormonal link. They tend to develop after menarche and regress after menopause. They may be triggered or increase in size during pregnancy or when taking hormone replacement therapy (HRT).

Question 13

… - A genetic basis has also been identified with a mutation to MED12 found in around 60% of tumours. MED12 has been implicated in many other conditions including uterine fibroids.

Answer 13

Fibroadenomas - A genetic basis has also been identified with a mutation to MED12 found in around 60% of tumours. MED12 has been implicated in many other conditions including uterine fibroids.

Question 14

Fibroadenomas present with a breast lump which is typically …

Answer 14

Fibroadenomas present with a breast lump which is typically painless.

Question 15

They classically occur on the outer, upper quadrant of the breast. In general, the breast lump can be described as:
Painless
Firm
Mobile
What is this referring to?

Answer 15

Fibroadenomas
They classically occur on the outer, upper quadrant of the breast. In general, the breast lump can be described as:
Painless
Firm
Mobile

Question 16

In up to …% of cases, there are multiple fibroadenomas affecting one or both breasts.

Answer 16

In up to 20% of cases, there are multiple fibroadenomas affecting one or both breasts.

Question 17

Fibroadenomas present with a breast lump that can be described as … (3)

Answer 17

They classically occur on the outer, upper quadrant of the breast. In general, the breast lump can be described as:

Painless
Firm
Mobile

Question 18

NICE have set out criteria to guide referral for patients with symptoms suggestive of breast cancer.

Patients should be referred on a two-week wait suspected cancer pathway if:

Answer 18

30 and over and have an unexplained breast lump with or without pain or
50 and over with any of the following symptoms in one nipple only:
Discharge
Retraction
Other changes of concern

NICE also recommend clinicians consider a two-week wait suspected cancer pathway for people:

With skin changes that suggest breast cancer or
Aged 30 and over with an unexplained lump in the axilla

Question 19

Consider non-urgent referral in people aged under …. with an unexplained breast lump with or without pain.

Answer 19

Consider non-urgent referral in people aged under 30 with an unexplained breast lump with or without pain.

Question 20

The one-stop breast clinic incorporates a … assessment in one appointment. It requires localities to have access to appropriate specialists and diagnostic equipment but offers patients a convenient and efficient service.

Answer 20

The one-stop breast clinic incorporates a triple assessment in one appointment. It requires localities to have access to appropriate specialists and diagnostic equipment but offers patients a convenient and efficient service.

Question 21

The ..-.. breast clinic incorporates a triple assessment in one appointment.

Answer 21

The one-stop breast clinic incorporates a triple assessment in one appointment. The majority of patients can be reassured that they do not have evidence of breast cancer following a single visit. Some may need to await further tests (e.g. core biopsy results) whilst others may be given a likely diagnosis.

Question 22

In young patients (< … years) with a low-risk history; examination and imaging findings - these alone may be sufficient to make a diagnosis of fibroadenoma. In older patients or those with indeterminate (or concerning) examination or imaging, a biopsy must be considered.

Answer 22

In young patients (< 25 years) with a low-risk history; examination and imaging findings - these alone may be sufficient to make a diagnosis of fibroadenoma. In older patients or those with indeterminate (or concerning) examination or imaging, a biopsy must be considered.

Question 23

Triple assessment in the breast clinic

Answer 23

Question 24

The one-stop breast clinic incorporates a triple assessment in one appointment. First step involves…

Answer 24

1. Clinical history and examination

Each patient referred to the two-week wait one-stop clinic will be reviewed by a specialist. This will involve a detailed history including family history. Following this, the patient will be carefully examined.

Question 25

The one-stop breast clinic incorporates a triple assessment in one appointment. Second step involves…

Answer 25

2. Imaging

This will depend in part on the history and examination and the patient’s age. Clinics are set up to conduct both breast ultrasound scans (USS) and mammograms.

Mammogram: A mammogram utilises x-rays to image breast tissue. Finding suggestive of cancer include soft tissue masses and microcalcifications.
USS: Breast USS is the modality of choice in women under the age of 40. It is also used in older women, particularly when mammogram and clinical findings do not align. High-resolution scanners meeting NHSBSP standards are used.

Question 26

The one-stop breast clinic incorporates a triple assessment in one appointment. Last step involves…

Answer 26

3. Histopathology

Depending on what is found in the first two steps a tissue/cellular sample may be taken. This may be in the form of fine-needle aspiration (provisional same-day results) or core biopsy (often provisional same-day results, sometimes may have to wait a few days).

Question 27

The majority of fibroadenomas can be managed …

Answer 27

The majority of fibroadenomas can be managed conservatively.

Question 28

Simple, small and asymptomatic, biopsy-proven fibroadenomas - how do we treat/manage?

Answer 28

Simple, small and asymptomatic, biopsy-proven fibroadenomas do not need further treatment. If appearances are classical in young patients (e.g. under 25 years) biopsy may be avoided and interval imaging considered.

Patients should be advised to re-present if the mass changes in size, if they develop pain or any other features that may indicate breast cancer (e.g. skin and nipple changes).

Question 29

In certain circumstances excision of a Fibroadenomas may be discussed, this includes: (3)

Answer 29

Cellular fibroepithelial lesion (difficult to differentiate from phyllodes tumour)
Rapidly growing fibroadenoma
Persistent pain or discomfort (NB - no guarantee surgical excision will improve symptoms)

Question 30

The main options for Fibroadenomas intervention includes:

Answer 30

The main options are surgical excision and ultrasound-guided vacuum-assisted mammotome. Open surgical excision is recommended for cellular fibroepithelial lesions.

Other treatment options include High-Intensity Focused Ultrasound (HIFU) and cryoablation.